loading…
loading…
loading…
TITLE 8 SOCIAL SERVICES
CHAPTER 200 MEDICAID ELIGIBILITY - GENERAL RECIPIENT RULES
PART 400 GENERAL MEDICAID ELIGIBILITY
8.200.400.1 ISSUING AGENCY: New Mexico Health Care Authority (HCA).
[8.200.400.1 NMAC - Rp, 8.200.400.1 NMAC, 1/1/2019; A/E, 10/1/2024; A, 2/1/2025]
8.200.400 .2 SCOPE: The rule applies to the general public .
[8.200.400.2 NMAC - Rp, 8.200.400.2 NMAC, 1/1/2019]
8.200.400 .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 Section 27-1-12 et seq., NMSA 1978.
[8.200.400.3 NMAC - Rp, 8.200.400.3 NMAC, 1/1/2019]
8.200.400 .4 DURATION: Permanent.
[8.200.400.4 NMAC - Rp, 8.200.400.4 NMAC, 1/1/2019]
8.200.400 .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.
[8.200.400.5 NMAC - Rp, 8.200.400.5 NMAC, 1/1/2019]
8.200.400 .6 OBJECTIVE: The objective of this rule is to provide specific instructions when determining eligibility for the medicaid program and other health care programs. Generally, applicable eligibility rules are detailed in the medical assistance division (MAD) eligibility policy manual, specifically 8.200.400 NMAC, General Medicaid Eligibility . Processes for establishing and maintaining MAD eligibility are detailed in the income support division (ISD) general provisions 8.100 NMAC, General Provisions for Public Assistance Programs .
[8.200.400.6 NMAC - Rp, 8.200.400.6 NMAC, 1/1/2019]
8.200.400 .7 DEFINITIONS: [ RESERVED ]
8.200.400 .8 MISSION: We ensure that New Mexicans attain their highest level of health by providing whole-person, cost-effective, accessible, and high-quality health care and safety-net services.
[8.200.400.8 NMAC - Rp, 8.200.400.8 NMAC , 1/1/2019; A, 1/1/2022; A/E, 10/1/2024; A, 2/1/2025 ]
8.200.400.9 GENERAL MEDICAID ELIGIBILITY: Medicaid services are jointly financed by the federal government and the state of New Mexico and are administered by medical assistance division (MAD).
A. Within broad federal regulations, New Mexico determines categories of eligible recipients, eligibility requirements, types and range of services, levels of provider reimbursement and managed care capitation, and administrative and operating procedures.
B. New Mexico administers medical assistance programs using waivers of the Social Security Act for comparability of services, rules for income and resources and freedom of choice of provider.
C. Payments for medical and behavioral health services, durable equipment and supplies are made directly to service providers, not to the medicaid eligible recipient.
D. This chapter describes the New Mexico categories of medicaid and medical assistance programs eligibility. Each medicaid and medical assistance program includes detailed eligibility requirements which are organized into the following three chapter types:
(1) recipient requirements (.400);
(2) income and resource s standards (.500); and
(3) benefit description (.600).
[8.200.400.9 NMAC - Rp, 8.200.400.9 NMAC, 1/1/2019]
8.200.400.10 BASIS FOR DEFINING GROUP - MEDICAID CATEGORIES:
A. Except where noted, the HCA income support division (ISD) determines eligibility in the categories listed below:
(1) other adult (Category 100);
(2) parent caretaker (Category 200);
(3) pregnant women (Category 300);
(4) pregnancy-related services (Category 301);
(5) loss of parent caretaker due to earnings from employment or due to spousal support (Categories 027 and 028);
(6) newborn (Category 031);
(7) children under age 19 (Categories 400, 401, 402, 403, 420, and 421);
(8) children, youth, and families department medicaid (Categories 017, 037, 046, 04, 066, and 086); and
(9) family planning (Category 029).
B. Medicare savings program (MSP): MSP assists an eligible recipient with the cost of medicare .
(1) Medicare is the federal government program that provides health care coverage for individuals 65 or older; or under 65 who have a disability. Individuals under 65 who have a disability are subject to a waiting period of 24 months from the approval date of social security disability insurance (SSDI) benefits before they receive medicare coverage. Coverage under medicare is provided in four parts.
(a) Part A hospital coverage is usually free to beneficiaries when medicare taxes are paid while working.
(b) Part B medical coverage requires monthly premiums, co-insurance and deductibles to be paid by the beneficiary.
(c) Part C advantage plan allows a beneficiary to choose to receive all medicare health care services through a managed care organization.
(d) Part D provides prescription drug coverage.
(2) The following MSP programs can assist an eligible recipient with the cost of medicare .
(a) Qualified medicare beneficiaries (QMB) - Categories 041 and 044: QMB covers low income medicare beneficiaries who have or are conditionally eligible for medicare Part A. QMB benefits are limited to the following:
( i ) cost for the monthly medicare Part B premium;
(ii) cost of medicare deductibles and coinsurance; and
(iii) cost for the monthly medicare Part A premium (for those enrolling conditionally).
(b) Specified low-income medicare beneficiaries (SLIMB) - Category 045: SLIMB medicaid covers low-income medicare beneficiaries who have medicare Part A. SLIMB is limited to the payment of the medicare Part B premium.
(c) Qualified individuals 1 (QI1s) - Category 042: QI1 medicaid covers low-income medicare beneficiaries who have medicare Part A. QI1 is limited to the payment of the medicare part B premium.
(d) Qualified disabled working individuals (QDI) - Category 050: QDI medicaid covers low income individuals who lose entitlement to free medicare Part A hospital coverage due to gainful employment. QDI is limited to the payment of the monthly Part A hospital premium.
(e) Medicare Part D prescription drug coverage - low income subsidy (LIS) - Category 048: LIS provides individuals enrolled in medicare Part D with a subsidy that helps pay for the cost of Part D prescription premiums, deductibles and co-payments. An eligible recipient receiving medicaid through QMB, SLMB or QI1 is automatically deemed eligible for LIS and need not apply. Other low-income medicare beneficiaries must meet an income and resource test and submit an application to determine if they qualify for LIS.
C. Supplemental security income (SSI) related medicaid :
(1) SSI - Categories 001, 003 and 004: Medicaid for individuals who are eligible for SSI. Eligibility for SSI is determined by the social security administration (SSA). This program provides cash assistance and medicaid for an eligible recipient who is:
(a) aged (Category 001);
(b) blind (Category 003); or
(c) disabled (Category 004).
(2) SSI medicaid extension - Categories 001, 003 and 004: MAD provides coverage for certain groups of applicants or eligible recipients who have received supplemental security income (SSI) benefits and who have lost the SSI benefits for specified reasons listed below and pursuant to 8.201.400 NMAC:
(a) the pickle amendment and 503 lead;
(b) early widow(er);
(c) disabled widow(er) and a disabled surviving divorced spouse;
(d) child insurance benefits, including disabled adult children (DAC);
(e) nonpayment SSI status (E01);
(f) revolving SSI payment status “ping-pongs”; and
(g) certain individuals who become ineligible for SSI cash benefits and, therefore, may receive up to two months of extended medicaid benefits while they apply for another MAD category of eligibility.
(3) Working disabled individuals (WDI) and medicare wait period - Category 074: There are two eligibility types:
(a) a disabled individual who is employed; or
(b) a disabled individual who has lost SSI medicaid due to receipt of SSDI and the individual does not yet qualify for medicare .
D. Long term care medicaid :
(1) medicaid for individuals who meet a nursing facility (NF) level of care (LOC), intermediate care facilities for the intellectually disabled (ICF-ID) LOC, or acute care in a hospital. SSI income methodology is used to determine eligibility. An eligible recipient must meet the SSA definition of aged (Category 081); blind (Category 083); or disabled (Category 084).
(2) Institutional care (IC) medicaid - Categories 081, 083 and 084: IC covers certain inpatient, comprehensive and institutional and nursing facility benefits.
(3) Program of all-inclusive care for the elderly (PACE) - Categories 081, 083 and 084:
PACE uses an interdisciplinary team of health professionals to provide dual medicaid / medicare enrollees with coordinated care in a community setting. The PACE program is a unique three-way partnership between the federal government, the state, and the PACE organization. The PACE program is limited to specific geographic service area(s). Eligibility may be subject to a wait list for the following:
(a) the aged (Category 081);
(b) the blind (Category 083); or
(c) the disabled (Category 084).
(4) Home and community-based 1915 (c) waiver services (HCBS) - Categories 090, 091, 092, 093, 094, 095 and 096: A 1915(c) waiver allows for the provision of long term care services in home and community based settings. These programs serve a variety of targeted populations, such as people with mental illnesses, intellectual disabilities, or physical disabilities. Eligibility may be subject to a wait list.
(a) There are two HCBS delivery models:
( i ) traditional agency delivery where HCBS are delivered and managed by a MAD enrolled agency; or
(ii) mi via self-directed where an eligible recipient, or their representative, has decision-making authority over certain services and takes direct responsibility to manage the eligible mi via recipient’s services with the assistance of a system of available supports; self-direction of services allows an eligible mi via recipient to have the responsibility for managing all aspects of service delivery in a person-centered planning process.
(b) HCBS waiver programs include:
( i ) elderly (Category 091), blind (Category 093) and disabled (Category 094);
(ii) medically fragile (Category 095);
(iii) developmental disabilities (Category 096); and
(iv) self-directed model for Categories 090, 091, 093, 094, 095, 096 and 092).
E. Emergency medical services for non-citizens (EMSNC): EMSNC medicaid covers certain non-citizens who either are undocumented or who do not meet the qualifying non-citizen criteria specified in 8.200.410 NMAC. Non-citizens must meet all eligibility criteria for one of the medicaid categories noted in 8.285.400 NMAC, except for citizenship or qualified non-citizen status. Medicaid eligibility for and coverage of services under EMSNC are limited to the payment of emergency services from a medicaid provider.
F. Refugee medical assistance (RMA) - Categories 049 and 059: RMA offers health coverage to certain low-income refugees during the first twelve months from their date of entry to the United States (U.S.) when they do not qualify for other medicaid categories of eligibility. An RMA eligible refugee recipient has access to a benefit package that parallels the full coverage medicaid benefit package. RMA is funded through a grant under Title IV of the Immigration and Nationality Act (INA). An RMA applicant who exceeds the RMA income standards may “spend-down” below the RMA income standards for Category 059 by subtracting incurred medical expenses after arrival into the U.S.
G. Breast and cervical cancer (BCC) - Category 052: BCC medicaid provides coverage to an eligible uninsured woman, under the age of 65 who has been screened and diagnosed by the department of health (DOH) as having breast or cervical cancer to include pre-cancerous conditions. The screening criteria are set forth in the centers for disease control and prevention’s national breast and cervical cancer early detection program (NBCCEDP). Eligibility is determined using DOH notification and without a separate medicaid application or determination of eligibility.
[8.200.400.10 NMAC - Rp, 8.200.400.10 NMAC, 1/1/2019; A, 1/1/2022; A, 1/1/2023; A/E, 10/1/2024; A, 2/1/2025]
8.200.400.11 PRESUMPTIVE ELIGIBILITY FOR BREAST AND CERVICAL CANCER: PE provides immediate access to health services when an individual appears to be eligible for Category 052.
A. Breast and cervical cancer (BCC) (Category 052): PE provides temporary medicaid coverage for an uninsured woman, under the age of 65 who has been screened and diagnosed by the DOH as having breast or cervical cancer to include pre-cancerous conditions. Only one PE period is allowed per calendar year .
B. PE is determined by a qualified entity certified by HCA. Qualified entities may include community and rural health centers, hospitals, physician offices, local health departments, family planning agencies and schools.
C. The PE period begins on the date the provider determines presumptive eligibility and terminates at the end of the following month.
D. Providers shall notify the MAD claims processing contractor of the determination within 24-hours of the PE determination.
E. For continued medicaid eligibility beyond the PE period, a completed and signed application for medicaid must be submitted to HCA/ISD. An eligible PE provider must submit the application to ISD within 10 calendar days from the receipt of the application.
[8.200.400.11 NMAC - Rp, 8.200.400.11 NMAC, 1/1/2019; A/E, 10/1/2024; A, 2/1/2025]
8.200.400.12 CONTINUOUS ELIGIBILITY FOR CHILDREN (42 CFR 435.926) :
A. HCA provides continuous eligibility for the period specified in Subsection B and C of 8.200.400.12 NMAC for an individual who is:
(1) Under age 19 and
(2) Eligible and enrolled for mandatory or optional coverage under the state plan.
B. The continuous eligibility period is up to six years for children from birth until turning age six. A child enrolled for less than 12 months before turning age six is eligible for 12 months of continuous eligibility. T he continuous eligibility period begins on the effective date of the individual's eligibility or most recent redetermination or renewal of eligibility.
C. The continuous eligibility period is 12 months for children age six until turning age 19. The continuous eligibility period begins on the effective date of the individual's eligibility or most recent redetermination or renewal of eligibility.
D. A child's eligibility may not be terminated during a continuous eligibility period, regardless of any changes in circumstances, unless:
(1) the child attains the maximum age of 19;
(2) the child or child's representative requests a voluntary termination of eligibility;
(3) the child ceases to be a resident of New Mexico;
(4) the agency determines that eligibility was erroneously granted at the most recent determination, redetermination or renewal of eligibility because of agency error or fraud, abuse, or perjury attributed to the child or the child's representative; or
(5) the child dies.
[8.200.400.12 NMAC - Rp, 8.200.400.12 NMAC, 1/1/2019; A, 9/1/2024; A/E, 10/1/2024; A, 2/1/2025]
8.200.400.13 AUTHORIZED REPRESENTATIVE: HCA must permit applicants and beneficiaries to designate an individual or organization to act responsibly on their behalf in assisting with the individual’s application and renewal of eligibility and other ongoing communications.
A. Such a designation must be in writing including the applicant’s signature, and must be permitted at the time of application and at other times. Legal documentation of authority to act on behalf of an applicant or beneficiary under state law, such as a court order establishing legal guardianship or a power of attorney, shall serve in the place of written authorization by the applicant or beneficiary.
B. Representatives may be authorized to:
(1) sign an application on the applicant’s behalf;
(2) complete and submit a renewal form;
(3) receive copies of the applicant or beneficiary’s notices and other communications from the agency; and
(4) act on behalf of the applicant or beneficiary in all other matters with the agency.
C. The power to act as an authorized representative is valid until the applicant or beneficiary modifies the authorization or notifies the agency that the representative is no longer authorized to act on their behalf, or the authorized representative informs the agency that they are no longer acting in such capacity, or there is a change in the legal authority upon which the individual’s or organization’s authority was based. Such notice must be in writing and should include the applicant or authorized representative’s signature as appropriate.
D. The authorized representative is responsible for fulfilling all responsibilities encompassed within the scope of the authorized representation to the same extent as the individual they represent, and must agree to maintain, or be legally bound to maintain, the confidentiality of any information regarding the applicant or beneficiary provided by the agency.
E. As a condition of serving as an authorized representative, a provider, staff member or volunteer of an organization must sign an agreement that they will adhere to the regulations relating to confidentiality (relating to the prohibition against reassignment of provider claims as appropriate for a health facility or an organization acting on the facility’s behalf), as well as other relevant state and federal laws concerning conflicts of interest and confidentiality of information (42 CFR 435.923).
[ 8.200.400.13 NMAC - Rp, 8.200.400.13 NMAC, 1/1/2019; A, 1/1/2023; A/E, 10/1/2024; A, 2/1/2025 ]
8.200.400.14 RETROACTIVE MEDICAID:
A. HCA must make eligibility for medicaid effective no later than the first or up to the third month before the month of application if the individual:
(1) Requested coverage for months prior to the application month;
(2) received medicaid services, at any time during that period, of a type covered under the plan and;
(3) would have been eligible for medicaid at the time they received the services, if they had applied (or an authorized representative has applied for them) regardless of whether the individual is alive when application for medicaid is made.
B. Eligibility for medicaid is effective on the first day of the month if an individual was eligible at any time during that month.
C. Eligibility for each retroactive month is determined separately. Retroactive medicaid must be requested within 180 days of the date of the medicaid application.
D. Retroactive medicaid is allowed for up to three months prior to the application month for the following medicaid categories:
(1) other adults (COE 100);
(2) parent caretaker (COE 200);
(3) pregnant women (COE 300);
(4) pregnancy-related services (COE 301);
(5) children under age 19 (COEs 400, 401, 402, 403, 420, and 421);
(6) family planning (COE 029);
(7) children, youth and families department (CYFD COEs 017, 037, 046, 047, 066, and 086);
(8) supplemental security income (SSI COEs 001, 003, and 004);
(9) SSI (COEs 001, 003, and 004, e.g. 503s, disabled adult children, ping pongs, and early widowers);
(10) working disabled individuals (COE 074);
(11) breast and cervical cancer (BCC COE 052);
(12) specified low income beneficiaries (SLIMB COE 045);
(13) qualified individuals (QI1 COE 042);
(14) qualified disabled working individuals (COE 050);
(15) refugees (COE 049); and
(16) institutional care medicaid (COEs 081, 083, and 084) excluding the program for all-inclusive care for the elderly (PACE).
E. The following categories do not have retroactive medicaid :
(1) emergency medical services for non-citizens EMSNC (COE 085). EMSNC provides coverage for emergency services, which may be provided prior to the application month, but is not considered retroactive medicaid . Eligibility is determined in accordance with 8.285.400, 8.285.500, and 8.285.600 NMAC;
(2) home and community based-services waivers (COEs 091, 093, 094, 095, and 096);
(3) PACE (COEs 081, 083, and 084);
(4) qualified medicare beneficiaries (COEs 041 and 044); and
(5) transitional medicaid (COEs 027 and 028).
F. Newborns (COE 031) are deemed to have applied and been found eligible for the newborn category of eligibility from birth through the month of the child’s first birthday. This applies in instances where the labor and delivery services were furnished prior to the date of the application and covered by medicaid based on the mother applying for up to three months of retroactive eligibility.
[8.200.400.14 NMAC - Rp, 8.200.400.14 NMAC, 1/1/2019; A, 2/1/2020; A, 1/1/2022; A/E, 10/1/2024; A, 2/1/2025]
8.200.400.15 NMAC AUTOMATIC ENROLLMENT OF SSI RECIPIENTS IN THE QMB GROUP:
A. SSI recipients entitled to premium-free part A: Effective October 1, 2024, the HCA shall automatically deem SSI recipients into QMB the first month they are eligible for SSI Medicaid and entitled to premium-free part A. The start of the part B buy-in coverage is the first month of entitlement to premium-free part A and the QMB eligibility group coverage is the first day of the following month.
B. SSI recipients enrolled in part B only: Effective upon the centers for medicare and medicaid services (CMS) and HCA systems’ capacity, the HCA shall automatically deem individuals enrolled in SSI medicaid eligible for the QMB eligibility group the first month they are both enrolled in part B and eligible for a medicare enrollment period, bypassing the need for actual or conditional part A enrolment at the social security administration.
C. Effective January 1, 2024, the HCA’s liability for retroactive part B premiums for full-benefit medicaid beneficiaries, including individuals receiving SSI medicaid , is limited to a period of no greater than 36 months prior to the date of the medicare enrollment determination.
D. For SSI medicaid recipients deemed eligible for the QMB group, renewal for QMB is required only to the extent to verify that an individual continues to receive SSI medicaid and has continued medicare part A coverage. The regular renewal process for QMB applies when an individual loses their SSI medicaid .
[8.200.400.15 NMAC - N/E, 10/1/2024; A, 2/1/2025]
8.200.400.16 NMAC [RESERVED]
HISTORY OF 8.200.400 NMAC: The material in this part was derived from that previously filed with the State Records Center:
8 NMAC 4.MAD.400, Recipient Policies, Recipient Rights and Responsibilities, filed 12/30/1994.
History of Repealed Material:
8.200.400 NMAC, General Medicaid Eligibility, filed 6/15/2001 - Repealed effective 1/1/2014.
8.200.400 NMAC, General Medicaid Eligibility, filed 12/2/2013 - Repealed effective 10/1/2017.
8.200.400 NMAC, General Medicaid Eligibility, filed 9/14/2017 - Repealed effective 1/1/2019.
NMAC History:
8.200.400 NMAC, General Medicaid Eligibility, filed 12/2/2013 was replaced by 8.200.400 NMAC, General Medicaid Eligibility effective 10/1/2017 .
8.200.400 NMAC, General Medicaid Eligibility, filed 9/14/2017 was replaced by 8.200.400 NMAC, General Medicaid Eligibility effective 1/1/2019 .
TITLE 8 SOCIAL SERVICES
CHAPTER 200 MEDICAID ELIGIBILITY - GENERAL RECIPIENT RULES
PART 410 GENERAL RECIPIENT REQUIREMENTS
8.200.410.1 ISSUING AGENCY: New Mexico Health Care Authority.
[8.200.410.1 NMAC - Rp, 8.200.410.1 NMAC, 10/1/2017; A, 7/1/2024]
8.200.410.2 SCOPE: The rule applies to the general public .
[8.200.410.2 NMAC - Rp, 8.200.410.2 NMAC, 10/1/2017]
8.200.410.3 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 Section 27-1-12 et seq., NMSA 1978. 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.
[8.200.410.3 NMAC - Rp, 8.200.410.3 NMAC, 10/1/2017; A, 7/1/2024]
8.200.410.4 DURATION: Permanent.
[8.200.410.4 NMAC - Rp, 8.200.410.4 NMAC, 10/1/2017]
8.200.410.5 EFFECTIVE DATE: October 1, 2017, unless a later date is cited at the end of a section.
[8.200.410.5 NMAC - Rp, 8.200.410.5 NMAC, 10/1/2017]
8.200.410.6 OBJECTIVE: The objective of this rule is to provide specific instructions when determining eligibility for the medicaid program and other health care programs. Generally, applicable eligibility rules are detailed in the medical assistance division (MAD) eligibility policy manual, specifically 8.200.400 NMAC, General Medicaid Eligibility . Processes for establishing and maintaining MAD eligibility are detailed in the income support division (ISD) general provisions 8.100 NMAC, General Provisions for Public Assistance Programs .
[8.200.410.6 NMAC - Rp, 8.200.410.6 NMAC, 10/1/2017]
8.200.410.7 DEFINITIONS: [ RESERVED ]
8.200.410.8 MISSION: To transform lives. Working with our partners, we design and deliver innovative, high quality health and human services that improve the security and promote independence for New Mexicans in their communities.
[8.200.410.8 NMAC - A, 1/1/2022]
8.200.410.9 GENERAL RECIPIENT REQUIREMENTS: To be eligible or continue eligibility for medicaid or other medical assistance programs, an applicant or eligible recipient must meet specific non-financial requirements. In addition to the rules in this chapter, refer to 8.100.130 NMAC regarding the following requirements:
A. citizenship or non-citizen status;
B. enumeration;
C. residence;
D. non-concurrent receipt of assistance;
E. applications for other benefits; and
F. assignment of medical support rights.
[8.200.410.9 NMAC - Rp, 8.200.410.9 NMAC, 10/1/2017]
8.200.410.10 USE OF SOCIAL SECURITY NUMBER (42 CFR 435.910): Federal law requires, as a condition of eligibility, that each individual (including children) seeking medicaid furnish each of his or her social security numbers (SSN).
A. HSD will advise the applicant of:
(1) the statute or other authority under which the agency is requesting the applicant's SSN; and
(2) the uses HSD will make of each SSN, including its use for verifying income, eligibility, and amount of medical assistance payments per 42 CFR 435.940 through 435.960.
B. If an applicant cannot recall his or her SSN or SSNs or has not been issued a SSN HSD will:
(1) assist the applicant in completing an application for an SSN;
(2) obtain evidence required under the social security administration (SSA) regulations to establish the age, the citizenship or non-citizen status, and the true identity of the applicant; and
(3) either send the application to SSA or, if there is evidence that the applicant has previously been issued a SSN, request SSA to furnish the number.
C. HSD cannot deny or delay services to an otherwise eligible individual pending issuance or verification of the individual's SSN by SSA or if the individual meets one of the exceptions in Paragraph (5) of Subsection A of 8.200.410.10 NMAC.
D. HSD will verify the SSN furnished by an applicant or beneficiary with SSA to ensure the SSN was issued to that individual, and to determine whether any other SSNs were issued to that individual.
E. Exception:
(1) The requirement of Paragraph (3) of Subsection A of 8.200.410.10 NMAC does not apply and HSD may give a medicaid identification number to an individual who:
(a) is not eligible to receive an SSN;
(b) does not have an SSN and may only be issued an SSN for a valid non-work reason in accordance with 20 CFR 422.104; or
(c) refuses to obtain an SSN because of well-established religious objections.
(2) The identification number may be either an SSN obtained by HSD on the applicant’s behalf or another unique identifier.
(3) The term well established religious objections means that the applicant;
(a) is a member of a recognized religious sect or division of the sect; and
(b) adheres to the tenets or teachings of the sect or division of the sect and for that reason is conscientiously opposed to applying for or using a national identification number.
(4) HSD may use the medicaid identification number established by HSD to the same extent as an SSN is used for purposes described in Subparagraph (b) of Paragraph (1) of Subsection A of 8.200.410.NMAC.
[8.200.410.10 NMAC - Rp, 8.200.410.10 NMAC, 10/1/2017]
8.200.410.11 CITIZENSHIP: To be eligible for medicaid , an individual must be a citizen of the United States; United States national or a non-citizen who meets the requirements set forth in either Subsection A or B of 8.200.410.11 NMAC.
A. Non-citizens who entered the United States prior to August 22, 1996: Non-citizens who entered the United States prior to August 22, 1996, will not be subject to the five-year bar for purposes of medicaid eligibility. These classes of non-citizens are as follows.
(1) Qualified non-citizens who entered the United States prior to August 22, 1996 and obtained their qualified non-citizens status prior to that date, are eligible for medicaid without the five-year waiting period.
(2) Non-citizens who entered the United States prior to August 22, 1996, and remained continuously present in the United States until the date they obtained qualified non-citizen status on or after August 22, 1996; any single absence from the United States of more than 30 days, or a total aggregate of absences of more than 90 days, is considered to interrupt “continuous presence”.
(3) Lawful Permanent Residents (LPRs) are qualified non-citizens per 8 USC 1641.
(4) A non-qualified non-citizen who was permanently residing in the United States under color of law (PRUCOL) on or before August 22, 1996, does not lose medicaid eligibility provided all other factors of eligibility continue to be met. These non-citizens are “grandfathered”. For these individuals, non-citizen eligibility may continue to be based on the PRUCOL standard. An individual eligible under the PRUCOL standard retains his or her grandfathering rights even if benefits terminate.
