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 Health Care Authority.
[8.309.4.1 NMAC - N, 1/1/2014; A, 7/1/2024]
8.309.4.2 SCOPE:
This rule applies to the general public.
[8.309.4.2 NMAC - N, 1/1/2014]
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. 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.
[8.309.4.3 NMAC - N, 1/1/2014; A,
7/1/2024]
8.309.4.4 DURATION:
Permanent.
[8.309.4.4 NMAC - N, 1/1/2014]
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, 1/1/2014]
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, 1/1/2014]
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, 1/1/2014]
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, 1/1/2014]
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, 1/1/2014]
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, 1/1/2014]
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, 1/1/2014; 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, 1/1/2014]
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, 1/1/2014]
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, 1/1/2014]
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, 1/1/2014]
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, 1/1/2014]
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, 1/1/2014]
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, 1/1/2014]
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, 1/1/2014]
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, 1/1/2014]
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, 1/1/2014]
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, 1/1/2014]
HISTORY OF 8.309.4 NMAC: [RESERVED]