TITLE 8 SOCIAL SERVICES
CHAPTER 309 ALTERNATIVE BENEFIT PROGRAM
PART 4 MAD ADMINISTERED BENEFITS AND LIMITATION OF SERVICES
8.309.4.1 ISSUING AGENCY:
New Mexico Human Services Department (HSD).
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8.309.4.2 SCOPE: This rule
applies to the general public.
[8.309.4.2 NMAC - N, 1-1-14]
8.309.4.3 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.
[8.309.4.3 NMAC - N, 1-1-14]
8.309.4.4 DURATION: Permanent.
[8.309.4.4 NMAC - N, 1-1-14]
8.309.4.5 EFFECTIVE DATE:
January 1, 2014, unless a later date is cited at the end of a section.
[8.309.4.5 NMAC - N, 1-1-14]
8.309.4.6 OBJECTIVE:
The objective of this rule is to provide instructions for the service
portion of the New Mexico medical assistance division programs.
[8.309.4.6 NMAC - N, 1-1-14]
8.309.4.7 DEFINITIONS:
[RESERVED]
8.309.4.8 MISSION STATEMENT:
To reduce the impact of poverty on people living in New Mexico by
providing support services that help families break the cycle of dependency on
public assistance.
[8.309.4.8 NMAC - N, 1-1-14]
8.309.4.9 ALTERNATIVE BENEFITS PLAN SERVICES WITH LIMITATIONS
(ABP): The medical
assistance division (MAD) category of eligibility “other adults” has an
alternative benefit plan (ABP). MAD
covers ABP specific services for an ABP eligible recipient. Services are made available through MAD under
a benefit plan similar to services provided by commercial insurance plans. ABP benefits include preventive services and
treatment services. An ABP eligible
recipient: (1) has limitations on
specific benefits; (2) does not have all standard medicaid state plan benefits
available; and (3) has some benefits, primarily preventive services,
that are available only to an ABP eligible recipient. All early and periodic screening, diagnosis
and treatment (EPSDT) program services are available to an ABP eligible recipient under 21
years. ABP services for an ABP eligible
recipient under the age of 21 years not subject to the duration, frequency, and
annual or lifetime benefit limitations that are applied to an ABP eligible
recipient 21 years of age and older. A
MAD ABP provider and ABP eligible recipient have rights and responsibilities as
described in chapters 349 through 352 of Title 8 NMAC, Social Services. Long term care in a nursing facility (NF), mi
via and community benefits are not available to an ABP eligible recipient.
[8.309.4.9 NMAC - N, 1-1-14]
8.309.4.10 ALTERNATIVE BENEFITS PLAN
GENERAL BENEFITS FOR ABP-EXEMPT ELIGIBLE RECIPIENTS (ABP-exempt): An ABP eligible recipient who self-declares
he or she has a qualifying condition is evaluated by the MAD utilization review
(UR) contractor for determination of whether he or she meets the qualifying
condition. An ABP-exempt eligible
recipient may select to no longer utilize his or her ABP benefits package. Instead, the ABP-exempt eligible recipient
would then utilize the standard medicaid state plan benefit package. See Section 19 of this rule for detailed
descriptions of the standard medicaid state plan benefits. Long term care in a nursing facility (NF), mi
via and community benefits are available to an eligible ABP-exempt recipient
when all conditions for accessing those services are met.
[8.309.4.10 NMAC - N, 1-1-14]
8.309.4.11 MAD ABP GENERAL PROGRAM DESCRIPTION:
The ABP benefits and services are detailed in Sections 12 through 17 of
this rule. The ABP-exempt benefits and
services are detailed in Section 19 of this rule.
[8.309.4.11 NMAC - N, 1-1-14]
8.309.4.12 GENERAL ABP COVERED SERVICES:
A. Ambulatory surgical services: The
benefit package includes surgical services rendered in an ambulatory surgical
center setting as detailed in 8.324.10 NMAC.
B. Anesthesia services: The
benefit package includes anesthesia and monitoring services necessary for the
performance of surgical or diagnostic procedures as detailed 8.310.2 NMAC.
C. Audiology services: The
benefit package includes audiology services as detailed in 8.310.2 and 8.324.5
NMAC with some limitations. For a ABP
eligible recipient 21 years and older, audiology services are limited to
hearing testing or screening when part of a routine health exam and are not
covered as a separate service.
Audiologist services, hearing aids and other aids are not covered for an
ABP recipient.
D. ABP
eligible recipient transportation:
The benefit package covers expenses for transportation, meals, and
lodging it determines are necessary to secure MAD covered medical or behavioral
health services for an ABP eligible recipient in or out of his or her home
community as detailed in 8.310.2 NMAC.