B. Qualified non-citizens who entered the United States on or after August 22, 1996:
(1) Qualified non-citizens who entered the United States on or after August 22, 1996, are barred from medicaid eligibility for a period of five years, other than emergency services (under Category 085), unless meeting an exception below. LPRs who adjust from a status exempt from the five-year bar are not subject to the five-year bar. The five-year bar begins on the date the non-citizen obtained qualified status. The following classes of qualified non-citizens are exempt from the five-year bar:
(a) a non-citizen admitted to the United States as a refugee under Section 207 of the Immigration and Nationality Act;
(b) a non-citizen granted asylum under Section 208 of the Immigration and Nationality Act;
(c) a non-citizen whose deportation is withheld under Section 243(h) of the Immigration and Nationality Act;
(d) a non-citizen who is lawfully residing in the state and who is a veteran with an honorable discharge not on account of non-citizen status; is on active duty other than on active duty for training, in the armed forces of the United States; or the spouse or unmarried dependent child under the age of 18 of such veteran or active duty non-citizen;
(e) a non-citizen who was granted status as a Cuban and Haitian entrant, as defined in Section 501(e) of the Refugee Education Assistance Act of 1980;
(f) a non-citizen granted Amerasian immigrant status as defined under Section 584 of the Foreign Operations, Export Financing and Related Programs Appropriations Act, 1988;
(g) victims of a severe form of trafficking, in accordance with Paragraph (1) of Subsection B of Section 107 of the Trafficking Victims Protection Act of 2000, P.L. 106-386;
(h) members of a federally recognized Indian tribe, as defined in 25 U.S.C. 450b(e);
( i ) American Indians born in Canada to whom Section 289 of the Immigration and Nationality Act applies;
(j) Afghan and Iraqi special immigrants under Section 8120 of Pub. L. 111-118 of the Department of Defense Appropriations Act, 2010;
(k) non-citizens receiving SSI; and
(l) battered non-citizens who meet the conditions set forth in Section 431(c) of the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) as added by Section 501 of the Illegal Immigration Reform and Immigrant Responsibility Act of 1996, P.L. 104-208 (IIRIRA), and amended by Section 5571 of the Balanced Budget Act of 1997, P.L. 105-33 (BBA), and Section 1508 of the Violence Against Women Act of 200, P.L. 106-386; Section 431(c) of PRWORA, as amended, is codified at 8 USC 1641(c). HSD covers battered non-citizens with state general funds until the five-year bar is met.
(2) Qualified non-citizen: A "qualified non-citizen ", for purposes of this regulation, is a non-citizen, who at the time the non-citizen applies for, receives, or attempts to receive a federal public benefit, is:
(a) a non-citizen who is lawfully admitted for permanent residence under the Immigration and Nationality Act;
(b) a non-citizen who is granted asylum under Section 208 of such act; or
(c) a refugee who is admitted to the United States under Section 207 of the act; or
(d) an Amerasian who is admitted to the United States under Section 207 of the act; or
(e) a non-citizen who is paroled into the United States under Section 212(d)(5) of such act for a period of at least one year; or
(f) a non-citizen whose deportation is being withheld under Section 243(h) of such act or under Section 241(b)(3); or
(g) a non-citizen who is granted conditional entry pursuant to 203(a)(7) or such act as in effect prior to April 1, 1980; or
(h) a non-citizen who is a Cuban or Haitian entrant (as defined in Section 501(e) of the Refugee Education Assistance Act of 1980); or
( i ) certain battered women and non-citizen children of battered parents (only those who have begun the process of becoming a lawful permanent resident under the Violence Against Women Act); or
(j) victims of a severe form of trafficking and their spouses, children, siblings, or parents; or
(k) members of a federally recognized Indian tribe, as defined in 25 U.S.C. 450b(e); or
(l) American Indians born in Canada to whom Section 289 of the Immigration and Nationality Act applies; or
(m) Afghan and Iraqi special immigrants under Section 8120 of Pub. L. 111-118 of the Department of Defense Appropriations Act, 2010.
C. Lawfully present : New Mexico medicaid covers certain individuals who are lawfully residing in the United States. An individual is lawfully residing in the United States if they are lawfully present and otherwise meet the eligibility requirements, such as state residency and income requirements, in the state plan. The following individuals are lawfully present and are exempt from the five-year bar:
(1) Children under age 21 and pregnant individuals under Section 214 of the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA 214 option). A child or pregnant individual is considered lawfully present if they are:
(a) a qualified non-citizen as defined in Section 431 of PRWORA (8 USC Section 1641);
(b) a non-citizen in nonimmigrant status who has not violated the terms of the status under which they were admitted or to which they have changed after admission as defined under 8 USC 1101(a)(15);
(c) a non-citizen who has been paroled into the United States pursuant to Section 212(d)(5) of the Immigration and Nationality Act (8 U.S.C. Section 1182(d)(5)) for less than one year, except for a non-citizen paroled for prosecution, for deferred inspection or pending removal proceedings;
(d) a non-citizen who belongs to one of the following classes:
( i ) non-citizen currently in temporary resident status pursuant to Section 210 or 245A of the Immigration and Nationality Act (8 U.S.C. Section1160 or 1255a, respectively);
(ii) non-citizens granted temporary protected status (TPS) pursuant to Section 244 of the Immigration and Nationality Act (8 U.S.C. Section 1254a), and pending applicants for TPS who have been granted employment authorization;
(iii) non-citizens who have been granted employment authorization under 8 CFR 274a.12(c)(9), (10), (16), (18), (20), (22), or (24);
(iv) family unity beneficiaries pursuant to Section 301 of Pub. L. 101-649, as amended including individuals who are granted benefits under Section 1504 of the Legal Immigration and Family Equity (LIFE) Act amendments of 2000;
(v) non-citizens currently under deferred enforced departure (DED) pursuant to a decision made by the president;
(vi) non-citizens currently in deferred action status except those with deferred action under “deferred action for childhood arrivals” who are not considered lawfully present.
(vii) non-citizens who have pending or approved visa petitions and who have a pending application for adjustment of status;
(e) a non-citizen with pending applicants for asylum under Section 208(a) of the INA (8 U.S.C. Section 1158) or for withholding of removal under Section 241(b)(3) of the INA (8 U.S.C. Section 1231) or under the convention against torture who has been granted employment authorization, or is an applicant under the age of 14;
(f) children who have pending or approved applications for special immigrant juvenile status as described in Section 101(a)(27)(J) of the Immigration and Nationality Act (8 U.S.C. Section1101(a)(27)(J)); or
(g) victims of trafficking.
(2) Effective December 27, 2020, per section 208 of the Consolidated Appropriations Act, 2021 individuals who are considered compact of free association migrants (COFA) are also referred to as compact citizens. COFA is an agreement between the United States and the three Pacific Island sovereign states of federated states of Micronesia, the republic of the Marshall Islands, and the republic of Palau known as freely associated states.
D. The income and resources of a non-citizen sponsor, of any individual applying for medicaid , are deemed available to the applicant, when an affidavit of support is executed pursuant to Section 213 of the Immigration and Nationality Act, on or after August 22, 1996. This counting of non-citizen sponsor income and resources is effective until the sponsored non-citizen achieves citizenship.
E. The state assures that it provides limited medicaid services for treatment of an emergency medical condition, not related to an organ transplant procedure, as defined in 1903(v)(3) of the social security act and 8.285.400 NMAC and implemented at 42 CFR 440.255, to the following individuals who meet all medicaid eligibility requirements, except documentation of citizenship or satisfactory immigration status or present an SSN.
(a) qualified non-citizens subject to the five-year waiting period described in 8 USC 1613; or
(b) non-qualified non-citizens, unless covered as a lawfully residing child or pregnant individual by the state under the option in accordance with 1903(v)(4) and implemented at 42 CFR 435.406(b).
[8.200.410.11 NMAC - Rp, 8.200.410.11 NMAC, 10/1/2017; A/E, 1/18/2018; A, 8/1/2018; A, 1/1/2022; A, 9/1/2024]
8.200.410.12 TYPES OF ACCEPTABLE DOCUMENTARY EVIDENCE OF CITIZENSHIP (42 CFR 435.407):
A . Stand-alone evidence of citizenship: The following must be accepted as sufficient documentary evidence of citizenship:
(1) A U.S. passport, including a U.S. passport card issued by the department of state, without regard to any expiration date as long as such passport or card was issued without limitation.
(2) A certificate of naturalization.
(3) A certificate of U.S. citizenship.
(4) A valid state-issued driver's license if the state issuing the license requires proof of U.S. citizenship, or obtains and verifies a SSN from the applicant who is a citizen before issuing such license.
(a) A real ID issued on or after November 14, 2016 is sufficient documentary evidence of citizenship.
(b) A driver authorization card (DAC) is not sufficient documentary evidence of citizenship.
(5) Documentary evidence issued by a federally recognized Indian tribe identified in the federal register by the bureau of Indian affairs within the U.S. department of the interior, and including tribes located in a state that has an international border, which;
(a) Identifies the federally recognized Indian tribe that issued the document;
(b) Identifies the individual by name; and
(c) Confirms the individual's membership, enrollment, or affiliation with the tribe.
(d) Documents described in Paragraph (5) of Subsection A of 8.200.410.12 NMAC include, but are not limited to:
( i ) A tribal enrollment card;
(ii) A certificate of degree of Indian blood;
(iii) A tribal census document;
(iv) Documents on tribal letterhead, issued under the signature of the appropriate tribal official, that meet the requirements of Paragraph (5) of Subsection A of 8.200.410.12 NMAC.
(6) A data match with the SSA.
B. Evidence of citizenship: If an applicant does not provide documentary evidence from the list in Subsection A of 8.200.410.12 NMAC, the following must be accepted as satisfactory evidence to establish citizenship if also accompanied by an identity document listed in Subsection C of 8.200.410.12 NMAC:
(1) A U.S. public birth certificate showing birth in one of the 50 States, the District of Columbia, Guam, American Samoa, Swain's Island, Puerto Rico (if born on or after January 13, 1941), the Virgin Islands of the U.S. or the Commonwealth of the Northern Mariana Islands (CNMI) (if born after November 4, 1986, (CNMI local time)). The birth record document may be issued by a state, commonwealth, territory, or local jurisdiction. If the document shows the individual was born in Puerto Rico or the Northern Mariana Islands before the applicable date referenced in Paragraph (1) of Subsection B of 8.200.410.12 NMAC, the individual may be a collectively naturalized citizen. The following will establish U.S. citizenship for collectively naturalized individuals:
(a) Puerto Rico: Evidence of birth in Puerto Rico and the applicant's statement that they were residing in the U.S., a U.S. possession, or Puerto Rico on January 13, 1941;
(b) Northern Mariana Islands (NMI) (formerly part of the Trust Territory of the Pacific Islands (TTPI));
( i ) Evidence of birth in the NMI, TTPI citizenship and residence in the NMI, the U.S., or a U.S. Territory or possession on November 3, 1986, (NMI local time) and the applicant's statement that they did not owe allegiance to a foreign state on November 4, 1986 (NMI local time);
(ii) Evidence of TTPI citizenship, continuous residence in the NMI since before November 3, 1981 (NMI local time), voter registration before January 1, 1975, and the applicant's statement that they did not owe allegiance to a foreign state on November 4, 1986 (NMI local time);
(iii) Evidence of continuous domicile in the NMI since before January 1, 1974, and the applicant's statement that they did not owe allegiance to a foreign state on November 4, 1986 (NMI local time). Note: If a person entered the NMI as a nonimmigrant and lived in the NMI since January 1, 1974, this does not constitute continuous domicile and the individual is not a U.S. citizen.
(2) A certification of report of birth, issued to U.S. citizens who were born outside the U.S.
(3) A report of birth abroad of a U.S. citizen.
(4) A certification of birth in the U.S.
(5) A U.S. citizen identification card.
(6) A Northern Marianas identification card issued by the U.S. department of homeland security (or predecessor agency).
(7) A final adoption decree showing the child's name and U.S. place of birth, or if an adoption is not final, a statement from a state-approved adoption agency that shows the child's name and U.S. place of birth.
(8) Evidence of U.S. civil service employment before June 1, 1976.
(9) U.S. military record showing a U.S. place of birth.
(10) A data match with the Systematic Alien Verification for Entitlements (SAVE) Program or any other process established by the department of homeland security (DHS) to verify that an individual is a citizen.
(11) Documentation that a child meets the requirements of section 101 of the Child Citizenship Act of 2000 as amended (8 U.S.C. 1431).
(12) Medical records, including, but not limited to, hospital, clinic, or doctor records or admission papers from a nursing facility, skilled care facility, or other institution that indicate a U.S. place of birth.
(13) Life, health, or other insurance record that indicates a U.S. place of birth.
(14) Official religious record recorded in the U.S. showing that the birth occurred in the U.S.
(15) School records, including pre-school, head start and daycare, showing the child's name and U.S. place of birth.
(16) Federal or state census record showing U.S. citizenship or a U.S. place of birth.
(17) If the applicant does not have one of the documents listed in Subsection A or Paragraph (1) through (17) of Subsection B of 8.200.410.12 NMAC, they may submit an affidavit signed by another individual under penalty of perjury who can reasonably attest to the applicant's citizenship, and that contains the applicant's name, date of birth, and place of U.S. birth. The affidavit does not have to be notarized.
C. Evidence of identity:
(1) HSD will accept the following as proof of identity, provided such document has a photograph or other identifying information sufficient to establish identity, including, but not limited to, name, age, sex, race, height, weight, eye color, or address:
(a) Identity documents listed at 8 CFR 274a.2 (b)(1)(v)(B)(1), except a driver's license issued by a Canadian government authority.
(b) Driver's license issued by a state or territory.
(c) School identification card.
(d) U.S. military card or draft record.
(e) Identification card issued by the federal, state, or local government.
(f) Military dependent's identification card.
(g) U.S. coast guard merchant mariner card.
(h) For children under age 19, a clinic, doctor, hospital, or school record, including preschool or day care records.
( i ) Two other documents containing consistent information that corroborates an applicant's identity. Such documents include, but are not limited to, employer identification cards; high school, high school equivalency and college diplomas; marriage certificates; divorce decrees; and property deeds or titles.
(2) Finding of identity from a federal or state governmental agency. The agency may accept as proof of identity a finding of identity from a federal agency or another state agency including but not limited to a public assistance, law enforcement, internal revenue or tax bureau, or corrections agency, if the agency has verified and certified the identity of the individual.
(3) If the applicant does not have any document specified in Paragraph (1) of Subsection C of 8.200.410.12 NMAC and identity is not verified under Paragraph (2) of Subsection C of 8.200.410.12 NMAC, the agency must accept an affidavit signed, under penalty of perjury, by a person other than the applicant who can reasonably attest to the applicant's identity. Such affidavit must contain the applicant's name and other identifying information establishing identity, as described in Paragraph (1) of Subsection C of 8.200.410.12 NMAC. The affidavit does not have to be notarized.
D. Verification of citizenship by a federal agency or another state: HSD may rely, without further documentation of citizenship or identity, on a verification of citizenship made by a federal agency or another state agency, if such verification was done on or after July 1, 2006.
E. Assistance with obtaining documentation : HSD will provide assistance to individuals who need assistance in securing satisfactory documentary evidence of citizenship in a timely manner.
F. Documentary evidence: A photocopy, facsimile, scanned or other copy of a document must be accepted to the same extent as an original document under this section, unless information on the copy submitted is inconsistent with other information available to HSD or HSD otherwise has reason to question the validity of, or the information in, the document.
[8.200.410.12 NMAC - N, 10/1/2017; A, 1/1/2022; A, 9/1/2024]
8.200.410.13 REASONABLE OPPORTUNITY PERIOD (42 CFR 435.956(b)):
A. HSD provides a reasonable opportunity period to individuals who have made a declaration of citizenship or satisfactory immigration status in accordance with 42 CFR 435.406, and for whom the HSD is unable to verify citizenship or satisfactory immigration status. During the reasonable opportunity period, the HSD continues efforts to complete verification of the individual's citizenship or satisfactory immigration status, or request documentation if necessary. The HSD provides notice of such opportunity that is accessible to persons who have limited English proficiency and individuals with disabilities, consistent with 42 CFR 435.905(b). During such reasonable opportunity period, the HSD must, if relevant to verification of the individual's citizenship or satisfactory immigration status:
(1) in the case of individuals declaring citizenship who do not have an SSN at the time of such declaration, assist the individual in obtaining an SSN in accordance with 42 CFR 435.910 and Paragraph (2) of Subsection A of 8.200.410.10 NMAC, and attempt to verify the individual's citizenship once an SSN has been obtained and verified;
(2) provide the individual with information on how to contact the electronic data source so that they can attempt to resolve any inconsistencies defeating electronic verification directly with such source, and pursue verification of the individual's citizenship or satisfactory immigration status if the individual or source informs the HSD that the inconsistencies have been resolved; and
(3) provide the individual with an opportunity to provide other documentation of citizenship or satisfactory immigration status, in accordance with section 1137(d) of the Act and 42 CFR 435.406 or 435.407 and 8.200.410.12 NMAC.
B. The reasonable opportunity period:
(1) begins on the date on which the notice is received by the individual. The date on which the notice is received is considered to be five days after the date on the notice, unless the individual shows that they did not receive the notice within the five-day period; and
(2) ends on the earlier of the date the HSD verifies the individual's citizenship or satisfactory immigration status or determines that the individual did not verify his or her citizenship or satisfactory immigration status or 90 days except that;
(3) HSD extends the reasonable opportunity period beyond 90 days, allowing for up to three 10 day extensions, for individuals declaring to be in a satisfactory immigration status if the HSD determines that the individual is making a good faith effort to obtain any necessary documentation or the agency needs more time to verify the individual's status through other available electronic data sources or to assist the individual in obtaining documents needed to verify his or her status.
(4) if, by the end of the reasonable opportunity period, the individual's citizenship or satisfactory immigration status has not been verified the HSD will take action within 30 days to terminate eligibility.
[8.200.410.13 NMAC - N, 10/1/2017; A, 9/1/2024]
8.200.410.14 RESIDENCE: To be eligible for medicaid , an applicant or eligible recipient must be living in New Mexico on the date of application and final determination of eligibility and have demonstrated an intention to remain in the state.
A. Establishing residence: Residence is established by living in the state and carrying out the types of activities associated with day-to-day living, such as occupying a home, enrolling a child in school or getting a state driver’s license. An applicant or recipient who is homeless is considered to have met the residence requirements if they intend to remain in the state.
B. Recipients receiving benefits out-of-state: An applicant or an eligible recipient who receives financial or medical assistance in another state which makes residence in that state a condition of eligibility are considered residents of that state until the ISD office receives verification from the other state agency indicating that it has been notified by an applicant or eligible recipient of the abandonment of residence in that state.
C. Individuals court ordered into full or partial responsibility of the state children youth and families department (CYFD): When CYFD places a child in a new state of residence, the new state of residence is responsible for the provision of medicaid ; however, the state must provide limited medicaid coverage for medicaid services that are part of the state medicaid benefit package and not available in the new state of residence.
D. Abandonment: Residence is not abandoned by temporary absences. Temporary absences occur when an eligible recipient leaves the state for specific purposes with time-limited goals. Residence is considered abandoned when the applicant or the eligible recipient leaves the state for any of the following reasons:
(1) intends to establish residence in another state;
(2) for no specific purpose with no clear intention of returning;
(3) applies for financial, food or medical assistance in another state which makes residence in that state a condition of eligibility; or
(4) for more than 30 consecutive calendar days, without notifying HSD of his or her departure or intention of returning.
E. Evidence of immigration status may not be used to determine that an individual is not a state resident per 42 CFR 435.956 (c)(2).
[8.200.410.14 NMAC - Rp, 8.200.410.12, 10/1/2017; A, 9/1/2024]
8.200.410.15 NON-CONCURRENT RECEIPT OF ASSISTANCE:
A. An applicant or an eligible recipient receiving medicaid in another state is not medical assistance program eligible in New Mexico except when:
(1) institutional care medicaid begins on a specific date within the month rather than automatically reverting to the first day of the month, if an applicant for institutional care medicaid (Category 081, 083 or 084) moves to New Mexico from another state and it can be verified that the other state will terminate the individual’s medicaid eligibility under that state program prior to the initial eligibility date in New Mexico, the application may be approved even though the individual receives medicaid from the other state for part of the month; coverage in New Mexico begins after the end date of services from the other state;
(2) an individual is court ordered into full or partial responsibility CYFD; when CYFD places a child in a new state of residence, the new state of residence is responsible for the provision of medicaid ; however, New Mexico must provide limited medicaid coverage for medicaid services that are part of New Mexico’s medicaid benefit package and not available in the new state of residence.
B. An individual who is eligible for a full-coverage medicaid program may also be eligible for one of the medicare cost sharing medical assistance program categories. See 8.200.400 NMAC.
C. When a supplemental security income (SSI) recipient enters into a nursing home or hospital (institutionalized), SSA will re-evaluate SSI and related medicaid eligibility.
(1) When SSA determines that the individual remains eligible for SSI while institutionalized, the SSI benefit is adjusted as follows:
(a) if institutionalized for more than 90 calendar days - the SSI benefit is limited to thirty ($30) a month; or
(b) if institutionalized for 90 calendar days or less - the SSI benefit continues at the regular amount.
(2) When SSA determines that the individual is not eligible for SSI, the individual or his or her authorized representative should file an application at HSD for institutional care medicaid . If the individual meets all factors of eligibility, approval of the institutional care medicaid application should be coordinated with the SSI closure date. If eligible, there will not be a break in eligibility and the individual shall not receive both SSI and institutional care medicaid in the same month pursuant to 8.281.400.10 NMAC.
[8.200.410.15 NMAC - Rp, 8.200.410.13, 10/1/2017]
8.200.410.16 APPLICATIONS FOR OTHER BENEFITS: As a condition of eligibility, a medicaid applicant or an eligible recipient must take all necessary steps to obtain any annuities, pensions, retirement, and disability benefits to which they are entitled, within 30 calendar days from the date HSD furnishes notice of the potential benefit, unless they can show good cause for not doing so.
A. Benefit types: Annuities, pensions, retirement and disability benefits include, but are not limited to, veterans' compensation and pensions, old age survivors and disability insurance (OASDI) benefits, railroad retirement benefits, and unemployment compensation.
B. Exceptions to general requirement/good cause: An individual may request a good cause waiver to this requirement by presenting ISD with corroborating evidence that:
(1) applying for other benefits is against the best interest of the individual, child or others, including physical or emotional harm to a child, parent or caregiver relative, adoption proceedings, and potential for emotional impairment; or
(2) exceptions applicable to institutional care medicaid , the SSI-related categories and the home and community based waivers are pursuant to Subsection B of 8.215.500.9 NMAC, Subsection B of 8.281.500.9 NMAC, and Subsection B of 8.290.500.9 NMAC.
C. Failure to apply for and take steps to determine eligibility for other benefits: When the parent(s) or where applicable the specified relative fails or refuses to apply for and take steps to determine eligibility within 30 calendar days from the date HSD furnishes notice of the potential benefit, the parent(s) or specified relative is not eligible for medicaid . An eligible recipient under the age of 18 years shall not lose his or her medicaid eligibility under this provision.
[8.200.410.16 NMAC - Rp, 8.200.410.14, 10/1/2017]
8.200.410.17 INMATE IN A PUBLIC INSTITUTION:
A. A public institution is a:
(1) state and private correctional facility;
(2) county and privately operated jail;
(3) department of health behavioral health facility forensic unit;
(4) detention facility operated under the authority of CYFD; or
(5) facility that is operated under the authority of CYFD that provides for the care and rehabilitation of an individual who is under 18 years of age and who has committed an act that would be designated as a crime under the law if committed by an individual who is 18 years of age or older.
B. An inmate is a person incarcerated in a public institution listed in Subsection A of 8.200.410.15 NMAC for 30 or more days.
C. An inmate who is incarcerated in a public institution is not eligible for MAP services. The only exception are those services provided to an inmate while they are an inpatient in a medical facility outside the public institution for 24 hours or longer.
D. Incarceration in a public institution is not a basis for denying or terminating a MAP category of eligibility. During the time of incarceration an inmate may apply or recertify for a MAP category of eligibility.
[8.200.410.17 NMAC - Rp, 8.200.410.15, 10/1/2017; A, 9/1/2024]
8.200.410.18 AUTOMATIC ENROLLMENT INTO MEDICARE PART B COVERAGE:
A. Beginning August 1, 2019, HSD automatically enrolls into medicare part B individuals:
(1) who are active on a full medicaid or medicare savings program category of eligibility with the exception of the following categories:
(a) other adults (COE 100);
(b) newborn (COE 031);
(c) children, youth and families department medicaid categories (COEs 017, 037, 046, 047, 066, and 086);
(d) family planning (COE 029);
(e) pregnancy services (COE 301);
(f) refugee (COE 049 and 059);
(g) qualified disabled working individuals (COE 050);
(h) breast and cervical cancer (COE 052); and
(2) who are enrolled in medicare part A and eligible for and not enrolled in medicare part B.
B. HSD informs applicants and recipients in writing who may be eligible for automatic enrollment into medicare part B. HSD will automatically enroll eligible individuals into medicare part B regardless of whether general or open enrollment of medicare part B is allowed under federal law at the time an individual is approved for medicaid .
[8.200.410.18 NMAC - N, 8/1/2019]
HISTORY OF 8.200.410 NMAC:
History of Repealed Material:
8.200.410 NMAC, General Recipient Requirements, filed 6/11/2003 - Repealed effective 1/1/2014.
8.200.410 NMAC, General Recipient Requirements, filed 12/2/2013 - Repealed effective 10/1/2017.
NMAC History:
8.200.410 NMAC, General Recipient Requirements, filed 12/2/2013 was replaced by 8.200.410 NMAC, General Recipient Requirements effective 10/1/2017.
TITLE 8 SOCIAL SERVICES
CHAPTER 200 MEDICAID ELIGIBILITY - GENERAL RECIPIENT RULES
PART 420 SPECIAL RECIPIENT REQUIREMENTS
8.200.420.1 ISSUING AGENCY: New Mexico Health Care Authority.
[8.200.420.1 NMAC - Rp, 8.200.420.1 NMAC, 1/1/2014 ; A,7/1/2024]
8.200.420.2 SCOPE: The rule applies to the general public .
[8.200.420.2 NMAC - Rp, 8.200.420.2 NMAC, 1/1/2014]
8.200.420.3 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.
