TITLE 8 SOCIAL SERVICES

CHAPTER 308 MANAGED CARE PROGRAM

PART 13 MEMBER REWARDS

8.308.13.1 ISSUING AGENCY: New Mexico Health Care Authority.

[8.308.13.1 NMAC - N, 1/1/2014; A, 7/1/2024]

8.308.13.2 SCOPE: This rule applies to the general public.

[8.308.13.2 NMAC - N, 1/1/2014]

8.308.13.3 STATUTORY AUTHORITY: The New Mexico medicaid program and other health care programs are administered pursuant to regulations promulgated by the federal department of health and human services under Title XIX of the Social Security Act as amended or by state statute. See NMSA 1978, Section 27-1-12 et seq. 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.

[8.308.13.3 NMAC - N, 1/1/2014; A, 7/1/2024]

8.308.13.4 DURATION: Permanent.

[8.308.13.4 NMAC - N, 1/1/2014]

8.308.13.5 EFFECTIVE DATE: May 1, 2018, unless a later date is cited at the end of a section.

[8.308.13.5 NMAC - N, 1/1/2014; A, 5/1/2018]

8.308.13.6 OBJECTIVE: The objective of this rule is to provide instructions for the service portion of the New Mexico medical assistance programs.

[8.308.13.6 NMAC - N, 1/1/2014]

8.308.13.7 DEFINITIONS: [RESERVED]

8.308.13.8 [RESERVED]

[8.308.13.8 NMAC - N, 1/1/2014; Repealed, 5/1/2018]

8.308.13.9 ELIGIBLE MEMBERS: A member of a HSD contracted managed care organization (MCO) is eligible to participate in the managed care member rewards program.

A. For a native American member who elects to opt out of receiving medical assistance division (MAD) services through a HSD contracted MCO, and retains MAP category of eligibility, he or she no longer will earn reward credits as of the last day of enrollment in his or her MCO.

B. Upon losing eligibility for continued enrollment in a HSD contracted MCO, the individual no longer will earn member reward credits.

[8.308.13.9 NMAC - N, 1/1/2014; A, 5/1/2018]

8.308.13.10 REWARD CREDITS: A member may earn reward credits when engaging in healthy behaviors included in the member rewards program. Reward credits are determined for specific member healthy behaviors. Details on the requirements to earn a healthy behavior reward credit are made available to a member on MAD’s website and provided in writing to a member through his or her MCO.

A. Maximum amount of a member’s reward credit balance: A member must use credits earned during the calendar year by the end of the following calendar year. Any credits that are not used by the end of the following calendar year in which they are earned are lost.

B. Portability of reward credits: A member may carry his or her reward credits when transitioning from one HSD contracted MCO to another HSD contracted MCO. When a member earns reward credits for a specific healthy behavior, he or she may not earn reward credits for the same healthy behavior within the same calendar year with his or her new MCO.

C. Retention of reward credits: A member’s reward credit balance will be accessible for the member’s use up to 365 days after he or she loses MAP eligibility. For a native American who was a member of a HSD contracted MCO, and later opts in to fee-for-service (FFS) administration of benefits, the previously earned MCO reward credits are accessible up to 365 days after the close of his or her HSD contracted MCO membership.

D. Reward credit disputes: If a member believes there is a discrepancy in the way his or her HSD contracted MCO has determined a reward credit or balance, the member shall contact his or her MCO for resolution.

[8.308.13.10 NMAC - N, 1/1/2014]

HISTORY OF 8.308.13 NMAC: [RESERVED]