E. Dental Services: The benefit package includes dental services
as detailed in 8.310.2 NMAC.
F. Diagnostic imaging and
therapeutic radiology services: The benefit package includes medically
necessary diagnostic imaging and radiology services as detailed in 8.310.2
NMAC.
G. Dialysis services: The
benefit package includes medically necessary dialysis services as detailed in
8.310.2 NMAC. A dialysis provider shall
assist an ABP eligible recipient in applying for and pursuing final medicare eligibility determination.
H. Durable medical equipment and
medical supplies: The benefit package includes:
(1) durable
medical equipment as detailed in 8.310.2 NMAC;
(2) covered
prosthetic and orthotic services as detailed in 8.310.2 NMAC and 8.324.5 NMAC;
and
(3) medical
supplies as detailed in 8.310.2 NMAC with some limitations; for an ABP eligible
recipient 21 years of age and older the only medical supplies that are covered:
(a) diabetic
supplies, such as reagents, test strips, needles, test tapes, and alcohol
swabs; and
(b) medical supplies that are a necessary
component of durable medical equipment, medical supplies applied as part of a
treatment in a practitioner’s office, outpatient hospital, residential
facility, as a home health service and in other similar settings are covered as
part of a service (office visit), which are not reimbursed separately; and
(c) family
planning supplies.
I. Emergency and non-emergency
transportation services: The benefit package includes
transportation service such as ground ambulance, or air ambulance in an
emergency and when medically necessary, taxicab and handivan,
commercial bus, commercial air, meal and lodging services as indicated for
medically necessary physical and behavioral health services as detailed in
8.324.7 NMAC. Non-emergency transportation
is covered only when an ABP eligible recipient does not have a source of
transportation available and when the ABP eligible recipient does not have
access to alternative free sources. MAD
or its UR contractor shall coordinate efforts when providing transportation
services for an ABP eligible recipient requiring physical or behavioral health
services.
J. Home health services: The
benefit package for an ABP eligible recipient as detailed in 8.325.9 NMAC with
some limitations. For an ABP eligible
recipient 21 years of age and older, home health services are limited to 100
visits annually that do not exceed four hours-per-visit.
K. Hospice services: The
benefit package for an ABP eligible recipient as detailed in 8.325.4 NMAC.
L. Hospital
outpatient service: The benefit package includes hospital
outpatient services for preventive, diagnostic, therapeutic, rehabilitative or
palliative medical or behavioral health services as detailed in 8.311.2 and
8.321.2 NMAC.
M. Inpatient
hospital services: The benefit
package includes hospital inpatient acute care, procedures and services for the
eligible recipient as detailed in 8.311.2 NMAC and inpatient rehabilitation
hospitals detailed in 8.311.2 NMAC. Long-term acute care hospitals (extended
care hospitals) are covered only as a temporary step-down level of care (LOC)
following the eligible recipient’s discharge from a hospital prior to being
discharged to home.
N. Laboratory services: The
benefit package includes laboratory services provided according to the
applicable provisions of Clinical Laboratory Improvement Act (CLIA) as detailed
in 8.310.2 NMAC. Additionally, ABP
diagnostic testing coverage includes physical measurements and performance
testing, such as cardiac stress tests and sleep studies.
O. Physical health services: The benefit package
includes primary, primary care in a school-based setting, family planning and
specialty physical health services provided by a licensed practitioner
performed within the scope of practice; see 8.310.2 and 8.310.3 NMAC. Benefits also include:
(1) an out of hospital birth and other
related birthing services performed by a certified nurse midwife or a
direct-entry midwife licensed by the state of New Mexico, who is either validly
contracted with and fully credentialed by or validly contracted with HSD and
participates in MAD birthing options program as detailed in 8.310.2 NMAC; and
(2) bariatric
surgery is limited to one per lifetime; meeting additional criteria to assure
medical necessity may be required prior to accessing services.
P. Rehabilitation and habilitation
services: The benefit package includes
rehabilitative and habilitative services as detailed
in 8.323.5 NMAC. For an eligible
recipient 21 years and older there are service limitations listed below:
(1) cardiac
rehabilitation is limited to 36 visits per cardiac event;
(2) pulmonary
rehabilitation is limited to short-term therapy as defined in Paragraph (3)
below; and
(3) physical and
occupational therapies and speech and language pathology:
(a) are
short-term therapies that produce significant and demonstrable improvement
within the two-month period of the initial date of treatment; and
(b) the
short-term therapy may be extended beyond the initial two month period for one
additional period of up to two months dependent upon the MAD UR contractor,
only if such services can be expected to result in continued significant
improvement of the ABP eligible recipient’s physical condition within the
extension period.