[8.200.420.3 NMAC - Rp, 8.200.420.3 NMAC, 1/1/2014; A, 7/1/2024]
8.200.420.4 DURATION: Permanent.
[8.200.420.4 NMAC - Rp, 8.200.420.4 NMAC, 1/1/2014]
8.200.420.5 EFFECTIVE DATE: January 1, 2014, unless a later date is cited at the end of a section.
[8.200.420.5 NMAC - Rp, 8.200.420.5 NMAC, 1/1/2014]
8.200.420.6 OBJECTIVE: The objective of this rule is to provide specific instructions when determining eligibility for the medicaid program and other health care programs. Generally, applicable eligibility rules are detailed in the medical assistance division (MAD) eligibility policy manual, specifically 8.200.400 NMAC, General Medicaid Eligibility . Processes for establishing and maintaining MAD eligibility are detailed in the income support division (ISD) general provisions 8.100 NMAC, General Provisions for Public Assistance Programs .
[8.200.420.6 NMAC - Rp, 8.200.420.6 NMAC, 1/1/2014]
8.200.420.7 DEFINITIONS: [ RESERVED ]
8.200.420.8 MISSION: 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.
[8.200.420.8 NMAC - Rp, 8.200.420.8 NMAC, 1/1/2014]
8.200.420.9 AGE: For certain medicaid categories, an individual must meet specified age requirements. See specific NMAC eligibility chapters for each medicaid category for age requirements.
[8.200.420.9 NMAC - Rp, 8.200.420.9 NMAC, 1/1/2014]
8.200.420.10 SCHOOL ATTENDANCE: School attendance is a factor in determining JUL medicaid eligibility for 18 year-old applicants or re-determining recipients. School attendance is not a factor in determining JUL medicaid for children under the age of 18 years.
[8.200.420.10 NMAC - Rp, 8.200.420.10 NMAC, 1/1/2014]
8.200.420.11 DISABILITY: For an individual applying for a specific medical assistance division (MAD) category of eligibility, disability is a condition of eligibility. The determination of disability is made by the disability determination services unit. The social security administration's (SSA) definition of disability is used for that determination.
[8.200.420.11 NMAC - Rp, 8.200.420.11 NMAC 1/1/2014]
8.200.420.12 THIRD PARTY LIABILITY: Refer to 8.200.430.13 NMAC.
[8.200.420.12 NMAC - Rp, 8.200.420.12 NMAC, 1/1/2014]
8.200.420.13 MEDICAID ESTATE RECOVERY: Refer to 8.200.430.20 NMAC.
[8.200.420.13 NMAC - Rp, 8.200.420.13 NMAC, 1/1/2014]
HISTORY 8.200.420 NMAC:
Pre-NMAC History: The material in this part was derived from that previously filed with the State Records Center:
ISD 304.1000, Provider Reimbursement Responsibility, filed 1/17/1980.
ISD 304.1000, Provider Reimbursement Responsibility, filed 9/8/1981.
ISD 304.2000, Recipient Reimbursement Responsibility, filed 1/9/1980.
ISD 304.3000, Reimbursement Limitations, filed 1/17/1980.
ISD 304.3000, Reimbursement Limitations, filed 9/8/1981.
ISD Rule 304.3000, Reimbursement Limitations, filed 12/17/1985.
ISD 304.4000, Billing Limitations, filed 1/17/1980.
ISD 304.4000, Billing Limitations, filed 9/8/1981.
ISD 304.7000, Reimbursement To Out-Of-State Providers, filed 1/17/1980.
ISD 304.7000, Reimbursement To Out-Of-State Providers, filed 9/8/1981.
ISD 304.8000, Third Party Liability, filed 1/17/1980.
ISD 304.8000, Third Party Liability, filed 9/8/1981.
ISD 304.9000, Usual And Customary, filed 1/17/1980.
ISD 304.9000, Reasonable Charge Pricing, filed 9/8/1981.
ISD Rule 304.9000, Reasonable Charge Pricing, filed 2/17/1984.
ISD Rule 304.9000, Reasonable Charge Pricing, filed 3/30/1984.
MAD Rule 304.9, Reimbursement, filed 12/15/1987.
MAD Rule 304.9, Reimbursement, filed 8/11/1988.
MAD Rule 304, Billing And Reimbursement, filed 11/8/1989.
MAD Rule 304, Billing And Reimbursement, filed 4/21/1992.
History of Repealed Material:
8.200.420 NMAC, Special Recipient Requirements, filed 6/13/2001 - Repealed effective 1/1/2014.
TITLE 8 SOCIAL SERVICES
CHAPTER 200 MEDICAID ELIGIBILITY - GENERAL RECIPIENT RULES
PART 430 RECIPIENT RIGHTS AND RESPONSIBILITIES
8.200.430.1 ISSUING AGENCY: Health Care Authority (HCA).
[8.200.430.1 NMAC - Rp, 8.200.430.1 NMAC, 1/1/2014; A, 11/1/2024]
8.200.430.2 SCOPE: The rule applies to the general public .
[8.200.430.2 NMAC - Rp, 8.200.430.2 NMAC, 1/1/2014]
8.200.430.3 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 Section 27-1-12 et seq., NMSA 1978.
[8.200.430.3 NMAC - Rp, 8.200.430.3 NMAC, 1/1/2014]
8.200.430.4 DURATION: Permanent.
[8.200.430.4 NMAC - Rp, 8.200.430.4 NMAC, 1/1/2014]
8.200.430.5 EFFECTIVE DATE: January 1, 2014, unless a later date is cited at the end of a section.
[8.200.430.5 NMAC - Rp, 8.200.430.5 NMAC, 1/1/2014]
8.200.430.6 OBJECTIVE: The objective of this rule is to provide specific instructions when determining eligibility for the medicaid program and other health care programs. Generally, applicable eligibility rules are detailed in the medical assistance division (MAD) eligibility policy manual, specifically 8.200.400 NMAC, General Medicaid Eligibility . Processes for establishing and maintaining MAD eligibility are detailed in the income support division (ISD) general provisions 8.100 NMAC, General Provisions for Public Assistance Programs .
[8.200.430.6 NMAC - Rp, 8.200.430.6 NMAC, 1/1/2014]
8.200.430.7 DEFINITIONS: [RESERVED]
8.200.430.8 [RESERVED]
[8.200.430.8 NMAC - N, 1/1/2014; A, 10/1/2017]
8.200.430.9 RECIPIENT RIGHTS AND RESPONSIBILITIES:
A. An individual has the right to apply for medicaid and other health care programs HCA administers regardless of whether it appears they may be eligible.
(1) Income support division (ISD) determines eligibility for the medical assistance division’s medical assistance programs (MAP), unless otherwise determined by another entity as stated in 8.200.400 NMAC. A decision shall be made promptly on applications in accordance with the timeliness standards set forth in 8.100.130 NMAC.
(2) Individuals who might be eligible for supplemental security income (SSI) are referred to the social security administration (SSA) office to apply.
B. Application: A paper or electronic application is required from the applicant, an authorized representative, or, if the applicant is incompetent or incapacitated, someone acting responsibly for the applicant. The applicant may complete a joint MAP, cash assistance, supplemental nutrition assistance program (SNAP) and low income home energy assistance (LIHEAP) application or a MAP-only application.
(1) The following do not require an application unless a re-determination is due in that month or the following month, as applicable:
(a) switching from one of the medical assistance for women, children (MAWC) and families MAP categories to another;
(b) switching between medicaid and refugee medical assistance; and
(c) switching to or from one of the long term care medicaid categories.
(2) Medicare savings programs (MSP):
(a) A MAP eligible recipient receiving full benefits is automatically deemed eligible for MSP when they receive free medicare Part-A hospital insurance; the eligible recipient does not have to apply for medicare MSP;
(b) When an individual is not eligible for free medicare Part A hospital insurance, a separate application for the MAP qualified medicare beneficiary (QMB) eligibility category 040 is required. Individuals must apply for medicare Part A with the SSA. This is called, “conditional Part A” because they will receive medicare Part A on the condition that the MAP QMB category of eligibility is approved. When QMB is approved, the cost of the premium for Part A will be covered by MAD.
C. Responsibility in the application or recertification process: The applicant or the re-determining eligible recipient is responsible for providing verification of eligibility. Refer to 8.100.130 NMAC.
(1) An applicant or an eligible recipient's failure to provide necessary verification results in MAP ineligibility.
(2) An applicant or a re-determining eligible recipient must give HCA permission to contact other individuals, agencies, or sources of information which are necessary to establish eligibility.
[8.200.430.9 NMAC - Rp, 8.200.430.9 NMAC, 1/1/2014; A, 10/15/2014; A, 11/1/2024]
8.200.430.10 FREEDOM OF CHOICE: Except when specifically waived from MAD, an eligible recipient has the freedom to obtain physical and behavioral health services from a MAD provider of their choice.
[8.200.430.10 NMAC - Rp, 8.200.430.10 NMAC, 1/1/2014; A, 10/15/2014; A, 11/1/2024]
8.200.430.11 RELEASE OF INFORMATION: By signing the MAP application, an applicant or a re-determining eligible recipient gives HCA explicit consent to release information to applicable state or federal agencies, physical or behavioral health providers, or an HCA designee when the information is needed to provide, monitor, or approve MAD services. Physical and behavioral health information is confidential and is subject to the standards for confidentiality per 8.300.11 NMAC.
[8.200.430.11 NMAC - Rp, 8.200.430.11 NMAC, 1/1/2014; A, 10/15/2014; A, 11/1/2024]
8.200.430.12 RIGHT TO HEARING: An applicant or an eligible recipient is entitled to adequate notice of a HCA adverse action regarding their termination or re-categorization of their MAP category of eligibility. The applicant or re-determining eligible recipient has specific rights and responsibilities when requesting a HCA administrative hearing. A HCA administrative hearing affords the applicant or re-determining eligible recipient the opportunity to have an impartial review of these decisions. See 8.352.2, 8.100.180 and 8.100.970 NMAC for a detailed description of these rights, responsibilities and the HCA administrative hearing process. 8.352.2 NMAC further details the rights, responsibilities and the HCA administrative hearing process for other adverse actions MAD, its utilization review contractor or a HCA contracted managed care organization (MCO) may initiate (42 CFR Section 431.220(a)(1)(2)).
[8.200.430.12 NMAC - Rp, 8.200.430.12 NMAC, 1/1/2014; A, 10/15/2014; A, 11/1/2024]
8.200.430.13 ASSIGNMENT OF SUPPORT: As a condition of MAP eligibility, HCA requires an applicant or a re-determining eligible recipient to assign their medical care support rights to HCA for medical support and any third party payments. The assignment authorizes HCA to pursue and make recoveries from liable third parties (42 CFR 433.146; Subsection G of 27-2-28 NMSA 1978.
A. Assigning medical support rights : The assignment to HCA of an eligible recipient’s rights to medical support and payments occurs automatically under New Mexico law when the applicant or the re-determining eligible recipient signs the application.
B. Third party liability (TPL): This section describes HCA’s responsibility to identify and collect from primarily responsible third parties and the eligible recipient’s responsibility to cooperate with HCA to uncover such payments. MAD is the payer of last resort. If other third party resources are available, these health care resources must be used before MAD makes a reimbursement . As a condition of MAP eligibility, an applicant assigns their rights to physical and behavioral health support and payments to HCA and promises to cooperate in identifying, pursuing, and collecting payments from these resources. Third party resources include the gross recovery by eligible recipient, including personal injury protection benefits, before any reduction in attorney’s fees or costs, obtained through settlement or verdict, for personal injury negligence or intentional tort claims or actions, up to the full amount of MAD payments for treatment of injuries causally related to the occurrence that is the subject of the claim or action.
(1) Required TPL information: During the initial determination or re-determination of eligibility for MAP enrollment, ISD must obtain information about TPL from either the applicant or the re-determining eligible recipient.
(a) HCA is required to take all reasonable measures to determine the legal liability of third parties, including health insurers in paying for the physical and behavioral health services furnished to an eligible recipient (42 CFR 433.138(a)).
(b) HCA uses the information collected at the time of determination in order for MAD to pursue claims against third parties.
(2) Availability of health insurance: If an applicant or an eligible recipient has health insurance, the applicant or the eligible recipient shall notify ISD. ISD must collect all relevant information, including name and address of the insurance company; individuals covered by the policy, effective dates, covered services, and appropriate policy numbers.
(a) An applicant or an eligible recipient with health insurance coverage or coverage by a health maintenance organization (HMO) or other managed care plan (plan) must be given a copy of the TPL recipient information letter.
(b) If there is an absent parent, ISD may request the absent parent's name and social security number (SSN).
(c) ISD must determine if an absent parent, relative, applicant or any member of the household is employed and has health insurance coverage.
(3) Eligible recipients with health insurance coverage: An applicant or an eligible recipient must inform their MAD providers of their TPL. An applicant or an eligible recipient must report changes to or terminations of insurance coverage to ISD. If an applicant or an eligible recipient has health coverage through an HMO or plan, payment from MAD is limited to applicable copayments required under the HMO or plan and to MAD covered services documented in writing as exclusions by the HMO or plan.
(a) If the HMO or plan uses a drug formulary, the medical director of the HMO or plan must sign and attach a written certification for each drug claim to document that a pharmaceutical product is not covered by the HMO or plan. The signature is a certification that the HMO or plan drug formulary does not contain a therapeutic equivalent that adequately treats the physical or behavioral health condition of the HMO or plan subscriber.
(b) Physical and behavioral health services not included in the HMO or plan are covered by MAD only after review of the documentation and on approval by MAD.
(c) An applicant or an eligible recipient covered by an HMO or plan is responsible for payment of medical services obtained outside the HMO or plan and for medical services obtained without complying with the rules or policies of the HMO or plan.
(d) An applicant or an eligible recipient living outside an HMO or plan coverage area may request a waiver of the requirement to use HMO or plan providers and services. The applicant or the eligible recipient for whom a coverage waiver is approved by MAD may receive reimbursement for expenses which allow them to travel to an HMO or plan participating provider, even when the provider is not located near the applicant or the eligible recipient's residence.
(4) Potential health care resources: ISD must evaluate the presence of a TPL source if certain factors are identified during the MAD eligibility interview.
(a) When the age of the applicant or the eligible recipient is over 65 years old medicare must be explored. A student, especially a college student, may have health or accident insurance through their school.
(b) An application on behalf of deceased individual must be examined for "last illness" coverage through a life insurance policy.
(c) Certain specific income sources are indicators of possible TPL which include:
( i ) railroad retirement benefits and social security retirement or disability benefits indicating eligibility for Title XVIII ( medicare ) benefits;
(ii) workers' compensation (WC) benefits paid to employees who suffer an injury or accident caused by conditions arising from employment; these benefits may compensate employees for physical and behavioral health expenses and lost income; payments for physical and behavioral health expenses may be made as physical and behavioral health bills are incurred or as a lump sum award;
(iii) black lung benefits payable under the coal mine workers' compensation program, administered by the federal department of labor (DOL), can produce benefits similar to railroad retirement benefits if the treatment for illness is related to the diagnosis of pneumoconiosis; beneficiaries are reimbursed only if services are rendered by specific providers, authorized by the DOL; black lung payments are made monthly and physical and behavioral health expenses are paid as they are incurred; and
(iv) Title IV-D support payments or financial support payments from an absent parent may indicate the potential for physical and behavioral health support; if a custodial party does not have health insurance that meets a minimum standard, the court in a divorce, separation or custody and support proceeding may order the parent(s) with the obligation of support to purchase insurance for the eligible recipient child (45 CFR 303.31(b)(1); Paragraph (1) of Subsection A of Section 40-4C-4 NMSA 1978; insurance can be obtained through the parent's employer or union (Paragraph (2) of Subsection A of Section 40-4C-4 NMSA 1978; parents may be ordered to pay all or a portion of the physical and behavioral health expenses; for purposes of physical l and behavioral health support, the minimum standards of acceptable coverage, deductibles, coinsurance, lifetime benefits, out-of-pocket expenses, co-payments, and plan requirements are the minimum standards of health insurance policies and managed care plans established for small businesses in New Mexico; see New Mexico insurance code.
(d) An a pplicant or an eligible recipient has earned income: Earned income may indicate physical, behavioral health and health insurance made available by an employer.
(e) Work history or military services: Work history may indicate eligibility for other cash and physical and behavioral benefits. Previous military service suggests the potential for veterans administration (VA) or department of defense (DOD) health care, including the civilian health and the medical program of the United States (CHAMPUS), for individuals who reside within a 40-mile radius of a military health care facility. An applicant or an eligible recipient who is eligible for DOD health care must obtain certification of non-availability of medical services from the base health benefits advisor in order to be eligible for CHAMPUS.
(f) A n applicant or an eligible recipient's expenses show insurance premium payments: Monthly expense information may show that the applicant or the eligible recipient pays private insurance premiums or is enrolled in an HMO or plan.
(g) The applicant or the eligible recipient has a disability: Disability information contained in applications or brought up during interviews may indicate casualties or accidents involving legally responsible third parties.
(h) T he applicant or the eligible recipient has a chronic disease: Individuals with chronic renal disease are probably entitled to medicare . Applications for social security disability may be indicative of medicare coverage.
(5) C ommunicating TPL information: Information concerning health insurance or health plans is collected and transmitted to MAD by ISD, child support enforcement division (CSED), SSA, and the children, youth and families department (CYFD).
[8.200.430.13 NMAC - Rp, 8.200.430.13 NMAC, 1/1/2014; A, 10/15/2014; A, 11/1/2024]
8.200.430.14 ELIGIBLE RECIPIENT RESPONSIBILITY TO COOPERATE WITH ASSIGNMENT OF SUPPORT RIGHTS:
A. Cooperation: As a condition of MAP eligibility, an applicant or an eligible recipient must cooperate with HCA to:
(1) obtain physical and behavioral health support and payments for them and other individuals for whom they can legally assign rights;
(2) pursue liable third parties by identifying individuals and providing information to HCA;
(3) cooperate with CSED to establish paternity and medical support as appropriate, see 8.50.105.12 NMAC;
(4) appear at a state or local office designated by HCA to give information or evidence relevant to the case, appear as a witness at a court or other proceeding or give information or attest to lack of information, under penalty of perjury;
(5) refund HCA any money received for physical or behavioral health care that has already been paid; this includes payments received from insurance companies, personal injury settlements, and any other liable third party; and
(6) respond to the trauma inquiry letter that is mailed to an eligible recipient (42 CFR 433.138(4); the letter asks an eligible recipient to provide more information about possible accidents, causes of accidents, and whether legal counsel has been obtained (42 CFR 433.147; 45 CFR 232.42, 232.43; Paragraph (3) of Subsection G of Section 27-2-28 NMSA 1978.
B. Good cause waiver of cooperation: The requirements for cooperation may be waived by HCA if it decides that the applicant or the eligible recipient has good cause for refusing to cooperate. Waivers can be obtained for cooperating with CSED. The applicant or the eligible recipient should request a good cause waiver from CSED per 8.50.105.14 NMAC.
C. Penalties for failure to cooperate:
(1) When the parent, the specified relative or legal guardian fails or refuses to cooperate, the parent or specified relative will not be eligible for MAD services. The eligible recipient child maintains MAP eligibility provided all other eligibility criteria are met.
(2) When the parent or the specified relative fails or refuses to refund payments received from insurance or other settlement sources, such as personal injury case awards, they are not eligible for MAD services for one year and until full restitution has been made to HCA. The eligible recipient child maintains MAP eligibility provided all other eligibility criteria are met.
[8.200.430.14 NMAC - Rp, 8.200.430.14 NMAC, 1/1/2014; A, 10/15/2014; A, 11/1/2024]
8.200.430.15 ELIGIBLE RECIPIENT RESPONSIBILITY TO GIVE PROVIDER PROPER IDENTIFICATION AND NOTICE OF ELIGIBILITY CHANGES:
A. An eligible recipient is responsible for presenting a current MAP eligibility card and evidence of any other health insurance to a MAD provider each time service is requested.
(1) An eligible recipient is responsible for any financial liability incurred if they fail to furnish current MAP eligibility identification before the receipt of a service and as a result the provider fails to adhere to MAD rules, such as a failure to request prior approval. If this omission occurs, the settlement of claims for services is between the eligible recipient and the provider. An individual is financially responsible for services received if they were not eligible for MAD services on the date services are furnished.
(2) When a provider bills MAD and the claim is denied, the provider cannot bill the eligible recipient. Exceptions exist for denials caused by MAP ineligibility or by an eligible recipient's failure to furnish MAP identification in a timely manner.
(3) If an eligible recipient fails to notify the provider that they have received services that are limited by time or amount, the eligible recipient is responsible for payment of the service prior to rendering the service if the provider made reasonable efforts to verify whether the eligible recipient has already received services.
B. Notification of providers following retroactive eligibility determinations: If an eligibility determination is made, the eligible recipient is responsible for notifying MAD providers of this eligibility determination. When an individual receives retro MAP eligibility, the now-eligible recipient must notify all of their MAD providers of their change of eligibility. If the eligible recipient fails to notify the provider and the provider can no longer file a claim for reimbursement, the eligible recipient becomes the responsible payer for those services.
C. Notification if an eligible recipient has private insurance: If an eligible recipient is covered under a private health insurance policy or health plan, they are required to inform their MAD providers of the private health coverage, including applicable policy numbers and special claim forms.
[8.200.430.15 NMAC - Rp, 8.200.430.15 NMAC, 1/1/2014; A, 10/15/2014; A, 11/1/2024]
8.200.430.16 ELIGIBLE RECIPIENT FINANCIAL RESPONSIBILITIES:
A. A MAD provider agrees to accept the amount paid as payment in full. A provider cannot bill an eligible recipient for any unpaid portion of the bill (balance billing) or for a claim that is not paid because of a provider administrative error or failure of multiple providers to communicate eligibility information.
(1) An eligible recipient is responsible for any financial liability incurred if they fail to furnish current MAP eligibility identification before the receipt of a MAP service and as a result the provider fails to adhere to MAD reimbursement rules, such as a failure to request prior approval. If this omission occurs, the settlement of claims for services is between the eligible recipient and the MAP provider. An individual is financially responsible for services received if they were not eligible for MAD services on the date services are furnished.
(2) When a provider bills MAD and the claim is denied, the provider cannot bill the eligible recipient. Exceptions exist for denials caused by MAP ineligibility or by an eligible recipient's failure to furnish MAP identification at the time of service.
(3) If an eligible recipient fails to notify a provider that they have received services that are limited by time or amount, the eligible recipient is responsible to pay for services if, before furnishing the services, the provider makes reasonable efforts to verify whether the eligible recipient has already received services.
B. Failure of an eligible recipient to follow their privately held health insurance carrier’s requirements: An eligible recipient must be aware of the physician, pharmacy, hospital, and other providers who participate in their HMO or other managed care plan. An eligible recipient is responsible for payment for services if they use a provider who is not a participant in their plan or if they receive any services without complying with the rules, policies, and procedures of their plan.
C. Other eligible recipient payment responsibilities: If all the following conditions are met before a MAD service is furnished, the eligible recipient can be billed directly by a MAD provider for services and is liable for payment:
(1) the eligible recipient is advised by a provider that the particular service is not covered by MAD or is advised by a provider that they are not a MAD provider;
(2) the eligible recipient is informed by a provider of the necessity, options, and charges for the services and the option of going to another provider who is a MAD provider; and
(3) the eligible recipient agrees in writing to have the service provided with full knowledge that they are financially responsible for the payment.
[8.200.430.16 NMAC - Rp, 8.200.430.16 NMAC, 1/1/2014; A, 10/15/2014; A, 10/1/2017; A, 2/1/2020; A, 11/1/2024]
8.200.430.17 RESTITUTION:
A. A MAP eligible recipient must return overpayments or medical payments received from liable third parties to the applicable medical service provider or to MAD. If payments are not returned or received, recoupment proceedings against the eligible recipient will be initiated.
B. The restitution bureau of HCA is responsible for the tracking and collection of overpayments made to MAP eligible recipients, vendors, and MAD providers. See Section OIG-940, RESTITUTIONS. The MAD third party liability unit is responsible for monitoring and collecting payments received from liable third parties. See 8.302.3 NMAC.
[8.200.430.17 NMAC - Rp, 8.200.430.17 NMAC, 1/1/2014; A, 10/15/2014; A, 11/1/2024]
8.200.430.18 REPORTING REQUIREMENTS: A medicaid eligible recipient is required to report certain changes which might affect their eligibility to ISD within 10 calendar days from the date the change occurred. A timely change that is reported within 10 calendar days that may result in a more beneficial medicaid eligibility category shall be evaluated in the month the change occurred. An untimely change that is reported after 10 calendar days that may result in a more beneficial medicaid eligibility category shall be evaluated in the month the change was reported. A reported change that does not result in the same or a more beneficial medicaid category is considered an adverse action and is applied prospectively in accordance with 8.100.180.10 NMAC. See 8.100.110.9 NMAC for the various ways applicants and recipients can submit changes to the HCA. The following changes must be reported to ISD:
A. Living arrangements or change of address : Any change in where an eligible recipient lives or gets their mail must be reported.
B. Household size: Any change in the household size must be reported. This includes the death of an individual included in the either or both the assistance unit and budget group.
C. Enumeration: Any new social security number must be reported.
D. Income: Except for continuous eligibility in 8.200.400 NMAC any increase or decrease in the amount of income or change in the source of income must be reported.
E. Resource: Resources only apply to non-modified adjusted gross income (MAGI) medicaid categories. Any change in what an eligible recipient owns must be reported. This includes any property the eligible recipient owns or has interest in, cash on hand, money in banks or credit unions, stocks, bonds, life insurance policies or any other item of value.
[8.200.430.18 NMAC - Rp, 8.200.430.18 NMAC, 1/1/2014; A, 2/14/2014; 8.200.430.18 NMAC - Rn & A, 8.200.430.19 NMAC, 10/15/2014; A, 10/1/2017; A, 11/1/2024]
8.200.430.19 MAD ESTATE RECOVERY: HCA is mandated to seek recovery from the estates of certain individuals up to the amount of medical assistance payments made by the HCA on behalf of the individual. See Social Security Act Section 1917 (42 USC 1396p(b) and Section 27-2A-1 et seq., NMSA 1978 "Medicaid Estate Recovery Act").
