TITLE 8 SOCIAL SERVICES

CHAPTER 281 MEDICAID ELIGIBILITY - INSTITUTIONAL CARE (CATEGORIES 081, 083 and 084)

PART 600 BENEFIT DESCRIPTION

8.281.600.1 ISSUING AGENCY: New Mexico Health Care Authority.

[8.281.600.1 NMAC - Rp, 8.281.600.1 NMAC, 1/1/2019; A, 7/1/2024]

8.281.600.2 SCOPE: The rule applies to the general public.

[8.281.600.2 NMAC - Rp, 8.281.600.2 NMAC, 1/1/2019]

8.281.600.3 STATUTORY AUTHORITY: The New Mexico medicaid program is administered pursuant to regulations promulgated by the federal department of health and human services under Title XIX of the Social Security Act, as amended and by the state health care authority pursuant to state statute. See Section 27-2-12 et seq., NMSA 1978 (Repl. Pamp. 1991). Section 9-8-1 et seq. NMSA 1978 establishes the health care authority (HCA) as a single, unified department to administer laws and exercise functions relating to health care facility licensure and health care purchasing and regulation.

[8.281.600.3 NMAC - Rp, 8.281.600.3 NMAC, 1/1/2019; A, 7/1/2024]

8.281.600.4 DURATION: Permanent.

[8.281.600.4 NMAC - Rp, 8.281.600.4 NMAC, 1/1/2019]

8.281.600.5 EFFECTIVE DATE: January 1, 2019, or upon a later approval date by the federal centers for medicare and medicaid services (CMS), unless a later date is cited at the end of the section.

[8.281.600.5 NMAC - Rp, 8.281.600.5 NMAC, 1/1/2019]

8.281.600.6 OBJECTIVE: The objective of these regulations is to provide eligibility policy and procedures for the medicaid program.

[8.281.600.6 NMAC - Rp, 8.281.600.6 NMAC, 1/1/2019]

8.281.600.7 DEFINITIONS: [RESERVED]

8.281.600.8 [RESERVED]

8.281.600.9 BENEFIT DESCRIPTION: Applicant/recipient who is eligible for institutional care medicaid is eligible to receive the full range of medicaid-covered services, unless coverage is restricted due to transfer of asset penalties.

[8.281.600.9 NMAC - Rp, 8.281.600.9 NMAC, 1/1/2019]

8.281.600.10 BENEFIT DETERMINATION:

A. Application for institutional care medicaid is made using the HSD 100 application. Completed applications must be acted upon and notice of approval, denial, or delay sent out within 45 days from the date of registration. The income support division (ISD) worker explains time limits to the applicant and informs him or her of the date by which the application should be processed.

B. Representatives applying on behalf of individuals: If a representative makes application on behalf of an institutionalized individual, the representative is relied upon for information. The ISD worker sends all notices to the applicant/recipient in care of the representative. If the individual who makes an application is an employee of the institution, the ISD worker contacts the applicant’s family or other involved individuals. The ISD worker focuses on the applicant/recipient’s current circumstances and on past circumstances which may provide clues to existing or potential resources.

[8.281.600.10 NMAC - Rp, 8.281.600.10 NMAC, 1/1/2019]

8.281.600.11 INITIAL BENEFITS:

A. For an applicant/recipient who loses supplemental security income (SSI) eligibility after entering an institution, the institutional care medicaid application date is the first day of the month of SSI termination, or the month the application is received by the ISD worker, whichever is earlier.

B. Notice of determination: Applicants eligible for institutional care medicaid are notified of the approval and advised of the amount, if any, of the medical care credit. Applicants who are ineligible are notified of the denial and provided with an explanation of appeal rights.

[8.281.600.11 NMAC - Rp, 8.281.600.11 NMAC, 1/1/2019]

8.281.600.12 ONGOING BENEFITS: A complete redetermination of eligibility must be performed by the ISD worker for each open case at least annually.

A. Regular reviews: For each regular yearly review, the ISD worker must determine:

(1) whether medical care credit payments are up to date; an overdue balance may indicate a change in circumstances that is unreported, particularly where rental property is involved; and

(2) whether the deposit to the recipient’s personal fund is consistently no more than the applicable personal needs allowance amount per month; a larger deposit may indicate an increase in income that is unreported or a previously unidentified source of income.

B. Level of care reviews are required to be completed at least annually. Level of care determinations are made by the utilization review contractor or a member’s selected or assigned managed care organization.

[8.281.600.12 NMAC - Rp, 8.281.600.12 NMAC, 1/1/2019]

8.281.600.13 RETROACTIVE BENEFIT COVERAGE: Up to three months of retroactive medicaid coverage can be furnished to applicants who have received medicaid-covered services during the retroactive period and would have met applicable eligibility criteria had they applied during the three months prior to the month of application. Retroactive medicaid coverage is provided in accordance with 8.200.400.14 NMAC.