(4) nursing
facility (NF) and acute long term care facility stays only as a temporary
step-down LOC from a hospital prior to the eligible recipient’s discharge to
home.
Q. Private
duty nursing: For an eligible
recipient under 21 years of age, private duty nursing services are covered
under EPSDT program. See Section 18 of
this rule for a detailed description.
For recipients age 21 and older, private duty nursing is only available
through the home health benefit. See
Subsection J of this section and 8.325.9 NMAC.
R. Tobacco
cessation services: The benefit
package includes cessation sessions as described in 8.310.2 NMAC but is not
limited to EPSDT or pregnant women.
S. Transplant services: The
following transplants are covered in the benefit package as long as the
indications are not considered experimental or investigational: heart transplants, lung transplants,
heart-lung transplants, liver transplants, kidney transplants, autologous bone
marrow transplants, allogeneic bone marrow transplants and corneal
transplants. For an ABP eligible
recipient 21 years or older, there is a lifetime limitation two
transplants. See 8.325.6 NMAC for
guidance whether MAD has determined if a transplant is experimental or
investigational.
T. Vision: The benefit package includes specific vision
care services that are medically necessary for the diagnosis of and treatment
of eye diseases for an ABP eligible recipient as detailed in 8.310.2 NMAC. All services must be furnished within the
scope and practice of the medical professional as defined by state law and in
accordance with applicable federal, state and local laws and rules. For an ABP eligible recipient 21 years or
older, the service limitations are:
(1) coverage is
limited to one routine eye exam in a 36-month period; and
(2) MAD does not cover refraction or
eyeglasses other than for aphakia following removal
of the lens.
[8.309.4.12 NMAC - N, 1-1-14; A,
10-15-14]
8.309.4.13 PHARMACY SERVICES: The benefit package includes pharmacy and related
services, as detailed in 8.324.4 NMAC.
[8.309.4.13 NMAC - N, 1-1-14]
8.309.4.14 REPRODUCTIVE HEALTH SERVICES: The benefit package includes reproductive health
services as detailed in 8.310.2 NMAC.
[8.309.4.14 NMAC - N, 1-1-14]
8.309.4.15 PREVENTATIVE PHYSICAL HEALTH SERVICES: The benefit package includes the current national
standards for preventive health services including behavioral health preventive
services. Standards are derived from
several sources, including the United States preventive services task force,
the centers for disease control and prevention; and the American college of
obstetricians and gynecologists. Unless
an ABP eligible recipient refuses and the refusal is documented, MAD shall make
available the preventive health services or screens or document that the
services (with the results) were provided by other means. The MAD provider shall document medical
reasons not to perform these services for an individual ABP eligible
recipient. ABP eligible recipient
refusal is defined to include refusal to consent to and refusal to access care.
A. Initial assessment: A MAD ABP provider may assist the ABP
eligible recipient with inquires to the MAD UR contractor for a NF assessment.
B. Prenatal care and screenings: The
benefit package includes prenatal care and related services, as detailed in
8.310.2 NMAC.
C. Preventive
medicine and supplements:
(1) An ABP eligible recipient can receive
supplements detailed below as medically indicated:
(a) aspirin to
prevent cardiovascular disease for a female between the ages of 45 to 79 years
when the potential benefit of a reduction of ischemic strokes outweighs the
potential harm of an increase in gastrointestinal hemorrhage;
(b) aspirin to
prevent cardiovascular disease for a male between the ages of 45 to 79 years
when the potential benefit due to a reduction in myocardial infarctions
outweighs the potential harm due to an increase in gastrointestinal hemorrhage;
(c) vitamin D
supplementation to prevent falls in a community-dwelling for an ABP eligible
recipient 65 years of age and older who is at increased risk for falls;
(d) folic acid supplementation for all
female ABP eligible recipients who are planning or are capable of pregnancy to
take a daily supplement containing 0.4 to 0.8 mg of folic acid;
(e) iron supplementation for all
asymptomatic ABP eligible recipients between the ages of six to 12 months who
are at increased risk for iron deficiency anemia; and
(f) breast cancer
preventive medication, such as chemoprevention, is made available.
(2) The MAD provider will discuss with a
female ABP eligible recipient who is at high risk for breast cancer and at low
risk for adverse effects of chemoprevention.
The PCP will provide information to the ABP eligible recipient of the
potential benefits and harms of chemoprevention.
D. Screens and preventative screens: screens and preventative screens include in the
recommendation of the United States preventative services task force A and B
recommendations are included in the benefit package.
[8.309.4.15 NMAC - N, 1-1-14]
8.309.4.16 TELEMEDICINE SERVICES: The benefit package
includes telemedicine services as detailed in 8.310.2 NMAC.