A. Definitions used in MAD estate recovery:
(1) Authorized representative: The individual designated to represent and act on the eligible recipient’s behalf. The eligible recipient or authorized representative must provide formal documentation authorizing the named individual or individuals to access the identified case information for a specified purpose and time frame. An authorized representative may be an attorney representing a person or household, a person acting under the authority of a valid power of attorney, a guardian, or any other individual or individuals designated in writing by the member.
(2) Estate: Real and personal property and other assets of an individual subject to probate or administration pursuant to the New Mexico Uniform Probate Code.
(3) Medical assistance: Amounts paid by HCA for long term care services including related hospital and prescription drug services.
B. Basis for defining the group: A MAP eligible recipient who was 55 years of age or older when medical assistance payments were made on their behalf for nursing facilities services, home and community based services, and related hospital and prescription drug services are subject to estate recovery.
C. The following exemptions apply to estate recovery:
(1) Qualified medicare beneficiaries, specified low-income beneficiaries, qualifying individuals, and qualified disabled and working individuals, are exempt from estate recovery for the receipt of hospital and prescription drug services unless they are concurrently in a MAP nursing facility category of eligibility or on a home and community based services waiver; this provision applies to medicare cost-sharing benefits (i.e., Part A and Part B premiums, deductibles, coinsurance, and co-payments) paid under the medicare savings programs.
(2) Certain income, resources, and property are exempted from MAD estate recovery for native Americans:
(a) interest in and income derived from tribal land and other resources held in trust status and judgment funds from the Indian claims commission and the United States claims court;
(b) ownership interest in trust or non-trust property, including real property and improvements;
( i ) located on a reservation or near a reservation as designated and approved by the bureau of Indian affairs of the U.S, department of interior; or
(ii) for any federally-recognized tribe located within the most recent boundaries of a prior federal reservation; and
(iii) protection of non-trust property described in Subparagraphs (a) and (b) is limited to circumstances when it passes from a native American to one or more relatives, including native Americans not enrolled as members of a tribe and non-native Americans such as a spouse and step-children, that their culture would nevertheless protect as family members; to a tribe or tribal organization; or to one or more native Americans;
(c) income left as a remainder in an estate derived from property protected in Paragraph (2) above, that was either collected by a native American, or by a tribe or tribal organization and distributed to native Americans that the individual can clearly trace the income as coming from the protected property;
(d) ownership interests left as a remainder in an estate in rents, leases, royalties, or usage rights related to natural resources resulting from the exercise of federally-protected rights, and income either collected by a native American, or by a tribe or tribal organization and distributed to native Americans derived from these sources as long as the individual can clearly trace the ownership interest as coming from protected sources; and
(e) ownership interest in or usage of rights to items, not covered by Subparagraphs (a) through (d) above, that have unique religious, spiritual, traditional, or cultural significance or rights that support subsistence or a traditional lifestyle according to applicable tribal law or custom.
(3) Effective July 1, 2024, the HCA does not seek payment from an achieving a better life experience (ABLE) account or its proceeds for medicaid benefits provided to the beneficiary of the account.
D. Recovery process: Recovery from an eligible recipient's estate will be made only after the death of the eligible recipient's surviving spouse, if any, and only at a time that the eligible recipient does not have surviving child who is less than 21 years of age, blind, or who meet the SSA definition of disability.
(1) Estate recovery is limited to payments for applicable services received on or after October 1, 1993; except that recovery also is permitted for pre-October 1993 payments for nursing facility services received by a MAP recipient who was 65 years of age or older when such nursing facility services were received.
(2) A recovery notice will be mailed to the authorized representative or next of kin upon the eligible recipient’s death informing them about the amount of claim against the estate and provide information on hardship waivers and hearing rights.
(3) It is the family or authorized representative’s responsibility to report the eligible recipient’s date of death to the ISD office within 10 calendar days after the date of death.
E. Eligible recipient rights and responsibilities:
(1) At the time of application or re-certification, the authorized representative must be identified or confirmed by the applicant or eligible recipient or their designee.
(2) Information explaining estate recovery will be furnished to the applicant or eligible recipient, their personal representative, or designee during the application or re-certification process. Upon the death of the MAP eligible recipient, a notice of intent to collect (recovery) letter will be mailed to the eligible recipient’s personal representative with the total amount of claims paid by MAD on behalf of the eligible recipient. The authorized representative must acknowledge receipt of this letter in the manner prescribed in the letter within 30 calendar days of the date on the letter.
(3) During the application or re-certification process for] MAP eligibility, the local
county ISD office will identify the assets of an applicant or the eligible recipient. This includes all real and personal property which belongs in whole or in part to the applicant or eligible recipient and the current fair market value of each asset. Any known encumbrances on the asset should be identified at this time by the applicant or the eligible recipient or their authorized representative.
(4) MAD, or its designee, will send notice of recovery to the probate court, when applicable, and to the eligible recipient’s authorized representative or successor in interest. The notice will contain the following information:
(a) statement describing the action MAD, or its designee , intends to take;
(b) reasons for the intended action;
(c) statutory authority for the action;
(d) amount to be recovered;
(e) opportunity to apply for the undue hardship waiver;
(f) procedures for applying for a hardship waiver and the relevant timeframes involved;
(g) explanation of the eligible recipient’s personal representative's right to request a HCA administrative hearing; and
(h) the method by which an affected person may obtain a HCA administrative hearing and the applicable timeframes involved.
(5) Once notified by MAD, or its designee, of the decision to seek recovery, it is the responsibility of the eligible recipient's authorized representative or successor in interest to notify other individuals who would be affected by the proposed recovery.
(6) The authorized representative will:
(a) remit the amount of medical assistance payments to HCA or its designee;
(b) apply for an undue hardship waiver; (see Paragraph (2) of Subsection F below); or
(c) request an administrative hearing.
F. Waivers:
(1) For a general waiver, HCA may compromise, settle, or waive recovery pursuant to the Medicaid Estate Recovery Act if it deems that such action is in the best interest of the state or federal government.
(2) Hardship provision: HCA, or its designee, may waive recovery because recovery would work an undue hardship on the heirs. The following are deemed to be causes for hardship:
(a) the deceased recipient's heir would become eligible for a needs-based assistance program such as medicaid or temporary assistance to needy families (TANF) or be put at risk of serious deprivation without the receipt of the proceeds of the estate;
(b) the deceased eligible recipient's heir would be able to discontinue reliance on a needs-based program (such as medicaid or TANF) if they received the inheritance from the estate;
(c) the deceased recipient’s assets which are subject to recovery are the sole income source for the heir;
(d) the homestead is worth 50 percent or less than the average price of a home in the county where the home is located based on census data compared to the property tax value of the home; or
(e) there are other compelling circumstances as determined by HCA or its designee.
[8.200.430.19 NMAC - N, 1/1/2014; 8.200.430.19 NMAC - Rn & A, 8.200.430.20 NMAC, 10/15/2014; A, 11/1/2024]
8.200.430.20 [RESERVED]
[8.200.430.20 NMAC - N, 1/1/2014; Repealed, 10/15/2014]
HISTORY OF 8.200.430 NMAC: The material in this part was derived from that previously filed with the State Records Center:
8 NMAC 4.MAD.430, Recipient Policies, Recipient Rights and Responsibilities, filed 12/30/1994.
History of Repealed Material:
8.200.430 NMAC, Recipient Rights and Responsibilities, filed 12/13/2000 - Repealed effective 1/1/2014.
TITLE 8 SOCIAL SERVICES
CHAPTER 200 MEDICAID ELIGIBILITY - GENERAL RECIPIENT RULES
PART 450 REPORTING REQUIREMENTS
8.200.450.1 ISSUING AGENCY: New Mexico Health Care Authority.
[8.200.450.1 NMAC - Rp 8.200.450.1 NMAC, 7/1/2024]
8.200.450.2 SCOPE: The rule applies to the general public .
[8.200.450.2 NMAC - Rp 8.200.450.2 NMAC, 7/1/2024]
8.200.450.3 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 NMSA 1978 et. seq. (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.
[8.200.450.3 NMAC - Rp 8.200.450.3 NMAC, 7/1/2024]
8.200.450.4 DURATION: Permanent.
[8.200.450.4 NMAC - Rp 8.200.450.4 NMAC, 7/1/2024]
8.200.450.5 EFFECTIVE DATE: July 1, 2024, unless a later date is cited at the end of a section.
[8.200.450.5 NMAC - Rp 8.200.450.5 NMAC, 7/1/2024]
8.200.450.6 OBJECTIVE: The objective of these regulations is to provide eligibility policy and procedures for the medicaid program.
[8.200.450.6 NMAC - Rp 8.200.450.6 NMAC, 7/1/2024]
8.200.450.7 DEFINITIONS [ RESERVED ]
8.200.450.8 MISSION: To reduce the impact of poverty on people living in New Mexico and to assure low income and disabled individuals in New Mexico equal participation in the life of their communities.
[8.200.450.8 NMAC - Rp 8.200.450.8 NMAC, 7/1/2024]
8.200.450.9 REPORTING REQUIREMENTS: A medicaid applicant/recipient must report any change in circumstances which might affect their eligibility within 10 days after the change to the local income support division (ISD) office. This provision does not apply to children’s medicaid (category of eligibility 032). See 8.232.600.14 NMAC, changes in eligibility .
[8.200.450.9 NMAC - Rp 8.200.450.9 NMAC, 7/1/2024]
HISTORY OF 8.200.450 NMAC: The material in this part was derived from that previously filed with the Commission of Public Records - State Records Center and Archives:
8 NMAC 4.MAD.430, Recipient Policies, Recipient Rights and Responsibilities, 12/30/1994.
History of Repealed Material: 8.200.450 NMAC - Reporting Requirements (filed 12/18/2000) Repealed effective 7/1/2024.
Other: 8.200.450 NMAC - Reporting Requirements (filed 12/18/2000) Replaced by 8.200.450 NMAC - Reporting Requirements effective 7/1/2024.
TITLE 8 SOCIAL SERVICES
CHAPTER 200 MEDICAID ELIGIBILITY - GENERAL RECIPIENT POLICIES
PART 510 RESOURCE STANDARDS
8.200.510.1 ISSUING AGENCY: New Mexico Health Care Authority (HCA).
[8.200.510.1 NMAC - Rp, 8.200.510.1 NMAC, 7/1/2015; A, 8/1/2024]
8.200.510.2 SCOPE: The rule applies to the general public .
[8.200.510.2 NMAC - Rp, 8.200.510.2 NMAC, 7/1/2015]
8.200.510.3 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 Section 27-1-12 et seq. NMSA 1978.
[8.200.510.3 NMAC - Rp, 8.200.510.3 NMAC, 7/1/2015]
8.200.510.4 DURATION: Permanent.
[8.200.510.4 NMAC - Rp, 8.200.510.4 NMAC, 7/1/2015]
8.200.510.5 EFFECTIVE DATE: July 1, 2015, unless a later date is cited at the end of a section.
[8.200.510.5 NMAC - Rp, 8.200.510.5 NMAC, 7/1/2015]
8.200.510.6 OBJECTIVE: The objective of this rule is to provide specific instructions when determining eligibility for the medicaid program and other health care programs. Generally, applicable eligibility rules are detailed in the medical assistance division (MAD) eligibility policy manual, specifically 8.200.400 NMAC, General Medicaid Eligibility . Processes for establishing and maintaining MAD eligibility are detailed in the income support division (ISD) general provisions 8.100 NMAC, General Provisions for Public Assistance Programs .
[8.200.510.6 NMAC - Rp, 8.200.510.6 NMAC, 7/1/2015]
8.200.510.7 DEFINITIONS: [RESERVED]
8.200.510.8 MISSION STATEMENT: We ensure that New Mexicans attain their highest level of health by providing whole-person, cost effective, accessible, and high-quality health care and safety-net services.
[8.200.510.8 NMAC - Rp, 8.200.510.8 NMAC, 7/1/2015; A/E, 3/1/2017; A/E, 1/16/2020, A, 8/1/2024]
8.200.510.9 GENERAL NEED DETERMINATION: To be eligible for medical assistance division (MAD) benefits, an applicant or recipient must meet specific resource and income standards based on eligibility category.
[8. 200.510 .9 NMAC - Rp, 8.200.510.9 NMAC, 7/1/2015]
8.200.510. 10 RESOURCE STANDARDS: For specific information on liquid, non-liquid and countable resources, resource exclusions, deemed resources, resource transfers or trusts see specific medical assistance programs (MAP) eligibility categories. Standards for community spouse resource allowance, medical care credit calculations and average cost for nursing facility care are included in this section.
[8. 200.510 .10 NMAC - Rp, 8.200.510.10 NMAC, 7/1/2015]
8.200.510.11 COMMUNITY SPOUSE RESOURCE ALLOWANCE (CSRA): The CSRA standard varies based on when the applicant or recipient become institutionalized for a continuous period. The CSRA remains constant even if it was calculated prior to submission of a formal MAP application. If institutionalization began:
A. Between September 30, 1989 and December 31, 1989, the state maximum CSRA is $30,000 and the federal maximum CRSA is $60,000.
B. On or after January 1, 1990, the state minimum is $31,290 and the federal maximum CSRA is $62,580.
C. On or after January 1, 1991, the state minimum is $31,290 and the federal maximum CSRA is $66,480.
D. On or before January 1, 1992, the state minimum is $31,290 and the federal maximum CSRA is $68,700.
E. On or after January 1, 1993, the state minimum is $31,290 and the federal maximum CSRA is $70,740.
F. On or after January 1, 1994, the state minimum is $31,290 and the federal maximum CSRA is $72,660.
G. On or after January 1, 1995, the state minimum is $31,290 and the federal maximum CSRA is $74,820.
H. On or after January 1, 1996, the state minimum is $31,290 and the federal maximum CSRA is $76,740.
I. On or after January 1, 1997, the state minimum is $31,290 and the federal maximum CSRA is $79,020.
J. On or after January 1, 1998, the state minimum is $31,290 and the federal maximum CSRA is $80,760.
K. On or after January 1, 1999, the state minimum is $31,290 and the federal maximum CSRA is $81,960.
L. On or after January 1, 2000, the state minimum is $31,290 and the federal maximum CSRA is $84,120.
M. On or after January 1, 2001, the state minimum is $31,290 and the federal maximum CSRA is $87,000.
N. On or after January 1, 2002, the state minimum is $31,290 and the federal maximum CSRA is $89,280.
O. On or after January 1, 2003, the state minimum is $31,290 and the federal maximum CSRA is $90,660.
P. On or after January 1, 2004, the state minimum is $31,290 and the federal maximum CSRA is $92,760.
Q. On or after January 1, 2005, the state minimum is $31,290 and the federal maximum CSRA is $95,100.
R. On or after January 1, 2006, the state minimum is $31,290 and the federal maximum CSRA is $99,540.
S. On or after January 1, 2007, the state minimum is $31,290 and the federal maximum CSRA is $101,640.
T. On or after January 1, 2008, the state minimum is $31,290 and the federal maximum CSRA is $104,400.
U. On or after January 1, 2009, the state minimum is $31,290 and the federal maximum CSRA is $109,560.
V. On or after January 1, 2010, the state minimum is $31,290 and the federal maximum CSRA remains $109,560.
W. On or after January 1, 2011, the state minimum is $31,290 and the federal maximum CSRA remains $109,560.
X. On or after January 1, 2012, the state minimum is $31,290 and the federal maximum CSRA is $113,640.
Y. On or after January 1, 2013, the state minimum is $31,290 and the federal maximum CSRA is $115,920.
Z. On or after January 1, 2014, the state minimum is $31,290 and the federal maximum CSRA is $117,240.
AA. On or after January 1, 2015, the state minimum is $31,290 and the federal maximum CSRA is $119,220.
BB. On or after January 1, 2016, the state minimum is $31,290 and the federal maximum CSRA is $119,220.
CC. On or after January 1, 2017, the state minimum is $31,290 and the federal maximum CSRA is $120,900.
DD. On or after January 1, 2018, the state minimum is $31,290 and the federal maximum CSRA is $123,600.
EE. On or after January 1, 2019, the state minimum is $31,290 and the federal maximum CSRA is $126,420.
FF. On or after January 1, 2020, the state minimum is $31,290 and the federal maximum CSRA is $128,640.
GG. On or after January 1, 2021, the state minimum is $31,290 and the federal maximum CSRA is $130,380.
HH. On or after January 1, 2022, the state minimum is $31,290 and the federal maximum CSRA is $137,400.
II. On or after January 1, 2023, the state minimum is $31,290 and the federal maximum CSRA is $148,620.
JJ. On or after January 1, 2024, the state minimum is $31,290 and the federal maximum CSRA is $154,140.
KK. On or after January 1, 2025, the state minimum is $31,584 and the federal maximum CSRA is $157,920.
[8. 200.510 .11 NMAC - Rp, 8.200.510.11 NMAC, 7/1/2015; A/E, 1/1/2016; A/E, 3/1/2017; A/E, 8/30/2018; A/E, 4/11/2019; A, 7/30/2019; A/E, 8/11/2020; A, 12/15/2020; A/E, 4/1/2021; A, 9/1/2021; A/E, 4/1/2022; A, 8/9/2022; A/E, 4/1/2023; A/E, 4/1/2024; A, 8/1/2024; A/E, 4/1/2025]
8.200.510.12 POST-ELIGIBILITY CALCULATION (MEDICAL CARE CREDIT): Apply applicable deductions in the order listed below when determining the medical care credit for an institutionalized spouse.
DEDUCTION AMOUNT
A. Personal needs allowance for institutionalized spouse :
July 1, 2024 $94
B. Minimum monthly maintenance needs allowance (MMMNA):
July 1, 2024 $2,555
C. The community spouse monthly income allowance (CSMIA) is calculated by subtracting the community spouse's gross income from the MMMNA:
(1) If allowable shelter expenses of the community spouse exceeds the minimum allowance then deduct an excess shelter allowance from community spouse's income that includes: expenses for rent; mortgage (including interest and principal); taxes and insurance; any maintenance charge for a condominium or cooperative; and an amount for utilities (if not part of maintenance charge above); use the standard utility allowance (SUA) deduction used in the food stamp program for the utility allowance.
July 1, 2024 $766.50
(2) Excess shelter allowance may not exceed the maximum:
(a) Jan. 1, 2025 $1,393
(b) Jan. 1, 2024 $1,388.50
(c) July 1, 2023 $1,251
(d) Jan. 1, 2023 $1,427
(e) July 1, 2022 $1,146
(f) Jan. 1, 2022 $1,257
(g) July 1, 2021 $1,082
(h) Jan. 1, 2021 $1,105
D. Any extra maintenance allowance ordered by a court of jurisdiction or a state administrative hearing officer.
E. Dependent family member income allowance (if applicable) calculated as follows: 1/3 X MMMNA - dependent member's income).
F. Non-covered medical expenses.
G. The maximum total of the community spouse monthly income allowance and excess shelter deduction may not exceed $3,853.50.
[8. 200.510 .12 NMAC - Rp, 8.200.510.12 NMAC, 7/1/2015; A/E, 3/1/2017; A/E. 8/30/2018; A/E, 4/11/2019; A, 7/30/2019; A/E, 1/16/2020; A/E, 8/11/2020; A, 12/15/2020; A/E, 4/1/2021; A, 9/1/2021; A/E, 4/1/2022; A, 8/9/2022; A/E, 4/1/2023; A/E, 4/1/2024; A, 8/1/2024; A/E, 4/1/2025]
8.200.510.13 AVERAGE MONTHLY COST OF NURSING FACILITIES FOR PRIVATE PATIENTS USED IN TRANSFER OF ASSET PROVISIONS: Costs of care are based on the date of application registration.
DATE AVERAGE COST PER MONTH
A. July 1, 1988 - Dec. 31, 1989 $1,726 per month
B. Jan. 1, 1990 - Dec. 31, 1991 $2,004 per month
C. Jan. 1, 1992 - Dec. 31, 1992 $2,217 per month
D. Effective July 1, 1993, for application $2,377 per month
register on or after Jan. 1, 1993
E. Jan. 1, 1994 - Dec. 31, 1994 $2,513 per month
F. Jan. 1, 1995 - Dec. 31, 1995 $2,592 per month
G. Jan. 1, 1996 - Dec. 31, 1996 $2,738 per month
H. Jan. 1, 1997 - Dec. 31, 1997 $2,889 per month
I. Jan. 1, 1998 - Dec 31, 1998 $3,119 per month
J. Jan. 1, 1999 - Dec. 31, 1999 $3,429 per month
K. Jan. 1, 2000 - Dec. 31, 2000 $3,494 per month
L. Jan. 1, 2001 - Dec. 31, 2001 $3,550 per month
M. Jan. 1, 2002 - Dec. 31, 2002 $3,643 per month
N. Jan. 1, 2003 - Dec. 31, 2003 $4,188 per month
O. Jan. 1, 2004 - Dec. 31, 2004 $3,899 per month
P. Jan. 1, 2005 - Dec. 31, 2005 $4,277 per month
Q. Jan. 1, 2006 - Dec. 31, 2006 $4,541 per month
R. Jan. 1, 2007 - Dec. 31, 2007 $4,551 per month
S. Jan. 1, 2008 - Dec. 31, 2008 $4,821 per month
T. Jan. 1, 2009 - Dec. 31, 2009 $5,037 per month
U. Jan. 1, 2010 - Dec. 31, 2010 $5,269 per month
V. Jan. 1, 2011 - Dec. 31, 2011 $5,774 per month
W. Jan. 1, 2012 - Dec. 31, 2012 $6,015 per month
X. Jan. 1, 2013 - Dec. 31, 2013 $6,291 per month
Y. Jan. 1, 2014 - Dec. 31, 2014 $6,229 per month
Z. Jan. 1, 2015 - Dec. 31, 2015 $6,659 per month
AA. Jan. 1, 2016 - Dec. 31, 2016 $7,786 per month
BB. Jan. 1, 2017 - Dec. 31, 2017 $7,485 per month
CC. Jan. 1, 2018 - Dec. 31, 2018 $7,025 per month
DD. Jan. 1, 2019 - Dec. 31, 2019 $7,285 per month
EE. Jan. 1, 2020 - Dec. 31, 2020 $7,480 per month
FF. Jan. 1, 2021 - Dec. 31, 2021 $7,590 per month
GG. Jan. 1, 2022 - Dec. 31, 2021 $7,811 per month
HH. Jan. 1, 2023 - Dec. 31, 2023 $8,275 per month
II. Jan. 1, 2024 - Dec. 31, 2024 $8,919 per month
JJ . Jan. 1, 2025 - $8,947 per month
[8. 200.510 .13 NMAC - Rp, 8.200.510.13 NMAC, 7/1/2015; A/E, 1/1/2016; A/E, 3/1/2017; A/E, 8/30/2018; A/E, 4/11/2019; A, 7/30/2019; A/E, 8/11/2020; A, 12/15/2020; A/E, 4/1/2021; A, 9/1/2021; A/E, 4/1/2022; A, 8/9/2022; A/E, 4/1/2023; A/E, 4/1/2024; A, 8/1/2024; A/E, 4/1/2025]
8.200.510.14 [ RESERVED ]
8.200.510.15 EXCESS HOME EQUITY AMOUNT FOR LONG-TERM CARE SERVICES:
A. Jan. 2024 $730,000
B. Jan. 2024 $713,000
C. Jan. 2023 $688,000
D. Jan. 2022 $636,000
E. Jan. 2021 $603,000
F. Jan. 2020 $595,000
G. Jan. 2019 $585,000
H. Jan. 2018 $572,000
I. Oct. 2017 $560,000
J. Jan. 2017 $840,000
K. Jan. 2016 $828,000
L. Jan. 2015 $828,000
M. Jan. 2014 $814,000
N. Jan. 2013 $802,000
O. Jan. 2012 $786,000
P. Jan. 2011 $758,000
Q. Jan. 2010 $750,000
[8.200.510.15 NMAC - Rp, 8.200.510.15 NMAC, 7/1/2015; A/E, 1/1/2016; A/E, 3/1/2017; A, 3/1/18; A/E, 8/30/2018; A/E, 4/11/2019; A, 7/30/2019; A/E, 8/11/2020; A, 12/15/2020; A/E, 4/1/2021; A, 9/1/2021; A/E, 4/1/2022; A, 8/9/2022; A/E, 4/1/2023; A/E, 4/1/2024; A, 8/1/2024; A/E, 4/1/2025]
HISTORY OF 8.200.510 NMAC: The material in this part was derived from that previously filed with the Commission of Public Records - State Records Center and Archives:
8 NMAC 4.MAD.500, Eligibility Policies, Income and Resource Standards; 12/30/1994.
8 NMAC 4.MAD.500, Eligibility Policies, Income and Resource Standards; 6/20/1995.
History of Repealed Material:
8.200.510 NMAC, Resource Standards, filed 6/13/2014 - Repealed 7/1/2015.
TITLE 8 SOCIAL SERVICES
CHAPTER 200 MEDICAID ELIGIBILITY - GENERAL RECIPIENT RULES
PART 520 INCOME STANDARDS
8.200.520.1 ISSUING AGENCY: New Mexico Health Care Authority (HCA).
[8.200.520.1 NMAC - Rp, 8.200.520.1 NMAC, 8/28/2015; A, 8/1/2024]
8.200.520.2 SCOPE: The rule applies to the general public .
[8.200.520.2 NMAC - Rp, 8.200.520.2 NMAC, 8/28/2015]
8.200.520.3 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 Section 27-1-12 et seq. NMSA 1978.
[8.200.520.3 NMAC - Rp, 8.200.520.3 NMAC, 8/28/2015]
8.200.520.4 DURATION: Permanent.
[8.200.520.4 NMAC - Rp, 8.200.520.4 NMAC, 8/28/2015]
8.200.520.5 EFFECTIVE DATE: August 28, 2015, unless a later date is cited at the end of a section.
[8.200.520.5 NMAC - Rp, 8.200.520.5 NMAC, 8/28/2015]
8.200.520.6 OBJECTIVE: The objective of this rule is to provide specific instructions when determining eligibility for the medicaid program and other health care programs. Generally, applicable eligibility rules are detailed in the medical assistance division (MAD) eligibility policy manual, specifically 8.200.400 NMAC, General Medicaid Eligibility . Processes for establishing and maintaining MAD eligibility are detailed in the income support division (ISD) general provisions 8.100 NMAC, General Provisions for Public Assistance Programs .