[8.281.600.13 NMAC - Rp, 8.281.600.13 NMAC, 1/1/2019]

8.281.600.14 CHANGES IN ELIGIBILITY:

A. The following procedures apply when an institutional care medicaid recipient leaves an institution:

(1) the recipient is notified in writing that his/her eligibility for institutional care medicaid has terminated;

(2) the institutional care medicaid case is closed;

(3) the recipient is screened for other medicaid program eligibility; or

(4) the recipient is referred to the social security administration for determination of eligibility for SSI benefits if appropriate; if a recipient dies in an institution, the case is closed the following month.

B. Discharge status: Discharge status continues after the utilization review (UR) contractor determines that there is no medical necessity for a high nursing facility (NF) or low NF placement. Discharge status does not apply to an acute care placement. After placement in discharge status, the recipient continues to be eligible for institutional care medicaid since he/she still requires institutional care.

(1) Abstract submission: Discharge status requires a new abstract be submitted at regular intervals. The institution must attach verification to the abstract that adequate placement has been and is being sought.

(2) Case closure: The ISD worker takes no action to close a case until the recipient is actually discharged from the institution. If the recipient is transferred from high NF to low NF, medicaid coverage is not interrupted, unless the recipient is ineligible for other reasons.

[8.281.600.14 NMAC - Rp, 8.281.600.14 NMAC, 1/1/2019]

HISTORY OF 8.281.600 NMAC:

Pre-NMAC History: The material in this part was derived from that previously filed with the State Records Center:

ISD Rule 380.0000, Medical Assistance for Persons Requiring Institutional Care, filed 12/29/1983.

ISD Rule 380.0000, Medical Assistance for Persons Requiring Institutional Care, filed 8/11/1987.

MAD Rule 380.0000, Medical Assistance for Persons Requiring Institutional Care, filed 2/5/1988.

MAD Rule 380.0000, Medical Assistance for Persons Requiring Institutional Care, filed 2/25/1988.

MAD Rule 380.0000, Medical Assistance for Persons Requiring Institutional Care, filed 6/1/1988.

MAD Rule 380.0000, Medical Assistance for Persons Requiring Institutional Care, filed 1/31/1989.

MAD Rule 380.0000, Medical Assistance for Persons Requiring Institutional Care, filed 6/21/1989.

MAD Rule 880.0000, Medical Assistance for Persons Requiring Institutional Care, filed 3/21/1990.

MAD Rule 880, Medical Assistance for Persons Requiring Institutional Care, filed 5/3/1991.

MAD Rule 880, Medical Assistance for Persons Requiring Institutional Care, filed 6/12/1992.

MAD Rule 880, Medical Assistance for Persons Requiring Institutional Care, filed 11/16/1994.

MAD Rule 882, Resources - Medical Assistance for Persons Requiring Institutional Care, filed 3/9/1993.

MAD Rule 882, Resources - Medical Assistance for Persons Requiring Institutional Care, filed 11/16/1994.

MAD Rule 882, Resources, filed 12/29/1994.

MAD Rule 883, Income - Medical Assistance for Persons Requiring Institutional Care, filed 3/18/1993.

MAD Rule 883, Income - Medical Assistance for Persons Requiring Institutional Care, filed 11/16/1994.

MAD Rule 883, Income, filed 12/29/1994.

MAD Rule 885, Medical Care Credit, filed 11/16/1994.

MAD Rule 888, Medicare Catastrophic Coverage Act of 1988 Regarding Transfers of Assets, filed 3/10/1994.

MAD Rule 888, Transfers of Assets, filed 12/27/1994.

MAD Rule 889, Spousal Impoverishment, filed 8/17/1992.

MAD Rule 889, Spousal Impoverishment, filed 2/17/1994.

History of Repealed Material:

MAD Rule 880, Medical Assistance for Persons Requiring Institutional Care, filed 11/16/1994 - Repealed effective 2/1/1995.

MAD Rule 882, Resources, filed 12/29/1994 - Repealed effective 2/1/1995.

MAD Rule 883, Income, filed 12/29/1994 - Repealed effective 2/1/1995.

MAD Rule 885, Medical Care Credit, filed 11/16/1994 - Repealed effective 2/1/1995.

MAD Rule 888, Transfers of Assets, filed 12/27/1994 - Repealed effective 2/1/1995.

MAD Rule 889, Spousal Impoverishment, filed 2/17/1994 - Repealed effective 2/1/1995.

8 NMAC 4.ICM.600, Benefit Description, filed 12/30/1994 - Repealed effective 4/1/2009.

8.281.600 NMAC – Benefit Description, filed 3/13/2009 - Repealed effective 1/1/2019.