[8.309.4.16 NMAC - N, 1-1-14]
8.309.4.17 BEHAVIORAL HEALTH SERVICES: The benefit package includes the behavioral health
services as detailed in 8.321.2 NMAC.
[8.309.4.17 NMAC - N, 1-1-14]
8.309.4.18 EARLY AND PERIODIC SCREENING DIAGNOSIS AND TREATMENT SERVICES (EPSDT): The benefit package includes the delivery of the
federally mandated EPSDT program services [42 CFR Section 441.57] provided by a
primary care provider (PCP) as detailed in 8.320.2 NMAC. These include the ABP benefit services found
in Sections 12 through 17 of this rule.
A. General
physical health EPSDT services: MAD
makes available access to early intervention programs and services for an ABP
eligible recipient identified in an EPSDT screen as being at-risk for
developing or having a severe emotional, behavioral or neurobiological
disorder. Unless otherwise specified in
a service rule, ESPDT services are for an ABP eligible recipient under 21 years
of age. For detailed description of each
service, see 8.320.2 and for school based health services, see 8.320.6 NMAC. Additional NMAC citations may be included as
reference.
B. Behavioral
health EPSDT services: The
benefit package includes services provided by a behavioral health practitioner
for an ABP eligible recipient. See
8.321.2 NMAC for a detailed description of each service. MAD makes available access to early
intervention programs and services for an ABP eligible recipient identified in
his or her EPSDT screen as being at-risk for developing or having a severe
emotional, behavioral or neurobiological disorder.
[8.309.4.18 NMAC - N, 1-1-14]
8.309.4.19 ABP-EXEMPT ELIGIBLE RECIPIENT
GENERAL BENEFIT DESCRIPTION: An ABP eligible
recipient with a qualifying condition may select ABP-exempt utilizing the
standard medicaid state plan benefits.
All services, services limitations and co-payments that apply to full
benefit medicaid recipients are available to APB-exempt recipients. An ABP-exempt recipient does not have access
to the benefits that are only apply to ABP
recipients. The ABP co-payments do not apply to an
ABP-exempt recipient. The limitations on
services that apply only to ABP-recipients do not apply to ABP-exempt
recipients. The following chapters of
Title 8 Social Services NMAC provide more detailed descriptions of services.
A. Chapter 301 medicaid general benefit description;
B. Chapter 302 medicaid general provider policies;
C. Chapter 310 health care professional services;
D. Chapter 311 hospital services;
E. Chapter 312 long term care-nursing services, with the exceptions detailed in
Section 10 of this rule);
F. Chapter 313 long-term care facilities -intermediate care facilities;
G. Chapter 314 long-term care services-waivers;
H. Chapter 320 early and periodic screening, diagnosis and treatment (EPSDT);
I. Chapter 321 behavioral health services;
J. Chapter 324 adjunct services;
K. Chapter 325 specialty services; and
L. Chapter 326 case management services.
[8.309.4.19 NMAC - N, 1-1-14]
8.309.4.20 ABP AND ABP-EXEMPT ELIGIBLE
PROVIDERS: Health care to an ABP eligible recipient is
furnished by a variety of providers and provider groups. Refer to the MAD NMAC specific service rules
for detailed description of unique provider requirements. For general information, see 8.310.2 and
8.310.3 NMAC.
[8.309.4.20 NMAC - N, 1-1-14]
8.309.4.21 ABP AND ABP-EXEMPT NONCOVERED
SERVICES: MAD does not cover certain procedures,
services, or miscellaneous items. Refer
to the NMAC specific service rules for detailed description of unique noncovered services.
For general information, see 8.310.2 NMAC for physical health noncovered services, 8.320.2 NMAC for EPSDT noncovered services, 8.320.6 for noncovered
school-based health services, and 8.321.2 NMAC for behavioral health noncovered services.
[8.309.4.21 NMAC - N, 1-1-14]
8.309.4.22 ABP AND ABP-EXEMPT PRIOR AUTHORIZATION AND UTILIZATION
REVIEW: All MAD services are
subject to UR for medical necessity and program compliance. Refer to the NMAC specific service rule for
detailed description of the service’s prior authorization and utilization
review requirements. For general
information, see 8.310.2 and 8.310.3 NMAC.
[8.309.4.22 NMAC - N, 1-1-14]
8.309.4.23 ABP AND ABP-EXEMPT RECIPIENT
RESPONSIBILITIES: Services provided may
be subject to cost sharing requirements.
Please see 8.302.2 NMAC for more information on any required recipient
co-payments.
[8.309.4.23 NMAC - N, 1-1-14]
HISTORY OF 8.309.4 NMAC: [RESERVED]