[8.200.520.6 NMAC - Rp, 8.200.520.6 NMAC, 8/28/2015]
8.200.520.7 DEFINITIONS: [RESERVED]
8.200.520.8 MISSION STATEMENT: We ensure that New Mexicans attain their highest level of health by providing whole-person, cost-effective, accessible, and high-quality health care and safety-net services.
[8.200.520.8 NMAC - Rp, 8.200.520.8 NMAC, 8/28/2015; Repealed/E, 4/1/2016; A/E, 8/11/2020; A, 8/1/2024]
8.200.520.9 GENERAL NEED DETERMINATION: To be medical assistance division (MAD) eligible, an applicant or a re-determining eligible recipient must meet specific income and as applicable, resource standards.
[8.200.520.9 NMAC - Rp, 8.200.520.9 NMAC, 8/28/2015]
8.200.520.10 INCOME STANDARDS: This part contains the federal income poverty rate tables for use with all eligibility categories, cost of living (COLA) disregard calculations and other applicable income tables.
[8.200.520.10 NMAC - Rp, 8.200.520.10 NMAC, 8/28/2015]
8.200.520.11 FEDERAL POVERTY INCOME GUIDELINES:
A. One hundred percent federal poverty limits (FPL):
Size of budget group FPL per month
1 $1,305*
2 $1,763*
3 $2,221
4 $2,680
5 $3,138
6 $3,596
7 $4,055
8 $4,513
Add $458 for each additional person in the budget group.
*FPL must be below 100% for an individual or couple for qualified medicare beneficiary (QMB) program.
B. One hundred twenty percent FPL: This income level is used only in the determination of the maximum income limit for specified low income medicare beneficiaries (SLIMB) applicants or eligible recipients.
Applicant or eligible recipient Amount
1 Individual At least $1,305 per month but no more than $1,565 per month.
2 Couple At least $1,763 per month but no more than $2,115 per month.
For purposes of this eligibility calculation, “couple” means an applicant couple or an applicant with an ineligible spouse when income is deemed.
C. One hundred thirty-three percent FPL:
Size of budget group FPL per month
1 $1,735
2 $2,345
3 $2,954
4 $3,564
5 $4,173
6 $4,783
7 $5,393
8 $6,002
Add $609 for each additional person in the budget group.
D. One hundred thirty-five percent FPL: This income level is used only in the determination of the maximum income limit for a qualified individual 1 (QI1) applicant or eligible recipient. For purposes of this eligibility calculation, “couple” means an applicant couple or an applicant with an ineligible spouse when income is deemed. The following income levels apply:
Applicant or eligible recipient Amount
1 Individual At least $1,565 per month but no more than $1,761 per month.
2 Couple At least $2,115 per month but no more than $2,380 per month.
E. One hundred eighty-five percent FPL:
Size of budget group FPL per month
1 $2,413
2 $3,261
3 $4,109
4 $4,957
5 $5,805
6 $6,653
7 $7,501
8 $8,349
Add $848 for each additional person in the budget group.
F. Two hundred percent FPL:
Size of budget group FPL per month
1 $2,609
2 $3,525
3 $4,442
4 $5,359
5 $6,275
6 $7,192
7 $8,109
8 $9,025
Add $916 for each additional person in the budget group.
G. Two hundred thirty-five percent FPL:
Size of budget group FPL per month
1 $3,065
2 $4,142
3 $5,219
4 $6,297
5 $7,374
6 $8,451
7 $9,528
8 $10,605
Add $1,077 for each additional person in the budget group.
H. Two hundred fifty percent FPL:
Size of budget group FPL per month
1 $3,261
2 $4,407
3 $5,553
4 $6,698
5 $7,844
6 $8,990
7 $10,136
8 $11,282
Add $1,146 for each additional person in the budget group.
[8.200.520.11 NMAC - Rp, 8.200.520.11 NMAC, 8/28/2015; A/E, 4/1/2016; A/E, 9/14/2017; A, 2/1/2018; A/E, 5/17/2018; A, 9/11/2018; A/E, 4/11/2019; A, 7/30/2019, A/E, 8/11/2020; A, 12/15/2020; A/E, 4/1/2021; A, 9/1/2021; A/E, 4/1/2022; A, 8/9/2022; A/E, 4/1/2023; A/E, 4/1/2024; 8/1/2024; A/E, 4/1/2025]
8.200.520.12 COST OF LIVING ADJUSTMENT (COLA) DISREGARD COMPUTATION: The countable social security benefit without the COLA is calculated using the COLA increase table as follows:
A. divide the current gross social security benefit by the COLA increase in the most current year; the result is the social security benefit before the COLA increase;
B. divide the result from Subsection A above by the COLA increase from the previous period or year; the result is the social security benefit before the increase for that period or year; and
C. repeat Subsection B above for each year, through the year that the applicant or eligible recipient received both social security benefits and supplemental security income (SSI); the final result is the countable social security benefit.
COLA Increase and disregard table Period and year COLA increase = benefit before 1 2025 Jan – Dec 2.5 Jan 25 2 2024 Jan - Dec 3.2 Jan 24 3 2023 Jan - Dec 8.7 Jan 23 4 2022 Jan - Dec 5.9 Jan 22 5 2021 Jan - Dec 1.3 Jan 21 6 2020 Jan - Dec 1.6 Jan 20 7 2019 Jan - Dec 2.8 Jan 19 8 2018 Jan - Dec 2.0 Jan 18 9 2017 Jan - Dec 0.3 Jan 17 10 2016 Jan - Dec 0 Jan 16 11 2015 Jan - Dec 1.017 Jan 15 12 2014 Jan - Dec 1.015 Jan 14 13 2013 Jan - Dec 1.017 Jan 13 14 2012 Jan - Dec 1.037 Jan 12 15 2011 Jan - Dec 0 Jan 11 16 2010 Jan - Dec 1 Jan 10 17 2009 Jan - Dec 1 Jan 09 18 2008 Jan - Dec 1.058 Jan 08 19 2007 Jan - Dec 1.023 Jan 07 20 2006 Jan - Dec 1.033 Jan 06 21 2005 Jan - Dec 1.041 Jan 05 22 2004 Jan - Dec 1.027 Jan 04 23 2003 Jan - Dec 1.021 Jan 03 24 2002 Jan - Dec 1.014 Jan 02 25 2001 Jan - Dec 1.026 Jan 01 26 2000 Jan - Dec 1.035 Jan 00 27 1999 Jan - Dec 1.025 Jan 99 28 1998 Jan - Dec 1.013 Jan 98 29 1997 Jan - Dec 1.021 Jan 97 30 1996 Jan - Dec 1.029 Jan 96 31 1995 Jan - Dec 1.026 Jan 95 32 1994 Jan - Dec 1.028 Jan 94 33 1993 Jan - Dec 1.026 Jan 93 34 1992 Jan - Dec 1.03 Jan 92 35 1991 Jan - Dec 1.037 Jan 91 36 1990 Jan - Dec 1.054 Jan 90 37 1989 Jan - Dec 1.047 Jan 89 38 1988 Jan - Dec 1.04 Jan 88 39 1987 Jan - Dec 1.042 Jan 87 40 1986 Jan - Dec 1.013 Jan 86 41 1985 Jan - Dec 1.031 Jan 85 42 1984 Jan - Dec 1.035 Jan 84 43 1982 Jul - 1983 Dec 1.035 Jul 82 44 1981 Jul - 1982 Jun 1.074 Jul 81 45 1980 Jul - 1981 Jun 1.112 Jul 80 46 1979 Jul - 1980 Jun 1.143 Jul 79 47 1978 Jul - 1979 Jun 1.099 Jul 78 48 1977 Jul - 1978 Jun 1.065 Jul 77 49 1977 Apr - 1977 Jun 1.059 Apr 77
[8.200.520.12 NMAC - Rp, 8.200.520.12 NMAC, 8/28/2015; A/E, 1/1/2016; A/E, 3/1/2017; A/E, 5/17/2018; A, 9/11/2018; A, 4/11/2019; A, 7/30/2019; A/E, 8/11/2020; A, 12/15/2020; A/E, 4/1/2021; A, 9/1/2021; A/E, 4/1/2022; A, 8/9/2022; A/E, 4/1/2023; A/E, 4/1/2024, 8/1/2024; A/E, 4/1/2025]
8.200.520.13 FEDERAL BENEFIT RATES (FBR) AND VALUE OF ONE-THIRD REDUCTION (VTR):
Year Individual Institution Individual Couple Institution Couple FBR FBR VTR FBR FBR VTR 1/89 to 1/90 $368 $30 $122.66 $553 $60 $184.33 1/90 to 1/91 $386 $30 $128.66 $579 $60 $193.00 1/91 to 1/92 $407 $30 $135.66 $610 $60 $203.33 1/92 to 1/93 $422 $30 $140.66 $633 $60 $211.00 1/93 to 1/94 $434 $30 $144.66 $652 $60 $217.33 1/94 to 1/95 $446 $30 $148.66 $669 $60 $223.00 1/95 to 1/96 $458 $30 $152.66 $687 $60 $229.00 1/96 to 1/97 $470 $30 $156.66 $705 $60 $235.00 1/97 to 1/98 $484 $30 $161.33 $726 $60 $242.00 1/98 to 1/99 $494 $30 $164.66 $741 $60 $247.00 1/99 to 1/00 $500 $30 $166.66 $751 $60 $250.33 1/00 to 1/01 $512 $30 $170.66 $769 $60 $256.33 1/01 to 1/02 $530 $30 $176.66 $796 $60 $265.33 1/02 to 1/03 $545 $30 $181.66 $817 $60 $272.33 1/03 to 1/04 $552 $30 $184.00 $829 $60 $276.33 1/04 to 1/05 $564 $30 $188 $846 $60 $282.00 1/05 to 1/06 $579 $30 $193 $869 $60 $289.66 1/06 to 1/07 $603 $30 $201 $904 $60 $301.33 1/07 to 1/08 $623 $30 $207.66 $934 $60 $311.33 1/08 to 1/09 $637 $30 $212.33 $956 $60 $318.66 1/09 to 1/10 $674 $30 $224.66 $1,011 $60 $337 1/10 to 1/11 $674 $30 $224.66 $1,011 $60 $337 1/11 to 1/12 $674 $30 $224.66 $1,011 $60 $337 1/12 to 1/13 $698 $30 $232.66 $1,048 $60 $349.33 1/13 to 1/14 $710 $30 $237 $1,066 $60 $355 1/14 to 1/15 $721 $30 $240 $1,082 $60 $361 1/15 to 12/15 $733 $30 $244 $1,100 $60 $367 1/16 to 12/16 $733 $30 $244 $1,100 $60 $367 1/17 to 12/17 $735 $30 $245 $1,103 $60 $368 1/18 to 12/18 $750 $30 $250 $1,125 $60 $375 1/19 to 12/19 $771 $30 $257 $1,157 $60 $386 1/20 to 12/20 $783 $30 $261 $1,175 $60 $392 1/21 to 12/21 $794 $30 $264.66 $1,191 $60 $397 1/22 to 12/22 $841 $30 $280.33 $1,261 $60 $420.50 1/23 to 12/23 $914 $30 $304.66 $1,371 $60 $456.99 1/24 to 12/24 $943 $30 $314.33 $1,415 $60 $471.66 1/25 to 12/25 $967 $30 $322.33 $1,450 $60 $483.33
A. Ineligible child deeming allocation is $483.
B. Part B premium is $185 per month.
C. VTR (value of one third reduction) is used when an individual or a couple lives in the household of another and receives food and shelter from the household or when the individual or the couple is living on their own household but receiving support and maintenance from others.
D. The SSI resource standard is $2000 for an individual and $3000 for a couple.
[8.200.520.13 NMAC - Rp, 8.200.520.13 NMAC, 8/28/2015; A/E, 1/1/2016; A/E, 3/1/2017; A/E, 5/17/2018; A, 9/11/2018; A/E, 4/11/2019; A, 7/30/2019; A/E, 8/11/2020; A, 12/15/2020; A/E, 4/1/2021; A, 9/1/2021; A/E, 4/1/2022; A, 8/9/2022; A/E, 4/1/2023; A/E, 4/1/2024; 8/1/2024; A/E, 4/1/2025]
8.200.520.14 UNISEX LIFE ESTATE AND REMAINDER INTEREST TABLES:
Age Life Estate Remainder
0 .97188 .02812
1 .98988 .01012
2 .99017 .00983
3 .99008 .00992
4 .98981 .01019
5 .98938 .01062
6 .98884 .01116
7 .98822 .01178
8 .98748 .01252
9 .98663 .01337
10 .98565 .01435
11 .98453 .01547
12 .98329 .01671
13 .98198 .01802
14 .98066 .01934
15 .97937 .02063
16 .97815 .02185
17 .97700 .02300
18 .97590 .02410
19 .97480 .02520
20 .97365 .02635
21 .97245 .02755
22 .97120 .02880
23 .96986 .03014
24 .96841 .03159
25 .96678 .03322
26 .96495 .03505
27 .96290 .03710
28 .96062 .03938
29 .95813 .04187
30 .95543 .04457
31 .95243 .04746
32 .94942 .05058
33 .94608 .05392
34 .94250 .05750
35 .93868 .06132
36 .93460 .06540
37 .93026 .06974
38 .92567 .07433
39 .92083 .07917
40 .91571 .08429
41 .91030 .08970
42 .90457 .09543
43 .89855 .10145
44 .89221 .10779
45 .88558 .11442
46 .87863 .12137
47 .87137 .12863
48 .86374 .13626
49 .85578 .14422
50 .84743 .15257
51 .83674 .16126
52 .82969 .17031
53 .82028 .17972
54 .81054 .18946
55 .80046 .19954
56 .79006 .20994
57 .77931 .22069
58 .76822 .23178
59 .75675 .24325
60 .74491 .25509
61 .73267 .26733
62 .72002 .27998
63 .70696 .29304
64 .69352 .30648
65 .67970 .32030
66 .66551 .33449
67 .65098 .34902
68 .63610 .36690
69 .62086 .37914
70 .60522 .39478
71 .58914 .41086
72 .57261 .42739
73 .55571 .44429
74 .53862 .46138
75 .52149 .47851
76 .50441 .49559
77 .48742 .51258
78 .47049 .52951
79 .45357 .54643
80 .43659 .56341
81 .41967 .58033
82 .42095 .59705
83 .38642 .61358
84 .36998 .63002
85 .35359 .64641
86 .33764 .66236
87 .32262 .67738
88 .30859 .69141
89 .29526 .70474
90 .28221 .71779
91 .26955 .73045
92 .25771 .74229
93 .24692 .75308
94 .23728 .76272
95 .22887 .77113
96 .22181 .77819
97 .21550 .78450
98 .21000 .79000
99 .20486 .79514
100 .19975 .80025
101 .19532 .80468
102 .19054 .80946
103 .18437 .81563
104 .17856 .82144
105 .16962 .83038
106 .15488 .84512
107 .13409 .86591
108 .10068 .89932
109 .04545 .95455
[8.200.520.14 NMAC - Rp, 8.200.520.14 NMAC, 8/28/2015]
8.200.520.15 SUPPLEMENTAL SECURITY INCOME (SSI) LIVING ARRANGEMENTS :
A. Individual living in their own household who own or rent:
Payment amount: $967 Individual
$1,450 Couple
B. Individual receiving support and maintenance payments: For an individual or couple living in their own household, but receiving support and maintenance from others (such as food, shelter or clothing), subtract the value of one third reduction (VTR).
Payment amount:
$967 - $322.33 = $644.67 Individual
$1,450 – $483.33 = $966.67 Couple
C. Individual or couple living household of another: For an individual or couple living in another person's household and not contributing their pro-rata share of household expenses, subtract the VTR.
Payment amount:
$967 - $322.33 = $644.67 Individual
$1,450 – $483.33 = $966.67 Couple
D. Child living in home with their parent:
Payment amount: $967
E. Individual in institution:
Payment amount: $30.00
[8.200.520.15 NMAC - Rp, 8.200.520.15 NMAC, 8/28/2015; A/E, 3/1/2017; A/E, 5/17/2018; A, 9/11/2018; A/E, 4/11/2019; A, 7/30/2019; A/E, 8/11/2020; A, 12/15/2020; A/E, 4/1/2021; A, 9/1/2021; A/E, 4/1/2022; A, 8/9/2022; A/E, 4/1/2023; A/E, 4/1/2024; A, 8/1/2024; A/E, 4/1/2025]
8.200.520.16 MAXIMUM COUNTABLE INCOME FOR INSTITUTIONAL CARE MEDICAID AND HOME AND COMMUNITY BASED WAIVER SERVICES (HCBS) CATEGORIES: Effective January 1, 2024, the maximum countable monthly income standard for institutional care medicaid and the home and community based waiver categories is $2,901.
[8.200.520.16 NMAC - Rp, 8.200.520.16 NMAC, 8/28/2015; A/E, 3/1/2017; A/E, 5/17/2018; A, 9/11/2018; A/E, 4/11/2019; A, 7/30/2019; A/E, 8/11/2020; A, 12/15/2020; A/E, 4/1/2021; A, 9/1/2021; A/E, 4/1/2022; A, 8/9/2022; A/E, 4/1/2023; A/E, 4/1/2024; A, 8/1/2024; A/E, 4/1/2025]
8.200.520.17 MAXIMUM COUNTABLE INCOME FOR CHILDREN YOUTH AND FAMILIES (CYFD): Effective July 1, 1995, the maximum countable monthly income standard for CYFD medicaid is $231.00.
[8.200.520.17 NMAC - Rp, 8.200.520.17 NMAC, 8/28/2015]
8.200.520.18 SSI RELATED CATEGORIES - DEEMING INCOME WHEN AN APPLICANT CHILD IS LIVING WITH INELIGIBLE PARENT:
A. Monthly computation:
(1) total gross unearned income of parent;
(2) deduct living allowance for ineligible child and SSI-eligible sponsored alien (one half of the monthly SSI FBR LA code A*) for each ineligible child/SSI-eligible sponsored alien);
(3) subtotal;
(4) deduct $20.00 general income exclusion - 20.00;
(5) unearned income subtotal;
(6) total gross earned income of parent;
(7) deduct any remaining allocation for ineligible child and/or SSI-eligible sponsored alien; s ee Paragraph (2) above;
(8) subtotal;
(9) deduct any remaining portion of the $20.00 general income exclusion only if not already totally deducted in Paragraph (4) above;
(10) subtotal;
(11) deduct $65.00; d o not apply this deduction if the only income is unearned - 65.00;
(12) s ubtotal;
(13) subtract one-half of Paragraph (12); do not apply this deduction if the only income is unearned;
(14) earned income subtotal;
(15) total of Paragraph (5) plus Paragraph (14);
(16) deduct parental allocation (1 parent = SSI FBR for an individual LA code A*) (2 parents = SSI FBR for an eligible couple LA code A*);
(17) income deemed to applicant child; if there is more than one applicant child, divide this amount equally between the children: * LA Code A = the full SSI FBR for an individual or a couple.
B. If the deemed income plus the applicant child's separate income exceeds the income standard for an individual, the applicant child is not eligible for that month.
[8.200.520.18 NMAC - Rp, 8.200.520.18 NMAC, 8/28/2015]
8.200.520.19 LIFE EXPECTANCY TABLES:
A. Males:
Life Life Life
Age expectancy Age expectancy Age expectancy
0 71.80 40 35.05 80 6.98
1 71.53 41 34.15 81 6.59
2 70.58 42 33.26 82 6.21
3 69.62 43 32.37 83 5.85
4 68.65 44 31.49 84 5.51
5 67.67 45 30.61 85 5.19
6 66.69 46 29.74 86 4.89
7 65.71 47 28.88 87 4.61
8 64.73 48 28.02 88 4.34
9 63.74 49 27.17 89 4.09
10 62.75 50 26.32 90 3.86
11 61.76 51 25.48 91 3.64
12 60.78 52 24.65 92 3.43
13 59.79 53 23.82 93 3.24
14 58.82 54 23.01 94 3.06
15 57.85 55 22.21 95 2.90
16 56.91 56 21.43 96 2.74
17 55.97 57 20.66 97 2.60
18 55.05 58 19.90 98 2.47
19 54.13 59 19.15 99 2.34
20 53.21 60 18.42 100 2.22
21 52.29 61 17.70 101 2.11
22 51.38 62 16.99 102 1.99
23 50.46 63 16.30 103 1.89
24 49.55 64 15.62 104 1.78
25 48.63 65 14.96 105 1.68
26 47.72 66 14.32 106 1.59
27 46.80 67 13.70 107 1.50
28 45.88 68 13.09 108 1.41
29 44.97 69 12.50 109 1.33
30 44.06 70 11.92 110 1.25
31 43.15 71 11.35 111 1.17
32 42.24 72 10.80 112 1.10
33 41.33 73 10.27 113 1.02
34 40.23 74 9.27 114 0.96
35 39.52 75 9.24 115 0.89
36 38.62 76 8.76 116 0.83
37 37.73 77 8.29 117 0.77
38 36.83 78 7.83 118 0.71
39 35.94 79 7.40 119 0.66
B. Females:
Life Life Life
Age expectancy Age expectancy Age expectancy
0 78.79 40 40.61 80 9.11
1 78.42 41 39.66 81 8.58
2 77.48 42 38.72 82 8.06
3 76.51 43 37.78 83 7.56
4 75.54 44 36.85 84 7.08
5 74.56 45 35.92 85 6.63
6 73.57 46 35.00 86 6.20
7 72.59 47 34.08 87 5.79
8 71.60 48 33.17 88 5.41
9 70.61 49 32.27 89 5.05
10 69.62 50 31.37 90 4.71
11 68.63 51 30.48 91 4.40
12 67.64 52 29.60 92 4.11
13 66.65 53 28.72 93 3.84
14 65.67 54 27.86 94 3.59
15 64.68 55 27.00 95 3.36
16 63.71 56 26.15 96 3.16
17 62.74 57 25.31 97 2.97
18 61.77 58 24.48 98 2.80
19 60.80 59 23.67 99 2.64
20 59.83 60 22.86 100 2.48
21 58.86 61 22.06 101 2.34
22 57.89 62 21.27 102 2.20
23 56.92 63 20.49 103 2.06
24 55.95 64 19.72 104 1.93
25 54.98 65 18.96 105 1.81
26 54.02 66 18.21 106 1.69
27 53.05 67 17.48 107 1.58
28 52.08 68 16.76 108 1.48
29 51.12 69 16.04 109 1.38
30 50.15 70 15.35 110 1.28
31 49.19 71 14.66 111 1.19
32 48.23 72 13.99 112 1.10
33 47.27 73 13.33 113 1.02
34 46.31 74 12.68 114 0.96
35 45.35 75 12.05 115 0.89
36 44.40 76 11.43 116 0.83
37 43.45 77 10.83 117 0.77
38 42.50 78 10.24 118 0.71
39 41.55 79 9.67 119 0.66
[8.200.520.19 NMAC - Rp, 8.200.520.19 NMAC, 8/28/2015]
8.200.520.20 COVERED QUARTER INCOME STANDARD:
Date Calendar Quarter Amount
Jan. 2025 - Dec. 2025 $1,810 per calendar quarter
Jan. 2024 - Dec. 2024 $1,730 per calendar quarter
Jan. 2023 - Dec. 2023 $1,640 per calendar quarter
Jan. 2022 - Dec. 2022 $1,510 per calendar quarter
Jan. 2021 - Dec. 2021 $1,470 per calendar quarter
Jan. 2020 - Dec. 2020 $1,410 per calendar quarter
Jan. 2019 - Dec. 2019 $1,360 per calendar quarter
Jan. 2018 - Dec. 2018 $1,320 per calendar quarter
Jan. 2017 - Dec. 2017 $1,300 per calendar quarter
Jan. 2016 - Dec. 2016 $1,260 per calendar quarter
Jan. 2015 - Dec. 2015 $1,220 per calendar quarter
Jan. 2014 - Dec. 2014 $1,200 per calendar quarter
Jan. 2013 - Dec. 2013 $1,160 per calendar quarter
Jan. 2012 - Dec. 2012 $1,130 per calendar quarter
Jan. 2011 - Dec. 2011 $1,120 per calendar quarter
Jan. 2010 - Dec. 2010 $1,120 per calendar quarter
Jan. 2009 - Dec. 2009 $1,090 per calendar quarter
Jan. 2008 - Dec. 2008 $1,050 per calendar quarter
Jan. 2007 - Dec. 2007 $1,000 per calendar quarter
Jan. 2006 - Dec. 2006 $970 per calendar quarter
Jan. 2005 - Dec. 2005 $920 per calendar quarter
Jan. 2004 - Dec. 2004 $900 per calendar quarter
Jan. 2003 - Dec. 2003 $890 per calendar quarter
Jan. 2002 - Dec. 2002 $870 per calendar quarter
[8.200.520.20 NMAC - Rp, 8.200.520.20 NMAC, 8/28/2015; A/E, 1/1/2016; A/E, 03/01/2017; A/E, 5/17/2018; A, 9/11/2018; A/E, 4/11/2019; A, 7/30/2019; A/E, 8/11/2020; A, 12/15/2020; A/E, 4/1/2021; A, 9/1/2021; A/E, 4/1/2022; A, 8/9/2022; A/E, 4/1/2023; A/E, 4/1/2024; A, 8/1/2024; A/E, 4/1/2025]
8.200.520.21 STANDARD OF NEED (SON) :
Budget group size Gross income test Net income test One hundred eighty-five percent Standard of need Standard of need 049/059 Refugee 049/059 Refugee 1 $791 $266 2 $1,072 $357 3 $1,352 $447 4 $1,633 $539 5 $1,913 $630 6 $2,194 $721 7 $2,474 $812 8 $2,755 $922 +1 + $281 + $91
[8.200.520.21 NMAC - Rp, 8.200.520.21 NMAC, 8/28/2015; A/E, 4/1/2016]
HISTORY OF 8.200.520 NMAC: The material in this part was derived from that previously filed with the State Records Center:
8 NMAC 4.MAD.500, Eligibility Policies, Income and Resource Standards, filed 12/30/1994.
8 NMAC 4.MAD.500, Eligibility Policies, Income and Resource Standards, filed 6/20/1995.
History of Repealed Material:
8.200.520 NMAC, Income Standard, filed 12/18/2000 - Repealed effective 1/1/2014.
8.200.520 NMAC, Income Standards, filed 12/2/2013 - Repealed effective 8/28/2015.
TITLE 8 SOCIAL SERVICES
CHAPTER 201 MEDICAID ELIGIBILITY - MEDICAID EXTENSION (CATEGORY 001, 003 and 004)
PART 400 RECIPIENT POLICIES
8.201.400.1 ISSUING AGENCY: New Mexico Health Care Authority.
[ 8.201.400.1 NMAC - Rp, 8.201.400.1 NMAC, 1/1/2019 ; A, 7/1/2024]
8.201.400.2 SCOPE: The rule applies to the general public .
[8.201.400.2 NMAC - Rp, 8.201.400.2 NMAC, 1/1/2019]
8.201.400.3 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 Sections 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.
[8.201.400.3 NMAC - Rp, 8.201.400.3 NMAC, 1/1/2019; A, 7/1/2024]
8.201.400.4 DURATION: Permanent.
[8.201.400.4 NMAC - Rp, 8.201.400.4 NMAC, 1/1/2019]
8.201.400.5 EFFECTIVE DATE: January 1, 2019, unless a later date is cited at the end of the section.
[8.201.400.5 NMAC - Rp, 8.201.400.5 NMAC, 1/1/2019]
8.201.400.6 OBJECTIVE: The objective of these regulations is to provide eligibility policy and procedures for the medicaid program.
[8.201.400.6 NMAC - Rp, 8.201.400.6 NMAC, 1/1/2019]
8.201.400.7 DEFINITIONS: [ RESERVED ]
8.201.400.8 [ RESERVED ]
8.201.400.9 MEDICAID EXTENSION - CATEGORIES 001, 003 AND 004: Medicaid extension (categories 001, 003 and 004) provides coverage for certain groups of individuals who have lost eligibility for supplemental security income (SSI) for specified reasons.
[8.201.400.9 NMAC - Rp, 8.201.400.9 NMAC, 1/1/2019]
8.201.400.10 BASIS FOR DEFINING THE GROUP: Medicaid provides coverage for the following groups of applicants/recipients who have received supplemental security income (SSI) benefits and who have lost their SSI benefits for specified reasons.
A. Pickle and 503 lead cases:
(1) Individuals who were entitled to SSI benefits and who subsequently lose eligibility for SSI solely due to the cost-of-living increase (COLA) in Title II benefits are automatically extended medicaid effective the month after the termination of SSI. These cases are referred to as 503 leads. See Public Law 94-566, Section 503 (also known as the “Pickle Amendment”).
(2) Individuals who lose SSI eligibility for any reason other than the COLA increases (Pickle cases) may be entitled to medicaid if the following conditions exist:
(a) the reason for loss of SSI no longer exists; and
(b) the adjusted income after applying the applicable income disregards is below the current SSI income ceiling federal benefit rate (FBR).
(3) Individuals who received both Title II and SSI benefits after April 1977 and who lost SSI eligibility, but would still be eligible for SSI if the Title II COLAs were deducted from countable income are eligible for medicaid extension. See Lynch V. Rank, 747 F.2d. 528 (9th Cir. 1984). These individuals must meet the requirements for SSI eligibility after the Title II COLAs are deducted.
(a) To determine the countable Title II income, deduct the Title II COLAs received after the last SSI eligibility period using the FBR table compared with the current SSI income ceiling. See 8.200.520 NMAC, Income Standards.
(b) The social security administration (SSA) office identifies applicants/recipients as “Pickle” or “503 lead” cases and the human services department (HSD) disseminates this information to the appropriate income support division (ISD) office. The income support division (ISD) worker approves the case effective the month after the SSI termination.
(c) After identification as a 503 lead or a Pickle case, the SSA office generates a notice to individuals advising them of their right to apply for medicaid .
B. Early widow(er)s:
(1) Widow(er)s between 60 and 64 years of age, who meet the following requirements are eligible for medicaid extension, (Public Law 100-203, which amended Section 1634D of the Social Security Act):
(a) current Title II recipients who were entitled to and received SSI benefits;
(b) subsequently lost eligibility for SSI due to initial receipt of, or increase in, early widow’s or widower’s benefits; and
(c) are not entitled to medicare part A, hospital insurance.
(2) Medicaid coverage is extended until an applicant/recipient either becomes eligible for the hospital insurance under medicare part A or reaches 65 years of age, whichever is earlier.
(3) The ISD worker disregards a Title II widow(er)’s benefit for the purpose of determining eligibility.
C. Child insurance benefits:
(1) Individuals who lose SSI eligibility after July 1, 1987 as a result of entitlement to or receipt of an increase in Title II benefits for disabled adult children (DACs) are eligible for medicaid extension. [Public Law 99-643, Section 6].
(2) The SSA office identifies DACs systematically and HSD alerts the appropriate ISD office to approve the case effective the month after the SSI termination.
(a) Title II DAC benefit is disregarded in determining eligibility.
(b) Title II benefits are awarded from the account(s) of the individual’s parent(s) and, in most instances, can be identified by a claim suffix of “C” following the claim number;
D. Disabled widow(er)s and disabled surviving divorced spouses:
(1) Disabled widow(er)s and disabled surviving divorced spouses who lost SSI on or after January 1, 1991 due to receipt of Title II benefits resulting from the liberalization of the definition of disability. See Section 503 of OBRA 1990. To qualify for medicaid , these applicant/recipients must meet all of the following conditions:
(a) received SSI for the month prior to the month in which they began receiving the Title II benefits;
(b) would continue to be eligible for SSI if the amount of the Title II benefit were not counted as income; and
(c) are not entitled to medicare part A.
(2) These applicants/recipients lose eligibility for medicaid extension when they become entitled to medicare part A.
E. Nonpayment SSI status (E01): Non-institutionalized SSI recipients who lose SSI eligibility due to initial receipt of Title II benefits in an amount exactly equal to the current income ceiling of the SSI program are eligible for medicaid extension (“E01” pay status); medicaid can cover non-institutionalized individuals with a nonpayment SSI status. The ISD worker must verify that the following standards are met:
(1) individual does not reside in an institution. Individuals who appear on the computer system (SDX) in payment status “E01” with living arrangement (LA) code “D” are not eligible for medicaid extension. These individuals lost SSI eligibility because they became institutionalized and their remaining income exceeds the $30 SSI FBR for institutionalized individuals. The ISD worker must evaluate eligibility under institutional care medicaid categories 081, 083 or 084;
(2) individual appears on the system with payment status code “E01” status;
(3) individual has unearned income equal to the current SSI income ceiling; and
(4) individual’s income comes from Title II benefits (source code “A” on the SDX).
F. Revolving SSI payment status “ping-pongs”: Individuals whose payment status “ping-pongs” back and forth between E01 and C01 status are eligible for medicaid extension.
(1) Revolving SSI eligibility due to payment of medicare Part B premiums by medicaid : The SSI recipient starts to receive Title II benefits and is entitled to medicare . The recipient is then entitled to medicaid payment of the part B medicare premium. This results in a recalculation of the Title II benefits. The recalculated Title II benefit equals the exact amount of the SSI income ceiling (SSI FBR). SSI payment status changes to E01 and medicaid stops paying the Part B premium. Without medicaid payment of the Part B premium, the Title II and (SSI) benefits are recomputed and the individual is eligible for SSI payments (C01). The scenario repeats, resulting in the ping-pong effect. Individuals initially eligible for medicaid extension under E01 status lose eligibility when their income exceeds the SSI income ceiling.
(2) Avoidance of revolving eligibility status: To avoid this situation, at the applicant/recipient’s request, he or she can be eligible for medicaid as a medicaid extension case though eligibility can ping-pong back and forth between SSI payment status (C01) and SSI nonpayment status (E01).
(3) Referral process: The SSA refers these individuals to HSD using the “E01-C01 medicaid extension referral form.” The ISD worker enters these applicants/recipients on the eligibility computer system as medicaid extension eligibles. SSA has already established that these individuals meet all SSI criteria except that their Title II benefit equals the exact amount of the SSI income ceiling.
G. Recipients ineligible for SSI cash benefits:
(1) Certain recipients of SSI who become ineligible for cash benefits are automatically extended medicaid benefits for an additional two months following the month in which the SSI case was closed. If the state is paying the recipient’s medicare premiums (buy-in), this benefit is also continued during the period of extended benefits.
(2) Applicants/recipients automatically eligible for two months extended medicaid and buy-in as former SSI recipients are limited to those who lost SSI cash benefit for the following reasons:
(a) E01-Eligible for benefits, but no payment is due based on the payment computation;
(b) N01-Non-pay recipient’s countable income exceeds Title XVI limitations;
(c) N04-Non-pay non-excludable resources exceed Title XVI limitations;
(d) N05-Non-pay recipient’s gross income from self-employment exceeds Title XVI limitations;
(e) N07-Non-pay recipient’s disability ceased;
(f) N08-Non-pay recipient’s blindness ceased;
(g) N12-Non-pay recipient voluntarily withdrew from the program;
(h) N14-Non-pay aged claim denied for age;
( i ) N16-Non-pay disability claim denied. Applicant not disabled;
(j) N19-Non-pay recipient has voluntarily terminated participation in the SSI program;
(k) N27-Non-pay disability terminated due to substantial gainful activity (SGA);
(l) N30-Non-pay slight impairment-medical consideration alone, no visual impairment;
(m) N31-Non-pay capacity for SGA-customary past work, no visual impairment;
(n) N32-Non-pay capacity for SGA-other work, no visual impairment;
(o) N33-Non-pay engaging in SGA despite impairment, no visual impairment;
(p) N34-Non-pay impairment is no longer severe at time of adjudication and did not last 12 months, no visual impairment;
(q) N35-Non-pay impairment is severe at time of adjudication but not expected to last 12 months, no visual impairment;
(r) N41-Non-pay slight impairment-medical condition alone, visual impairment;
(s) N42-Non-pay capacity for SGA-customary work visual impairment;
(t) N43-Non-pay capacity for SGA-other work, visual impairment, or impairment disabling for a period of less than 12 months;
(u) N44-Non-pay engaging in SGA despite impairment, visual impairment.
(v) N45-Non-pay impairment no longer severe at the time of adjudication and did not last 12 months, visual impairment;
(w) N46-Non-pay impairment is severe at the time of adjudication but not expected to last 12 months, visual impairment;
(x) N51-Non-pay impairment does not meet or equal listing (disabled child under 18 only);
(y) S07-Suspended-returned check for other than death, address, payee change, or death of representative payee;
(z) S08-Suspended-representative payee development pending;
(aa) S10-Suspended-adjudicative suspense (system generated);
(bb) S21-Suspended-the recipient is presumptively disabled or blind and has received three months payments;
(cc) T30-Terminated-received payments, but must be re-established to correct SSR;
(dd) T31-Terminated-system generated termination (payment previously made). Recipient met denial or non-pay terminated criteria;
( ee ) T33-Terminated-manual termination (previous payment made).
(3) Ex- Parte Review: Individuals who lose SSI eligibility, who are automatically extended for two months, per one of the reasons in Subsection G of 8.201.400.10 NMAC, are automatically evaluated for another medicaid category of eligibility before their extension period expires. If determined eligible the new medicaid category begins the month following the two month extension period.
[8.201.400.10 NMAC - Rp, 8.201.400.10 NMAC, 1/1/2019]
8.201.400.11 GENERAL RECIPIENT REQUIREMENTS:
[8.201.400.11 NMAC - Rp, 8.201.400.11 NMAC, 1/1/2019]
8.201.400.12 ENUMERATION: An applicant/recipient must furnish his or her social security number in accordance with 8.200.410.10 NMAC.
[8.201.400.12 NMAC - Rp, 8.201.400.12 NMAC, 1/1/2019]
8.201.400.13 CITIZENSHIP: Refer to Medical Assistance Program Manual Section 8.200.410.11 NMAC.
[8.201.400.13 NMAC - Rp, 8.201.400.13 NMAC, 1/1/2019]
8.201.400.14 RESIDENCE: Applicants/recipients must be physically present in New Mexico and have demonstrated intent to remain in the state. If an applicant/recipient does not have the present mental capacity to declare intent, a parent, guardian, or adult child may assume responsibility for the declaration of intent. If an applicant/recipient does not have the present mental capacity to declare intent and there is no guardian or relative to assume responsibility for a declaration of intent, the state where the applicant/recipient is living is recognized as the state of residence. Temporary absence from the state does not prevent eligibility. A temporary absence exists when an applicant/recipient leaves the state for a specific purpose with a time-limited purpose and intends to return to New Mexico when that purpose has been accomplished. Applicants/recipients who are eligible for New Mexico medicaid are terminated if they move out of state.
[8.201.400.14 NMAC - Rp, 8.201.400.14 NMAC, 1/1/2019]
8.201.400.15 NONCONCURRENT RECEIPT OF ASSISTANCE: To be eligible for medicaid extension under the 503 leads and Pickle group, an applicant/recipient must have been eligible for, and have received, both Title II and SSI benefits concurrently in any month that he/she is currently receiving Title II benefits.
[8.201.400.15 NMAC - Rp, 8.201.400.15 NMAC, 1/1/2019]
8.201.400.16 SPECIAL RECIPIENT REQUIREMENTS: To be eligible for medicaid extension, an applicant/recipient must be aged, blind, or disabled as defined by the social security administration (SSA). This determination is made by SSA prior to applicable for medicaid extension.
[8.201.400.16 NMAC - Rp, 8.201.400.16 NMAC, 1/1/2019]
8.201.400.17 AGE: Applicants/recipients for medicaid extension must meet the age requirements as specified in 8.201.400.10 NMAC, Basis for Defining the Group.
[8.201.400.17 NMAC - Rp, 8.201.400.17 NMAC, 1/1/2019]
8.201.400.18 RECIPIENT RIGHTS AND RESPONSIBILITIES: An applicant/recipient is responsible for establishing his/her eligibility for medicaid . As part of this responsibility, the applicant/recipient must provide required information and documents or take the actions necessary to establish eligibility. Failure to do so must result in a decision that eligibility does not exist. An applicant/recipient must also grant HSD permission to contact other persons, agencies or sources of information which are necessary to establish eligibility.
[8.201.400.18 NMAC - Rp, 8.201.400.18 NMAC, 1/1/2019]
8.201.400.19 ASSIGNMENT OF MEDICAL SUPPORT: Refer to Medical Assistance Program Manual Subsection F of 8.200.420.12 NMAC.
[8.201.400.19 NMAC - Rp, 8.201.400.19 NMAC, 1/1/2019]
8.201.400.20 REPORTING REQUIREMENTS: Medicaid applicant/recipients must report any change in circumstances which may affect eligibility to the local income support division (ISD) office within 10 days of the change.
[8.201.400.20 NMAC - Rp, 8.201.400.20 NMAC, 1/1/2019]
HISTORY OF 8.201.400 NMAC:
Pre-NMAC History: The material in this part was derived from that previously filed with the State Records Center:
ISD 370.0000, Procedures for Retroactive Supplemental Security Income (SSI) Medicaid and Medicaid Extension, filed 5/26/1980.
ISD 370.0000, Procedures for Retroactive Supplemental Security Income (SSI) Medicaid and Medicaid Extension, filed 1/26/1982.
MAD Rule 370.0000, Procedures for Retroactive Supplemental Security Income (SSI) Medicaid and Medicaid Extension, filed 12/1/1987.
MAD Rule 870, Retroactive Medicaid Coverage, filed 1/31/1990.
MAD Rule 870, Retroactive Medicaid Coverage, filed 3/11/1992.
MAD Rule 870, Retroactive Medicaid Coverage, filed 11/16/1994.
MAD Rule 372.0000, Medicaid Extension, 12/1/1987.
MAD Rule 872, Medicaid Extension, filed 1/31/1990.
MAD Rule 872, Medicaid Extension, filed 3/11/1992.
MAD Rule 872, Medicaid Extension, filed 8/20/1992.
MAD Rule 872, Medicaid Extension, filed 9/26/1994.
History of Repealed Material:
MAD Rule 872, Medicaid Extension, filed 9/26/1994 - Repealed effective 2/1/1995.
8.201.400 NMAC - Recipent Policies, filed 6/11/2203 - Repealed effective 1/1/2019.
TITLE 8 SOCIAL SERVICES
CHAPTER 201 MEDICAID ELIGIBILITY - MEDICAID EXTENSION (CATEGORY 01, 03 and 04)
PART 500 INCOME AND RESOURCE STANDARDS
8.201.500.1 ISSUING AGENCY: New Mexico Health Care Authority.
[8.201.500.1 NMAC - Rp 8.201.500.1 NMAC 7/1/2024]
8.201.500.2 SCOPE: The rule applies to the general public .
[8.201.500.2 NMAC - Rp 8.201.500.2 NMAC 7/1/2024]
8.201.500.3 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.
[8.201.500.3 NMAC - Rp 8.201.500.3 NMAC 7/1/2024]
8.201.500.4 DURATION: Permanent.
[8.201.500.4 NMAC - Rp 8.201.500.4 NMAC 7/1/2024]
8.201.500.5 EFFECTIVE DATE: July 1, 2024, unless a later date is cited at the end of a section.
[8.201.500.5 NMAC - Rp 8.201.500.5 NMAC 7/1/2024]
8.201.500.6 OBJECTIVE: The objective of these regulations is to provide eligibility policy and procedures for the medicaid program.
[8.201.500.6 NMAC - Rp 8.201.500.6 NMAC 7/1/2024]
8.201.500.7 DEFINITIONS: [ RESERVED ]
8.201.500.8 [ RESERVED ]
8.201.500.9 NEED DETERMINATION: [RESERVED]
[8.201.500.9 NMAC - Rp 8.201.500.9 NMAC 7/1/2024]
8.201.500.10 RESOURCE STANDARDS: To be eligible for medicaid extension, applicants/recipients must meet SSI resource standards. Recipients initially eligible for medicaid extension under E01 status lose eligibility when their resources exceed the SSI resource maximum. See 8.215.500.11 NMAC, resource standards, for information on exclusions, disregards, and countable resources.
[8.201.500.10 NMAC - Rp 8.201.500.10 NMAC 7/1/2024]
8.201.500.11 RESOURCE TRANSFERS: The social security administration excluded transfer of resources as a factor of eligibility for non-institutionalized SSI recipients. Transfer of resources is not a factor for consideration in categories that use SSI methodology in the eligibility determination.
[8.201.500.11 NMAC - Rp 8.201.500.11 NMAC 7/1/2024]
8.201.500.12 TRUSTS: See 8.281.510 NMAC and following subsections.
[8.201.500.12 NMAC - Rp 8.201.500.12 NMAC 7/1/2024]
8.201.500.13 INCOME STANDARDS: To be eligible for medicaid extension, an applicant/recipient must have countable income below the SSI FBR. See 8.215.500.18 NMAC, income, through 8.215.500.22 NMAC, disregards , for information on exclusions, disregards, and countable income.
[8.201.500.13 NMAC - Rp 8.201.500.13 NMAC 7/1/2024]
8.201.500.14 COMPUTATION OF COLA DISREGARDS IN PICKLE AND 503 LEADS CASES:
A. An applicant/recipient's countable income, after exclusion of the Title II COLAs received following SSI termination, must be less than the current SSI federal benefit rate (FBR).
B. To determine the total amount of the applicant/recipient's Title II COLAs received since the applicant/recipient lost SSI, the following calculation must be completed:
(1) divide the current Title II amount by the percentage amount of the previous year's COLA;
(2) repeat this calculation for each Title II COLA benefit received after the applicant lost SSI; computations are based on the previous year's COLA and previous benefit; see 8.200.520.12 NMAC, COLA disregard computation , of 503 leads and pickle cases;
(3) when the last computation is completed, the result is the Title II benefit amount the applicant/ recipient was receiving when they lost SSI;
(4) subtract this amount from the current Title II benefit amount; the result is the aggregate Title II COLAs the applicant/recipient received after losing SSI; and
(5) subtract the aggregate COLAs from the applicant/recipient's countable income to determine if the income is below the current SSI FBR.
C. If the resulting income is below the current SSI FBR, and the applicant/recipient meets all other requirements for SSI, they are eligible for medicaid extension.
[8.201.500.14 NMAC - Rp 8.201.500.14 NMAC 7/1/2024]
8.201.500.15 DEEMED INCOME: If an applicant/recipient is a minor who lives with a parent(s), deemed income from the parent(s) must be considered. If an applicant/recipient is married and lives with a spouse, deemed income from the spouse must be considered. See 8.215.500.21 NMAC, deemed income , for information on deemed income. If an applicant/recipient has a spouse or parent who receives Title II benefits, all COLAs received by the spouse/parent since the applicant/recipient lost SSI are deducted from the spouse/parent's income before it is deemed to the applicant/recipient.
[8.201.500.15 NMAC - Rp 8.201.500.15 NMAC 7/1/2024]
8.201.500.16 [ RESERVED ]
[8.201.500.16 NMAC - Rp 8.201.500.16 NMAC 7/1/2024]
HISTORY OF 8.201.500 NMAC:
Pre-NMAC History: The material in this part was derived from that previously filed with the State Records Center:
ISD 370.0000, Procedures for Retroactive Supplemental Security Income (SSI) Medicaid and Medicaid Extension, filed 5/26/1980.
ISD 370.0000, Procedures for Retroactive Supplemental Security Income (SSI) Medicaid and Medicaid Extension, filed 1/26/1982.
MAD Rule 370.0000, Procedures for Retroactive Supplemental Security Income (SSI) Medicaid and Medicaid Extension, filed 12/1/1987.
MAD Rule 870, Retroactive Medicaid Coverage, filed 1/31/1990.
MAD Rule 870, Retroactive Medicaid Coverage, filed 3/11/1992.
MAD Rule 870, Retroactive Medicaid Coverage, filed 11/16/1994.
MAD Rule 372.0000, Medicaid Extension, 12/1/1987.
MAD Rule 872, Medicaid Extension, filed 1/31/1990.
MAD Rule 872, Medicaid Extension, filed 3/11/1992.
MAD Rule 872, Medicaid Extension, filed 8/20/1992.
MAD Rule 872, Medicaid Extension, filed 9/26/1994.
History of Repealed Material:
MAD Rule 872, Medicaid Extension, filed 9/26/1994 - Repealed effective 2/1/1995.
8.201.500 NMAC - Income And Resource Standards (filed 9/2/2009), Repealed effective 7/1/2024.
Other: 8.201.500 NMAC - Income And Resource Standards (filed 9/2/2009), Replaced by 8.201.500 NMAC - Income And Resource Standards effective 7/1/2024.
TITLE 8 SOCIAL SERVICES
CHAPTER 201 MEDICAID ELIGIBILITY - MEDICAID EXTENSION (CATEGORY 001, 003 and 004)
PART 600 BENEFIT DESCRIPTION
8.201.600.1 ISSUING AGENCY: New Mexico Health Care Authority.
[ 8.201.600.1 NMAC - Rp, 8.201.600.1 NMAC, 1/1/2019 ; A, 7/1/2024]
8.201.600.2 SCOPE: The rule applies to the general public .
[8.201.600.2 NMAC - Rp, 8.201.600.2 NMAC, 1/1/2019]
8.201.600.3 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.
[8.201.600.3 NMAC - Rp, 8.201.600.3 NMAC, 1/1/2019; A, 7/1/2024]
8.201.600.4 DURATION: Permanent.
[8.201.600.4 NMAC - Rp, 8.201.600.4 NMAC, 1/1/2019]
8.201.600.5 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.
[8.201.600.5 NMAC - Rp, 8.201.600.5 NMAC, 1/1/2019]
8.201.600.6 OBJECTIVE: The objective of these regulations is to provide eligibility policy and procedures for the medicaid program.
[8.201.600.6 NMAC - Rp, 8.201.600.6 NMAC, 1/1/2019]
8.201.600.7 DEFINITIONS: [ RESERVED ]
8.201.600.8 [ RESERVED ]
8.201.600.9 BENEFIT DESCRIPTION: Applicants/recipients of medicaid extension receive the full range of medicaid -covered services.
[8.201.600.9 NMAC - Rp, 8.201.600.9 NMAC, 1/1/2019]
8.201.600.10 BENEFIT DETERMINATION: Application for the medicaid extension is made on the assistance application form. Applications must be acted on and notice sent to the applicant of the action taken within 45 days after the date of application. 503 lead cases, disabled adult child (DACs), and ping-pongs nonpayment SSI status (E01), SSI child cases, and SSI extension cases do not require a separate application for initial processing.
[8.201.600.10 NMAC - Rp, 8.201.600.10 NMAC, 1/1/2019]
8.201.600.11 INITIAL BENEFITS: When an eligibility determination is made, notice of the approval or denial is sent to the applicant. If the application is denied, this notice includes the reason for the denial and an explanation of rights to an administrative hearing.
[8.201.600.11 NMAC - Rp, 8.201.600.11 NMAC, 1/1/2019]
8.201.600.12 ONGOING BENEFITS: A periodic review is completed at least every 12 months.
[8.201.600.12 NMAC - Rp, 8.201.600.12 NMAC, 1/1/2019]
8.201.600.13 SSI EXTENSION RETROACTIVE BENEFIT COVERAGE: Retroactive medicaid coverage is provided in accordance with 8.200.400.14 NMAC.
[8.201.600.13 NMAC - Rp, 8.201.600.13 NMAC, 1/1/2019]
8.201.600.14 CHANGES IN ELIGIBILITY: If a recipient becomes ineligible, advance notice of the closure is sent by the ISD worker. If a recipient dies, the case is closed effective the following month.
[8.201.600.14 NMAC - Rp, 8.201.600.14 NMAC, 1/1/2019]
HISTORY OF 8.201.600 NMAC:
Pre-NMAC History: The material in this part was derived from that previously filed with the State Records Center:
ISD 370.0000, Procedures for Retroactive Supplemental Security Income (SSI) Medicaid and Medicaid Extension, filed 5/26/1980.
ISD 370.0000, Procedures for Retroactive Supplemental Security Income (SSI) Medicaid and Medicaid Extension, filed 1/26/1982.
MAD Rule 370.0000, Procedures for Retroactive Supplemental Security Income (SSI) Medicaid and Medicaid Extension, filed 12/1/1987.
MAD Rule 870, Retroactive Medicaid Coverage, filed 1/31/1990.
MAD Rule 870, Retroactive Medicaid Coverage, filed 3/11/1992.
MAD Rule 870, Retroactive Medicaid Coverage, filed 11/16/1994.
MAD Rule 372.0000, Medicaid Extension, 12/1/1987.
MAD Rule 872, Medicaid Extension, filed 1/31/1990.
MAD Rule 872, Medicaid Extension, filed 3/11/1992.
MAD Rule 872, Medicaid Extension, filed 8/20/1992.
MAD Rule 872, Medicaid Extension, filed 9/26/1994.
History of Repealed Material:
MAD Rule 872, Medicaid Extension, filed 9/26/1994 - Repealed effective 2/1/1995.
8.201.600 NMAC - Medicaid Eligibility - Medical Extension - Benefit Description filed 9/2/2009 - Repealed effective 1/1/2019.
TITLE 8 SOCIAL SERVICES
CHAPTER 206 MEDICAID ELIGIBILITY - RECIPIENTS FOR WHOM CYFD HAS FULL OR PARTIAL RESPONSIBILITY
PART 400 RECIPIENT REQUIREMENTS
8.206.400.1 ISSUING AGENCY: New Mexico Health Care Authority.
[8.206.400.1 NMAC - Rp, 8.206.400.1 NMAC, 10/1/2015; A, 7/1/2024]
8.206.400.2 SCOPE: The rule applies to the general public .
[8.206.400.2 NMAC - Rp, 8.206.400.2 NMAC, 10/1/2015]
8.206.400.3 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 Section 27-1-12 et seq. NMSA 1978. 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.
[8.206.400.3 NMAC - Rp, 8.206.400.3 NMAC, 10/1/2015; A, 7/1/2024]
8.206.400.4 DURATION: Permanent.
[8.206.400.4 NMAC - Rp, 8.206.400.4 NMAC, 10/1/2015]
8.206.400.5 EFFECTIVE DATE: October 1, 2015, unless a later date is cited at the end of a section.
[8.206.400.5 NMAC - Rp, 8.206.400.5 NMAC, 10/1/2015]
8.206.400.6 OBJECTIVE: The objective of this rule is to provide specific instructions when determining eligibility for the medicaid program and other health care programs. Generally, applicable eligibility rules are detailed in the medical assistance division (MAD) medical assistance programs (MAP) eligibility manual, specifically 8.200.400 NMAC, General Medicaid Eligibility . Processes for establishing and maintaining MAP eligibility are detailed in the income support division (ISD) general provisions 8.100 NMAC, General Provisions for Public Assistance Programs .
[8.206.400.6 NMAC - Rp, 8.206.400.6 NMAC, 10/1/2015]
8.206.400.7 DEFINITIONS:
A. “Full or partial financial responsibility” means a payment has been made by the children, youth and families department (CYFD) on behalf of the eligible recipient during each month for which MAP eligibility is sought. The nature of CYFD’s financial responsibility must be documented. Documentation must include either the court-ordered placement or custody award, and CYFD payments made on behalf of the eligible recipient at the time of application and each subsequent periodic review.
B. “Private institutions” includes accredited and non-accredited residential treatment centers and group homes, and treatment foster care. Institutions specifically excluded from this definition are the youth diagnostic development center, New Mexico boys and girls schools and reintegration centers which are not certified to furnish medical care. A child placed in one of these facilities is not eligible for a MAP category of eligibility.
C. “Substitute care placement” includes placement in a foster home or private institution.
[ 8.206.400.7 NMAC - Rp, 8.206.400.7 NMAC, 10/1/2015 ]
8.206.400.8 MISSION: 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.
[ 8.206.400.8 NMAC - Rp, 8.206.8 NMAC, 10/1/2015 ]
8.206.400.9 MAP CATEGORY OF CYFD ELIGIBILITY:
A. MAD is required to furnish coverage to an eligible recipient under 18 years of age for whom adoption assistance or foster care maintenance payments are made under Title IV-E of the Social Security Act )42 CFR Section 436.118).
B. MAD has opted to furnish coverage to an eligible recipient under 18 years of age who meets a MAP category of temporary assistance for needy families (TANF) eligibility requirements except for the definition of “dependent child” for whom CYFD has assumed full or partial financial responsibility (42 CFR Section 436.222).
C. MAD furnishes extended coverage to an eligible recipient over 18 years of age but under 21 years of age who is receiving Chafee independent living assistance.
[8.206.400.9 NMAC - Rp, 8.206.400.9 NMAC, 10/1/2015]
8.206.400.10 MAP CATEGORY OF PATIENT PROTECTION AND AFFORDABLE CARE ACT (ACA) ELIGIBILITY: MAD furnishes extended coverage under the Patient Protection and Affordable Care Act (ACA) to a former foster care recipient up to 26 years of age regardless if he or she also meets a MAP category of other adult eligibility when:
A. the applicant or recipient is a current resident of New Mexico; and
B. the applicant or recipient was in a medical assistance program in New Mexico or any other state at the time he or she turned 18 years of age or aged out of his or her foster care system; and
C. the applicant is not receiving supplemental security income (SSI).
[8.206.400.10 NMAC - N, 10/1/2015]
8.206.400.11 BASIS FOR DEFINING THE GROUP: An eligible recipient 18 years of age or under can be eligible for a MAP category of CYFD eligibility if New Mexico bears full or partial responsibility for the eligible recipient and makes a payment on behalf of him or her. An eligible recipient 18 years of age or under will be assigned one of the following MAP categories of eligibility.
A. Category 017: The eligible recipient resides in New Mexico and receives a Title IV-E adoptive subsidy from another state.
B. Category 037: The eligible recipient resides in New Mexico and receives a Title IV-E adoptive subsidy from New Mexico.
C. Category 046: The eligible recipient resides out-of-state and receives a Title IV-E foster care payment from New Mexico. A MAP card is issued by the state in which the eligible recipient resides.
D. Category 047: The eligible recipient currently resides out-of-state and receives a Title IV-E adoption subsidy payment. MAP is issued by the state in which the eligible recipient resides.
E. Category 066: The eligible recipient is in the child protective service component of CYFD and is IV-E eligible or is from a home that meets TANF eligibility requirements.
F. Category 086: The eligible recipient resides in New Mexico, is in the custody of another state and receives Title IV-E foster care payment from that state.
[8.206.400.11 NMAC - Rp, 8.206.400.10 NMAC, 10/1/2015]
8.206.400.12 LIVING ARRANGEMENTS: To be eligible for CYFD medicaid , an individual must be under 18 years of age and must be in a substitute care placement or temporarily in a medical facility with an ultimate plan to be placed in substitute care arrangement.
A. Removal from home: An individual who is in the custody of his or her parent or guardian is not eligible for medicaid . When a CYFD medicaid eligible recipient is returned to his or her parent or guardian’s custody, CYFD medicaid is terminated.
B. Release from jurisdiction of non-Title XIX facility: An eligible recipient who is released from the jurisdiction and control of the correctional system for whom CYFD has full or partial financial responsibility and is in a substitute care placement can be eligible for CYFD medicaid beginning the first of the month after release from the correctional system if all other eligibility criteria are met.
(1) Permanent release from jurisdiction requirements: An individual living in a correctional facility or under the jurisdiction and control of the correctional system is not eligible for MAD services. This includes an individual temporarily released from a correctional facility for the sole purpose of receiving medical treatment.
(2) Documentation of release: To document that the individual is no longer under the jurisdiction and control of the correctional system, the individual must be permanently released from the correction facility and the court or parole order must specify the following:
(a) the individual is in the custody of CYFD; or
(b) CYFD is required to make monthly payment for the care, maintenance and medical treatment of the individual; in addition, the individual must receive or be evaluated for (or both) the receipt of long-term medical treatment.
C. Independent living arrangements: MAD furnishes extended coverage to an eligible recipient between 18 and 21 years of age who is considered to be in an independent living arrangement if foster care payment is made to the eligible recipient and he or she meets all other MAD eligibility criteria.
[8.206.400.12 NMAC - Rp, 8.206.400.11 NMAC, 10/1/2015]
8.206.400.13 ENUMERATION: See 8.200.410 NMAC.
[8.206.400.13 NMAC - Rp, 8.206.400.13 NMAC, 10/1/2015]
8.206.400.14 CITIZENSHIP: See 8.200.410 NMAC.
[8.206.400.14 NMAC - Rp, 8.206.400.14 NMAC, 10/1/2015]
8.206.400.15 RESIDENCE: See 8.200.410 NMAC.
[8.206.400.15 NMAC - Rp, 8.206.400.15 NMAC, 10/1/2015]
8.206.400.16 AGE: To meet the requirements for a MAP category of CYFD eligibility, an applicant or re-determining recipient must be under 18 years of age, except as outlined in Section 9 and 10 of this rule.
A. Students under 19: When an eligible recipient reaches 18 years of age, he or she loses MAP eligibility unless (1) he or she is a full-time student in a secondary school or its equivalent and (2) he or she is expected to complete the program before reaching 19 years of age. In such cases, his or her MAP category of CYFD eligibility is terminated when he or she leaves school or upon his or her 19 th birthday, whichever comes first. School attendance must be verified each semester as part of the recipient’s MAP re-determination process.
B. Proof of age: The following documents constitute primary evidence of age:
(1) birth certificate;
(2) adoption papers or records;
(3) hospital or clinic records;
(4) church or baptismal records;
(5) bureau of vital statistics or local government records;
(6) United States passports or immigration and naturalization service’s records;
(7) American Indian census reports; or
(8) birth records maintained by the social security administration (SSA).
C. If the age of the applicant or re-determining recipient cannot be established using primary evidence, a minimum of two pieces of corroborating secondary evidence must be used to establish his or her age, such as school records, census records, a court support order not generated by CYFD, his or her physical health practitioner’s statement, juvenile court records not generated by CYFD, child welfare records not generated by CYFD, voluntary social services agency records, insurance policies, minister’s signed statement, affidavits or military records.
[8.206.400.16 NMAC - Rp, 8.206.400.18 NMAC, 10/1/2015]
8.206.400.17 ASSIGNMENT OF MEDICAL SUPPORT: MAD has established requirements of CYFD when the applicant or re-determining recipient meets a MAP category of CYFD eligibility; see 8.200.420 NMAC.
A. CYFD requirements: The authorized representative of CYFD who signs the MAP eligibility application on behalf of the applicant or re-determining recipient must notify MAD of any available third-party medical coverage.
B. CYFD responsibilities for cooperation with HSD child support enforcement division (CSED): CYFD is responsible for cooperating with CSED activities which include:
(1) identifying and locating the absent parent(s) of the eligible recipient receiving MAD services;
(2) establishing paternity of the applicant whose parents were not legally married at the time of his or her birth;
(3) obtaining child and medical support for the applicant or re-determining recipient;
(4) identifying and providing information necessary to pursue third-party health coverage; and
(5) developing procedures for referrals and determination of good cause for not pursuing child support or not requiring cooperation in pursuing such support.
[8.206.400.17 NMAC - Rp, 8.206.400.19 NMAC, 10/1/2015]
8.206.400.18 REPORTING REQUIREMENTS: When an applicant or re-determining recipient is approved for a MAP category of CYFD eligibility, the authorized CYFD representative must report within 10 calendar days any known change in the eligible recipient’s circumstances which may affect his or her continued eligibility.
[8.206.400.18 NMAC - Rp, 8.206.400.20 NMAC, 10/1/2015]
HISTORY OF 8.206.400 NMAC:
History of Repealed Material:
8 NMAC 4.CYM.430 Recipient Rights and Responsibilities, filed 12/30/1994 - Repealed effective 7/1/2003.
8.206.400 NMAC, Recipient Policies, filed 6/11/2003 - Repealed effective 1/1/2014.
8.206.400 NMAC, Recipient Requirements, filed 12/2/2013 - Repealed effective 10/1/2015.
TITLE 8 SOCIAL SERVICES
CHAPTER 206 MEDICAID ELIGIBILITY - CYFD CHILDREN (CATEGORIES 006, 017, 037, 046, 047, 060, 061, 066 & 086)
PART 500 INCOME AND RESOURCE STANDARDS
8.206.500.1 ISSUING AGENCY: New Mexico Health Care Authority.
[8. 206.500 .1 NMAC - Rp 8.206.500.1 NMAC, 7/1/2024]
8.206.500.2 SCOPE: This rule applies to the general public .
[8. 206.500 .2 NMAC - Rp 8.206.500.2 NMAC, 7/1/2024]
8.206.500.3 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. 206.500 .3 NMAC - Rp 8.206.500.3 NMAC, 7/1/2024]
8.206.500.4 DURATION: Permanent.
[8. 206.500 .4 NMAC - Rp 8.206.500.4 NMAC, 7/1/2024]
8.206.500.5 EFFECTIVE DATE: July 1, 2024, unless a later date is cited at the end of a section.
[8. 206.500 .5 NMAC - Rp 8.206.500.5 NMAC, 7/1/2024]
8.206.500.6 OBJECTIVE: The objective of these regulations is to provide eligibility policy and procedures for the medicaid program.
[8. 206.500 .6 NMAC - Rp 8.206.500.6 NMAC, 7/1/2024]
8.206.500.7 DEFINITIONS: [ RESERVED ]
8.206.500.8 [ RESERVED ]
8.206.500.9 [RESERVED]
8.206.500.10 RESOURCE STANDARDS: To be eligible for CYFD medicaid , the value of all countable personal and real property, considered belonging to or available to an applicant/recipient under 18 years of age or 21 years of age in expanded foster care medicaid category 006 or 066 cannot exceed $1,000. If an applicant/recipient owns resource or saving in excess of this amount, they are not eligible for CYFD medicaid .
[8. 206.500 .10 NMAC - Rp 8.206.500.10 NMAC, 7/1/2024]
8.206.500.11 APPLICABLE RESOURCE STANDARDS: The authorized representative from CYFD who completes the application on behalf of the applicant/recipient must initiate all appropriate steps to make available property or resources to which the applicant/recipient may be entitled. Normally, individuals under 18 do not own/control property. Property that is held or controlled on behalf of an applicant/recipient is considered available unless some specific provision in the title to the property precludes it availability.
A. Property not readily marketable: Even property that is not marketable must be assessed in the eligibility determination and is subject to transfer restrictions and penalties.
B. Property share owned: The current value of property which must be partitioned to be accessible is not considered available if the net value after estimated costs of partition and other closing costs is less than the resource limit. If the amount likely to be derived from the sale of the applicant/recipient's share of the property exceeds the resource limit, they must initiate attempts to obtain their share of the property.
C. Property owned by parent: The value of property owned by the parent who does not live with the applicant/recipient is not considered available to the applicant/recipient.
[8. 206.500 .11 NMAC - Rp 8.206.500.11 NMAC, 7/1/2024]
8.206.500.12 COUNTABLE RESOURCES: Countable resources include but are not limited to the following:
A. cash value of life insurance policy owned by the applicant/recipient;
B. cash, bank accounts and other readily negotiable assets owned by the applicant/recipient are countable resources;
C. equipment, tools, and motor vehicles (which do not fit the vehicle exemption);
D. livestock; and
E. asset conversion; money received from one-time or sporadic sales of real or personal property such as crops, rugs, or jewelry is considered a resource if the property is not sold or transferred in connection with a business of self-employment activity.
(1) Actual verified expenses associated with the purchase, sale, or production of the property are deducted from money received from the sale to arrive at the net resource value.
(2) Property converted into money is subject to the resource limitation regardless of whether it was fully or partially exempt prior to conversion.
[8. 206.500 .12 NMAC - Rp 8.206.500.12 NMAC, 7/1/2024]
8.206.500.13 RESOURCE EXCLUSIONS: Certain resources are excluded from the resource computation.
A. Vehicle exclusion: The equity value of one vehicle belonging to the applicant/recipient or in their name, is not considered a countable resource if the value of the vehicle is $1,500 or less. Any excess over $1,500 is a countable resource. The value of any apparatus for the handicapped which is installed on the vehicle is also excluded.
B. Income exclusion: Any income which is excluded under income provisions is also excluded from consideration as a resource. Excluded income which is saved must be kept separate from non-excluded savings.
C. Settlement fund payment exclusion: Payments received from the Radiation Exposure Compensation Act is excluded. Payments made under the Agent Orange Settlement Act is also excluded. Payments by the remembrance, responsibility and the future foundation to individual survivors forced into slave labor by the Nazis are excluded.
D. Earned income tax credit payment exclusion: Earned income tax credit payments are not considered resources until the third month after receipt of the payment.
E. Funeral agreement exclusion: The equity value of funeral agreement(s) owned by the applicant/recipients which do not exceed $1,500 are excluded.
F. Contingent and unliquidated claim exclusion: "Contingent and unliquidated claim" is defined as a yet unnamed right of the applicant/recipient to receive, at some future time, a resource such as an interest in an unprobated estate or damages/compensation from an accident or injury. These claims are excluded if the applicant/recipient can demonstrate that they have consulted an attorney or that under the circumstances it is reasonable not to have consulted an attorney but that they are making effort to prosecute their claim or to proceed with the probate. If the applicant/recipient can demonstrate that their share in an unprobated estate would be less than the expense of the proceeding to probate the estate, the value is not considered a resource.
G. Chafee medicaid : All resources belonging to recipients of chafee medicaid who are between 18 and 21 years of age are excluded.
[8. 206.500 .13 NMAC - Rp 8.206.500.13 NMAC, 7/1/2024]
8.206.500.14 RESOURCE TRANSFERS: To be eligible for CYFD Medicaid, the applicant/recipient must not have transferred resources within two years prior to application for the purpose of qualifying for CYFD medicaid . An applicant/recipient under eighteen years of age cannot transfer property, except through a guardian. Normally, such applicants/recipients do not own property in their own right . If facts indicate the existences of a trust, inheritance, or prior gift, the CYFD representative completing the application must determine if a transfer has taken place within the two year period.
A. Transfers made for the purpose of qualifying for medicaid : A transfer is considered to have been made for the purpose of becoming eligible if:
(1) the transfer was made without a reasonable return; and
(2) the applicant/recipient had no reasonable plan for support at the time of the transfer other than receiving CYFD medicaid .
(3) if the value of the applicant/recipient's equity in the transferred property plus all other countable resources is less than $1,000, the transfer is not considered to be for the purpose of becoming eligible.
B. Definitions:
(1) "Transfer" includes the sale, transfer by gift, or conveyance by deed or any other method of transferring the title to the property. The transfer can be for either the title to real property or any other interest or rights in real property, such as mineral rights.
(2) "Reasonable return" is considered to have been received when the applicant/recipient received compensation in cash or in kind equals the value of the property at the time of transfer. This determination is based on the applicant/recipient's equity interest in the property at the time of transfer.
C. Attempts to obtain reasonable return: If the property was transferred for the purpose of becoming eligible but the applicant/recipient subsequently makes and continues to make efforts to obtain a reasonable return or regain the title, the applicant/recipient is not ineligible because of the improper transfer of resources.
D. Period of ineligibility: If a transfer without fair return was made for the purpose of becoming eligible for CYFD Medicaid, the applicant/recipient is ineligible for a period of 24 months beginning with the month the resources were transferred.
[8. 206.500 .14 NMAC - Rp 8.206.500.14 NMAC, 7/1/2024]
8.206.500.15 TRUSTS: If an applicant/recipient is the beneficiary of a trust fund, a copy of the trust document and any other documents pertaining to the creation of the trust must be submitted to the eligibility unit of the medical assistance division for coordination of the trust analysis with the HCA’s office of general counsel.
[8. 206.500 .15 NMAC - Rp 8.206.500.15 NMAC, 7/1/2024]
8.206.500.16 INCOME STANDARDS:
A. To be eligible for CYFD medicaid , the applicant/recipient's income must be less than the maximum aid to families with dependent children (AFDC) standard for one person. See 8.200.520.10 NMAC, Income Standards . Any earned and unearned income that belongs to the applicant/recipient must be totaled and compared to the standard.
B. The authorized representative of CYFD who completes the medicaid application on behalf of the applicant/recipient must take all necessary steps to apply for or obtain any other income which the applicant/recipient may qualify for when the individual becomes aware of the income. If income becomes available to the applicant/recipient, their eligibility for CYFD medicaid must be re-evaluated.
C. Sources of potential income include social security, veterans benefits, supplement security income, trust funds, and contingent claims.
[8. 206.500 .16 NMAC - Rp 8.206.500.16 NMAC, 7/1/2024]
8.206.500.17 EARNED INCOME:
A. If an applicant/recipient of CYFD medicaid has earned income and is not a full-time student in elementary school, high school, or a course of vocational or technical training, their earnings are considered in the earned income calculation.
B. Earned income exclusions:
(1) Exclusion for full-time students: If an applicant/recipient of CYFD medicaid has earned income and is a full-time student in elementary school, high school, or in a course of vocational or technical training, their earnings are totally excluded.
(2) Job Training Partnership Act (JTPA) earnings and earned income tax credit exclusion: JTPA earning/reimbursement and earned income tax credit payments are excluded from consideration as income regardless of whether the applicant/recipient is a full-time student.
(3) Work-related expense disregard: An applicant/recipient of CYFD medicaid with earned income from employment is entitled to a deduction of $90 from gross monthly earnings for work-related expenses.
(4) Census bureau employment: Wages paid by the census bureau for temporary employment related to the census are excluded from consideration as income in the eligibility determination process.
(5) Recipients of Chafee medicaid : All earned income of an applicant/recipient between 18 and 21 years of age is excluded while receiving chafee independent living assistance from CYFD.
[8. 206.500 .17 NMAC - Rp 8.206.500.17 NMAC, 7/1/2024]
8.206.500.18 UNEARNED INCOME: Unearned incomes includes but is not limited to social security benefits, child support, gifts, contributions, and all other cash income which does not meet the definition of earned income. Unearned income is counted in the gross amount received.
A. Unearned income exclusions and disregards: Certain amounts of unearned income are excluded from the computation of unearned income.
(1) Educational assistance exclusions: Bona fide loans from private individuals or commercial institutions for education assistance are excluded from unearned income. Income from work study whose purpose is to assist with educational expenses are excluded from unearned income. Educational grants and scholarships whose purpose is to assist with education expenses are excluded regardless of the actual utilization of the funds.
(2) Child nutrition and school lunch benefit exclusion: Child nutritional and school lunch benefits provided in the form of money payments, vouchers, or foodstuffs authorized under the Child Nutritional Act and the National School Lunch Act are excluded.
(3) Income tax return income exclusion: State and federal income tax refunds are excluded from consideration as income. Tax refunds are considered resources.
(4) Native American payment exclusion: Certain payments to Native Americans can be excluded which include:
(a) per capita payment of tribal funds authorized by the tribe or by the secretary of the United States department of the interior; payments received and distributed by the bureau of Indian affairs (BIA) as a trustee for an individual members of a tribe, refer to as individual Indian monies (IAMB) are not considered as per capita payments;
(b) interest derived from retrained per capita payments is disregarded if the retained per capita payments have not been commingled with other savings; and
(c) BIA general assistance payments made to disabled tribal members by the BIA;
(d) any tax exempt payment made under the Alaska Native Claims Act are excluded from consideration as unearned income.
(5) Settlement fund payment exclusions: Payments received from the agent orange settlement fund or from any other fund established pursuant to the agent orange product liability litigation settlement are excluded from unearned income. Payments received from the Radiation Exposure Compensation Act are excluded from unearned income. Payments by the remembrance, responsibility and the future foundation to individual survivors forced into slave labor by the Nazis are excluded from unearned income.
(6) Payments made by division of vocational rehabilitation: Any payment made by the division of vocation rehabilitation to an applicant/recipient in training to help them meet additional training costs are disregarded. The entire payment is disregarded unless specific portion is designated for basic maintenance and the applicant/recipient is maintaining only one resident. The portion designated for basic maintenance is considered income.
(7) Child support disregard: The first $50 of child support payments received in a month from an absent parent which represents payment on a support obligation for the month is disregarded in the eligibility determination and redetermination process.
(a) If multiple child support payments are received such as cases where more than one parent is paying or a parent makes weekly or biweekly payments, the disregard is allowed only once during the month.
(b) If a payment included both current support and arrearage, the disregard is allowed only on the current support.
(8) Disregard for payments made by CYFD: Payment made by CYFD to a third party on behalf of an applicant/recipient are not considered income to the applicant/recipient.
(9) Chafee independent living assistance recipients: All unearned income of an applicant/recipient between 18 and 21 years of age is excluded.
[8. 206.500 .18 NMAC - Rp 8.206.500.18 NMAC, 7/1/2024]
8.206.500.19 DEEMED INCOME: Income is not deemed to an applicant/recipient from their parents if the applicant/recipient is the full or partial financial responsibility of CYFD. Any voluntary contributions made by the applicant/recipient's parent(s) is considered as unearned income.
[8. 206.500 .19 NMAC - Rp 8.206.500.19 NMAC, 7/1/2024]
8.206.500.20 TOTAL INCOME: The combination of the applicant/recipient's earned income and unearned income minus any applicable exclusions and disregards is compared to the maximum income standard for one person to determine if the applicant/recipient is eligible for CYFD medicaid .
[8. 206.500 .20 NMAC - Rp 8.206.500.20 NMAC, 7/1/2024]
8.206.500.21 LUMP SUM PAYMENTS: Lump sums are considered as income in the month received and resources (if retained) as of the first moment of the first day of the following month.
[8. 206.500 .21 NMAC - Rp 8.206.500.21 NMAC, 7/1/2024]
HISTORY OF 8.206.500 NMAC: [ RESERVED ]
History of Repealed Material: 8.206.500 NMAC - Income And Resource Standards (filed 12/15/2001), Repealed effective 7/1/2024.
Other: 8.206.500 NMAC - Income And Resource Standards (filed 12/15/2001), Replaced by 8.206.500 NMAC - Income And Resource Standards, effective 7/1/2024.
TITLE 8 SOCIAL SERVICES
CHAPTER 206 MEDICAID ELIGIBILITY - CYFD CHILDREN (CATEGORIES 006, 017, 037, 046, 047, 060, 061, 066 and 086)
PART 600 BENEFIT DESCRIPTION
8.206.600.1 ISSUING AGENCY: New Mexico Health Care Authority.
[8.206.600.1 NMAC - Rp 8.206.600.1 NMAC, 7/1/2024]
8.206.600.2 SCOPE: The rule applies to the general public .
[8.206.600.2 NMAC - Rp 8.206.600.2 NMAC, 7/1/2024]
8.206.600.3 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.
[8.206.600.3 NMAC - Rp 8.206.600.3 NMAC, 7/1/2024]
8.206.600.4 DURATION: Permanent.
[8.206.600.4 NMAC - Rp 8.206.600.4 NMAC, 7/1/2024]
8.206.600.5 EFFECTIVE DATE: July 1, 2024, unless a later date is cited at the end of a section.
[8.206.600.5 NMAC - Rp 8.206.600.5 NMAC, 7/1/2024]
8.206.600.6 OBJECTIVE: The objective of these regulations is to provide eligibility policy and procedures for the medicaid program.
[8.206.600.6 NMAC - Rp 8.206.600.6 NMAC, 7/1/2024]
8.206.600.7 DEFINITIONS: [ RESERVED ]
8.206.600.8 [ RESERVED ]
8.206.600.9 BENEFIT DESCRIPTION: An applicant/recipient who is eligible for medicaid under this category is eligible to receive the full range of medicaid -covered services.
[8.206.600.9 NMAC - Rp 8.206.600.9 NMAC, 7/1/2024]
8.206.600.10 BENEFIT DETERMINATION:
A. A written signed application must be made for every approved CYFD medicaid case.
(1) For voluntary placements, the parent(s) or guardian(s) must complete and sign the application on behalf of the child.
(2) For involuntary placements, information should be obtained from the parents. The social worker from CYFD may complete and sign the application on behalf of the child.
B. Applications must be acted on within 45 days of the date of application.
[8.206.600.10 NMAC - Rp 8.206.600.10 NMAC, 7/1/2024]
8.206.600.11 INITIAL BENEFITS: Notice of approval or denial of the application for CYFD medicaid is prepared. If the applicant is ineligible, the denial notice contains the reason for denial and explanation of the applicant’s right to request an administrative hearing.
[8.206.600.11 NMAC - Rp 8.206.600.11 NMAC, 7/1/2024]
8.206.600.12 ONGOING BENEFITS: A periodic review to re-establish eligibility for medicaid must be done every six months.
[8.206.600.12 NMAC - Rp 8.206.600.12 NMAC, 7/1/2024]
8.206.600.13 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 42 CFR Section 435.914. Retroactive coverage is not available prior to January 1, 1995, to applicants/recipients of Category 060 and 061.
A. Application for retroactive benefit coverage: Application for retroactive medicaid can be made by checking “yes” in the “application for retroactive medicaid payments” box on the application/redetermination of eligibility for medicaid assistance (MAD 381) form or by checking “yes” to the question “Does anyone in your household have unpaid medical expenses in the last three months?” on the application for assistance (ISD 100 S) form. Applications for retroactive medicaid benefits must be made by 180 days from the date of application for assistance. Medicaid-covered services which were furnished more than two years prior to application are not covered.
B. Approval requirements: To establish retroactive eligibility, the ISS must verify that all conditions of eligibility were met for each of the three retroactive months and that the applicant received medicaid -covered services. Each month must be approved or denied on its own merits. Retroactive eligibility can be approved on either the ISD2 system (for categories programmed on that system) or on the retroactive medicaid eligibility authorization (ISD 333) form.
C. Notice:
(1) Notice to applicant: The applicant must be informed if any of the retroactive months are denied.
(2) Recipient responsibility to notify provider: After the retroactive eligibility has been established, the ISS must notify the recipient that they are responsible for informing all providers with outstanding bills of the retroactive eligibility determination. If the recipient does not inform all providers and furnish verification of eligibility which can be used for billing and the provider consequently does not submit the billing within 120 days from the date of approval of retroactive coverage, the recipient is responsible for payment of the bill.
[8.206.600.13 NMAC - Rp 8.206.600.13 NMAC, 7/1/2024]
8.206.600.14 CHANGES IN ELIGIBILITY: Case closure must be effective the month following the month the case ceases to meet any of the financial or non-financial eligibility requirements. Case closure information must be transmitted to the medicaid claims processing contractor within 30 days of closure.
[8.206.600.14 NMAC - Rp 8.206.600.14 NMAC, 7/1/2024]
HISTORY OF 8.206.600 NMAC: [ RESERVED ]
History of Repealed Material: 8.206.600 NMAC - Benefit Description (filed 9/13/2013) Repealed effective 7/1/2024.
Other: 8.206.600 NMAC - Benefit Description (filed 9/13/2013), Replaced by 8.206.600 NMAC - Benefit Description, effective 7/1/2024.
TITLE 8 SOCIAL SERVICES
CHAPTER 215 MEDICAID ELIGIBILITY - SUPPLEMENTAL SECURITY INCOME (SSI) METHODOLOGY
PART 400 RECIPIENT POLICIES
8.215.400.1 ISSUING AGENCY: New Mexico Health Care Authority.
[8.215.400.1 NMAC - Rp, 8.215.400.1 NMAC, 1/1/2019; A, 7/1/2024]
8.215.400.2 SCOPE: The rule applies to the general public .
[8.215.400.2 NMAC - Rp, 8.215.400.2 NMAC, 1/1/2019]
8.215.400.3 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.
[8.215.400.3 NMAC - Rp, 8.215.400.3 NMAC, 1/1/2019; A, 7/1/2024]
8.215.400.4 DURATION: Permanent.
[8.215.400.4 NMAC - Rp, 8.215.400.4 NMAC, 1/1/2019]
8.215.400.5 EFFECTIVE DATE: January 1, 2019, unless a later date is cited at the end of the section.
[8.215.400.5 NMAC - Rp, 8.215.400.5 NMAC, 1/1/2019]
8.215.400.6 OBJECTIVE: The objective of these regulations is to provide eligibility policy and procedures for the medicaid program.
[8.215.400.6 NMAC - Rp, 8.215.400.6 NMAC, 1/1/2019]
8.215.400.7 DEFINITIONS: [ RESERVED ]
[8.215.400.7 NMAC - Rp, 8.215.400.7 NMAC, 1/1/2019]
8.215.400.8 [ RESERVED ]
[8.215.400.8 NMAC - Rp, 8.215.400.8 NMAC, 1/1/2019]
8.215.400.9 SUPPLEMENTAL SECURITY INCOME METHODOLOGY: All noninstitutionalized married couples who are eligible for supplemental security income (SSI) are treated as separate individuals for determining eligibility and benefit amounts, beginning the month after the month they begin living apart. In the case of an initial application or reinstatement following a period of ineligibility, each member of a married couple not living together is considered an individual as of the date of application or request for reinstatement, regardless of when the separation occurred. See Title 8, Chapter 281, Medicaid Eligibility - Institutional Care ( Categories 081, 083 and 084 ), for information on separation caused by the institutionalization of one member of a married couple.
[8.215.400.9 NMAC - Rp, 8.215.400.9 NMAC, 1/1/2019]
8.215.400.10 SUPPLEMENTAL SECURITY INCOME (Categories 001, 003, and 004):
A. The human services department (HSD) has an agreement under Section 1634 of the Social Security Act with the social security administration (SSA) for SSA to make medicaid eligibility determinations. Supplemental security income (SSI) recipients (categories 001, 003, and 004) who receive an SSI cash payment or are Section 1619(b) recipients automatically have medicaid eligibility unless they fail to meet the assignment of rights or third party liability requirements; or HSD has determined ineligibility under the medicaid trust provision.
B. Section 1619(b) recipients : To qualify for continuing medicaid coverage, a 1619(b) individual must:
(1) have been eligible for an SSI cash payment for at least one month; and
(2) still meet the disability requirement; and
(3) still meet all other non-disability SSI requirements; and
(4) need medicaid benefits to continue to work; and
(5) have gross earnings that are insufficient to replace SSI, medicaid and publicly funded attendant care services.
[8.215.400.9 NMAC - N, 1/1/2019]
HISTORY OF 8.215.400 NMAC:
Pre NMAC History: The material in this part was derived from that previously filed with the State Records Center.
MAD Rule 860, SSI Methodology for Computation of Countable Resources and Income, filed 3/7/1989.
MAD Rule 860, SSI Methodology for Computation of Countable Resources and Income, filed 3/21/1990.
MAD Rule 860, SSI Methodology for Computation of Countable Resources and Income, filed 4/24/1991.
MAD Rule 860, SSI Methodology for Computation of Countable Resources and Income, filed 6/19/1992.
MAD Rule 861, Resources - SSI Methodology for Computation of Countable Resources and Income, filed 3/18/1993.
MAD Rule 861, Resources - SSI Methodology for Computation of Countable Resources and Income, filed 12/29/1994.
MAD Rule 862, Income - SSI Methodology for Computation of Countable Resources and Income, filed 3/18/1993.
MAD Rule 864, Potential Income or Resources - SSI Methodology for Computation of Countable Resources and Income, filed 3/18/1993.
MAD Rule 866, Deeming Income, filed 11/16/1994.
History of Repealed Material:
MAD Rule 860, SSI Methodology for Computation of Countable Resources and Income, filed 6/19/1992 - Repealed effective 2/1/1995.
MAD Rule 861, Resources - SSI Methodology for Computation of Countable Resources and Income, filed 12/29/1994 - Repealed effective 2/1/1995.
MAD Rule 862, Income - SSI Methodology for Computation of Countable Resources and Income, filed 3/18/1993 - Repealed effective 2/1/1995.
MAD Rule 864, Potential Income or Resources - SSI Methodology for Computation of Countable Resources and Income, filed 3/18/1993 - Repealed effective 2/1/1995.
MAD Rule 866, Deeming Income, filed 11/16/1994 - Repealed effective 2/1/1995.
8.215.400 NMAC - Recipient Policies, filed 9/3/2013 - Repealed effective 1/1/2019.
TITLE 8 SOCIAL SERVICES
CHAPTER 215 MEDICAID ELIGIBILITY - SUPPLEMENTAL SECURITY INCOME (SSI) METHODOLOGY
PART 500 INCOME AND RESOURCE STANDARDS
8.215.500.1 ISSUING AGENCY: New Mexico Health Care Authority (HCA).
[8. 215.500 .1 NMAC - Rp, 8.215.500.1 NMAC, 3/1/2018 ; A,7/1/2024]
8.215.500.2 SCOPE: The rule applies to the general public.
[8. 215.500 .2 NMAC - Rp, 8.215.500.2 NMAC, 3/1/2018]
8.215.500.3 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. 215.500 .3 NMAC - Rp, 8.215.500.3 NMAC, 3/1/2018 ; A, 7/1/2024 ]
8.215.500.4 DURATION: Permanent.
[8. 215.500 .4 NMAC - Rp, 8.215.500.4 NMAC, 3/1/2018]
8.215.500.5 EFFECTIVE DATE: March 1, 2018, unless a later date is cited at the end of a section.
[8. 215.500 .5 NMAC - Rp, 8.215.500.5 NMAC, 3/1/2018]
8.215.500.6 OBJECTIVE: The objective of these regulations is to provide eligibility policy and procedures for the medicaid program.
[8. 215.500 .6 NMAC - Rp, 8.215.500.6 NMAC, 3/1/2018]
8.215.500.7 DEFINITIONS: Relative: A son/daughter; grandson/granddaughter; step-son/step-daughter; in-laws; mother/father; step-mother/step-father; half sister/ half brother ; grandmother/grandfather; aunt/uncle; sister/brother; step-brother/step-sister; and niece/nephew.
[8. 215.500 .7 NMAC - Rp, 8.215.500.7 NMAC, 3/1/2018]
8.215.500.8 [RESERVED]
8.215.500.9 NEED DETERMINATION: This section describes the methodology to be used in determining countable resources and income for medicaid eligibility categories which use supplemental security income (SSI) methodology. These guidelines are used for retroactive medicaid eligibility for SSI recipients as well as initial and on-going eligibility for qualified medicare beneficiaries (QMB), qualified disabled working individuals (QD), medicaid extension and specified low income medicare beneficiaries (SLIMB). Medicaid eligibility is determined prospectively. Applicants/recipients must meet, or expect to meet, all financial and nonfinancial eligibility criteria in the month for which a determination of eligibility is made. Applicants for and recipients of medicaid must apply for and take all necessary steps to obtain any income or resources to which they may be entitled. Such steps must be taken within 30 days of the date the human services department (HSD) furnishes notice of the potential entitlement.
A. Failure to apply for and take steps to determine eligibility for other benefits: Failure or refusal to apply for and take all necessary steps to determine eligibility for other benefits after notice is received results in an applicant/recipient becoming ineligible for medicaid .
B. Exceptions to general requirement: Applicants/recipients who have elected a lower VA payment do not need to reapply for veterans administration improved pension (VAIP) benefits. Crime victims are not required to accept victims compensation payments from a state-administered fund as a condition of medicaid eligibility.
[8. 215.500 .8 NMAC - Rp, 8.215.500.8 NMAC, 3/1/2018]
8.215.500.10 APPLICATION PROCESS: [ RESERVED ]
8.215.500.11 RESOURCE STANDARDS: A "resource" is defined as cash or liquid assets and real or personal property which is owned and can be used either directly, or by sale or conversion, for the applicant/recipient's support and maintenance. Resources may be liquid or non-liquid and may be excluded from the eligibility determination process under certain conditions. A liquid resource is an asset which can readily be converted to cash. A non-liquid resource is an asset or property which cannot readily be converted to cash.
A. Resource determination: The resource determination is made as of the first moment of the first day of the month of application. An applicant/recipient is ineligible for any month in which his/her countable resources exceed the allowable resource standard as of the first moment of the first day of the month. Changes in the amount of countable resources during a month do not affect eligibility or ineligibility for that month.
B. Distinguishing between resources and income: Resources must be distinguished from income to avoid counting a single asset twice. As a general rule, ownership of a resource precedes the current month while income is received in the current month. Income held by an applicant/recipient until the following month becomes a resource.
[8. 215.500 .11 NMAC - Rp, 8.215.500.11 NMAC, 3/1/2018]
8.215.500.12 APPLICABLE RESOURCE STANDARDS: The resource standard for medicaid extension as well as retroactive SSI medicaid eligibility determinations is $2,000. See Section 8.240.500.10 NMAC for resource standards applicable to QMB. See Section 8.242.500.10 NMAC for standards applicable to the qualified disabled working individuals program. See Section 8.245.500.10 NMAC for standards applicable to the SLIMB program.
A. Liquid resources: The face value of liquid resources such as cash, savings or checking accounts is considered in determining medicaid eligibility. The countable value of resources such as securities, bonds, real estate contracts and promissory notes is based on their current fair market value.
(1) An applicant/recipient must provide verification of the value of all liquid resources. The resource value of a bank account is customarily verified by a statement from the bank showing the account balance as of the first moment of the first day of the month in question. If an applicant/recipient cannot provide this verification, the ISD worker sends a bank or postal savings clearance to the appropriate institution(s).
(2) If the applicant/recipient can demonstrate that a check was written and delivered to a payee but not cashed by the payee prior to the first moment of the first day of the month, the amount of that check is subtracted from the applicant/recipient's checking account balance to arrive at the amount to be considered a countable resource.
B. Non-liquid resources: The value of non-liquid resources is computed at current fair market value. See below for discussion of equity value.
(1) Real property: If an applicant/recipient is the sole owner of real property other than a home and has the right to dispose of it, the entire equity value is included as a countable resource. If an applicant/recipient owns property with one or more individuals and the applicant/recipient has the right, authority or power to liquidate the property or his/her share of the property, it is considered a resource. If a property right cannot be liquidated, the property will not be considered a resource to the individual. The applicant/recipient must provide a copy of the legal document which indicates his/her interest in the property.
(2) Vehicles: One automobile is totally excluded regardless of value if it is used for transportation for the individual or a member of the individual’s household. Any other automobiles are considered to be Non-liquid resources. Equity in the other automobiles is counted as a resource. Recreational vehicles and boats are considered household goods and personal effects rather than vehicles.
(3) Household goods and personal effects: Household goods and personal effects are considered countable resources if the items were acquired or are held for their value or are held as an investment. Such items can include but are not limited to: gems, jewelry that is not worn or held for family significance, or collectibles.
[8. 215.500 .12 NMAC - Rp, 8.215.500.12 NMAC, 3/1/2018]
8.215.500.13 COUNTABLE RESOURCES: Before a resource can be considered countable, the three criteria listed below must be met.
A. Ownership interest: An applicant/recipient must have an ownership interest in a resource for it to be countable. The fact that an applicant/recipient has access to a resource, or has a legal right to use it, does not make it countable unless the applicant/recipient also has an ownership interest in it.
B. Legal right to convert resource to cash: An applicant/recipient must have the legal ability to spend the funds or to convert non-cash resources into cash.
(1) Physical possession of resource: The fact that an applicant/recipient does not have physical possession of a resource does not mean it is not his/her resource. If he/she has the legal ability to spend the funds or convert the resource to cash, the resource is considered countable. Physical possession of savings bonds is a legal requirement for cashing them.
(2) Unrestricted use of resource: An applicant/recipient is considered to have free access to the unrestricted use of a resource even if he/she can take those actions only through an agent, such as a representative payee or guardian.
(3) If there is a legal bar to the sale of a resource, the resource is not countable. If the co-owner of real property can bring an action to partition and sell the property, his/her interest in the property is a countable resource.
C. Legal ability to use a resource: If a legal restriction exists which prevents the use of a resource for the applicant/recipient's own support and maintenance, the resource is not countable.
D. Joint ownership of resources: If an applicant/recipient owns either liquid or non-liquid resources jointly with others, he/she has 30 days from the date requested by the ISD worker to submit all documentation required to prove his/her claims regarding ownership of, access to, and legal ability to use the resource for personal support and maintenance. Failure to do so results in the presumption that the resource is countable and belongs to the applicant/recipient.
(1) Jointly held property: If jointly held property is identified during review of an active case, the ISD worker must:
(a) determine whether the property is a countable resource;
(b) determine whether the value of the jointly held property plus the value of other countable resources exceeds the allowable resource maximum;
(c) if the value of countable resources exceeds the allowable maximum, advance notice is furnished to the applicant/recipient of the intent to close the case and his/her right to verify claims regarding ownership of, access to and legal ability to use the property for personal support and maintenance;
(d) if the applicant/recipient fails to provide required information or respond within the advance notice period, the case is closed; and
(e) if, after expiration of the advance notice period but prior to the end of the month in which the advance notice expires, the applicant/recipient provides the required evidence to show the property is not a countable resource, or is countable in an amount which, when added to the value of other countable resources, does not exceed the maximum allowable limit, and eligibility continues to exist on all other factors, the case is reinstated for the next month.
(2) Joint bank accounts: If liquid resources are in a joint bank account of any type, the applicant/recipient's ownership interest, while the parties to the account are alive, is presumed to be proportionate to the applicant/recipient's contributions to the total resources on deposit.
(a) The applicant/recipient is presumed to own a proportionate share of the funds on deposit unless he/she presents clear and convincing evidence that the parties to the account intended the applicant/recipient to have a different ownership interest.
(b) To establish the applicant/recipient's ownership interest in a joint account, the following are required:
( i ) statement by the applicant/recipient regarding contributions to the account; reasons for establishing the account; who owns the funds in the account; and any supporting documentation; plus
(ii) corroborating statements from the other account holder(s); if either the applicant/recipient or the other account holder is not capable of making a statement, the applicant/recipient or representative must obtain a statement from a third party who has knowledge of the circumstances surrounding the establishment of the joint account.
(c) Failure to provide required documentation within 30 days of the date requested by the ISD worker results in a determination that the entire account amount belongs to the applicant/recipient.
(d) If the existence of a jointly held bank account is identified during the review of an active case, the ISD worker requests evidence of ownership and accessibility. If the evidence is not furnished within 30 days of the request, the case is closed.
E. Other countable resources: Other liquid or non-liquid resources must be considered in the calculation of total countable resources. Under certain circumstances, the following non-liquid resources may be included in the calculation of countable resources:
(1) burial funds;
(2) burial spaces;
(3) life estates;
(4) life insurance and other insurance products;
(5) income-producing property; and
(6) other financial investment products.
F. The home as a countable resource: If the applicant/recipient or his/her representative states the applicant/recipient does not intend to return to the home and it is not the residence of the applicant/recipient's spouse or dependent relative, the home is considered a countable resource. If the applicant/recipient or his/her representative puts the home up for sale and it is not the primary residence of the applicant/recipient's spouse or a dependent relative, the home is considered a countable resource.
G. Value of property: The applicant/recipient must supply the ISD worker with written documentation regarding the fair market value of the property from a real estate agent, title company or mortgage insurance company in and familiar with the area in which the property is located in addition to any encumbrances against the property. The ISD worker determines the equity value of the property by subtracting the amount of the encumbrances from the fair market value of the property.
H. ABLE ACT: as Public Law 113-295, The Stephen Beck, Jr., Achieving a Better Life Experience Act (ABLE Act) - enacted December 19, 2014. The ABLE Act shall establish state-run tax advantaged accounts for eligible individuals to use for disability related expenses. Tax-advantaged accounts allow an eligible individual to save and use the funds for disability-related expenses. An ABLE program has been established and maintained by the state. An eligible individual can open an ABLE account through the ABLE program in any state.
(1) Under the ABLE act, individual eligibility is determined if the person is:
(a) Entitled to benefits based on blindness or disability under Title II or Title XVI of the Social Security Act; or
(b) Has a disability certification filed with the U.S. secretary of the treasury and a disability that began before age 26.
(2) ABLE account balances and distributions are considered in determining eligibility for SSI.
(a) Amounts over $100,000 count toward the $2,000 SSI resource limit.
(b) If an ABLE account balance exceeds $100,000 by an amount that causes the recipient to exceed the SSI resource limit the recipient is ineligible for SSI.
(c) The social security administration (SSA) will place such an ineligible individual into a special ABLE suspension period where:
( i ) The recipient’s SSI benefits are suspended without time limit (as long as he or she remains otherwise eligible).
(ii) The recipient will still be considered to be SSI eligible for the SSI medical assistance program (MAP).
(iii) After 12 months of suspension, eligibility is terminated and the person must reapply for benefits.
(iv) If a person who does not meet other SSI eligibility criteria during a suspension period is ineligible for SSI during a suspension period he or she is also ineligible for the SSI MAP.
(3) Section 529A(d)(4) of the act requires that the state electronically submit on a monthly basis to the Commissioner of Social Security statements on relevant distributions and account balances from all ABLE accounts.
(4) Resource exclusions related to the ABLE ACT can be found at Subsection N of Section 8.215.500.14 NMAC resource exclusions .
(5) For how the ABLE ACT contributions treatment in regards to income please see Section 8.215.500.18 NMAC income .
(6) For how the ABLE ACT distributions please see Subsection D of Section 8.215.500.20 NMAC. unearned income exclusions .
[8. 215.500 .13 NMAC - Rp, 8.215.500.13 NMAC, 3/1/2018]
8.215.500.14 RESOURCE EXCLUSIONS: Some types of resources can be excluded from the calculation of countable resources if they meet the specific criteria listed below.
A. Burial fund exclusion: Up to one thousand five hundred dollars ($1,500) can be excluded from the countable liquid resources of an applicant/recipient if designated as burial funds. An additional amount of up to one thousand five hundred dollars ($1,500) can be excluded from countable liquid resources if designated as burial funds for the spouse of the applicant/recipient. The burial fund exclusion is separate from the burial space exclusion.
(1) Retroactive designation of burial funds: An applicant/recipient can retroactively designate funds for burial back to the first day of the month in which the applicant/recipient intended the funds to be set aside for burial. The applicant/recipient must sign a statement indicating the month the funds were set aside for burial.
(2) Limit on exclusion: An applicant/recipient can designate as much of his/her liquid resources as he/she wishes for burial purposes. However, only one burial fund allowance of up to one thousand five hundred dollars ($1,500) each for the applicant/recipient and his/her spouse can be excluded from countable resources. A burial fund does not continue from one period of eligibility to another (i.e., across a period of ineligibility). For each new period of eligibility, any exclusion of burial funds must be developed as for an initial application.
(3) Removal of designation: An applicant/recipient cannot " undesignate " burial funds unless one of the following occurs:
(a) eligibility terminates;
(b) part, or all, of the funds can no longer be excluded because the applicant/recipient purchased excluded life insurance or an irrevocable burial contract which partially or totally offsets the available burial fund exclusion; or
(c) the applicant/recipient uses the funds for another purpose.
(4) Reduction of burial fund exclusion: The one thousand five hundred dollars ($1,500) burial fund exclusion is reduced by the following:
(a) the face value of excluded life insurance policies;
(b) assets held in irrevocable burial trusts; irrevocable means the value paid cannot be returned to the applicant/recipient;
(c) assets that are not burial space items held in irrevocable burial contracts;
(d) assets held in other irrevocable burial arrangements.
(5) Interest from burial fund: Interest derived from a burial fund is not considered a countable resource or income if all of the following conditions exist:
(a) the original amount is excluded;
(b) the excluded burial fund is not commingled with non-excluded burial funds; and
(c) the interest earned remains with the excluded burial funds.
(6) Commingling of burial funds: Burial funds cannot be commingled with non-burial funds. If only part of the funds in an account is designated for burial, the burial fund exclusion cannot be applied until the funds designated for burial expenses are separated from the non-burial funds. Countable and excluded burial funds can be commingled.
(7) Life insurance policy designated as burial fund: An applicant/recipient can designate a life insurance policy as a burial fund at the time of application. The ISD worker must first analyze the rule according to Subsection H of Section 8.215.500.14.NMAC, life insurance exclusion , and following subsections.
(8) Burial contracts: If an applicant/recipient has a prepaid burial contract, the ISD worker determines whether it is revocable or irrevocable and whether it is paid for. Until all payments are made on a burial contract, the amounts paid are considered burial funds and no burial space exclusions apply. An applicant/recipient may have a burial contract which is funded by a life insurance policy. The life insurance may be either revocably or irrevocably assigned to a funeral director or mortuary. A revocable contract exists if the value can be returned to the applicant/recipient. An irrevocable contract exists when the value cannot be returned.
(a) If the contract or insurance policy assignment is revocable, the following apply.
( i ) If the burial contract is funded by a life insurance policy, the policy is the resource which must be evaluated. The burial contract itself has no value. It exists only to explain the applicant/recipient's burial arrangements.
(ii) No exclusions can be made for burial space items because the applicant/recipient does not have a right to them if the contract is not paid for or the policy is not paid up.
(b) If the assignment is irrevocable, the life insurance or burial contract is not a countable resource because the applicant/recipient does not own it.
( i ) The burial space exclusions can apply if the applicant/recipient has the right to the burial space items.
(ii) The value of the irrevocable burial arrangement is applied against the one thousand five hundred dollars ($1,500) burial fund exclusion only if the applicant/recipient has other liquid resources to designate for burial.
B. Burial space exclusion: A burial space or an agreement which represents the purchase of a burial space held for the burial of an applicant/recipient, his/her spouse, or any other member of his/her immediate family, is an excluded resource regardless of value. Interest and accruals on the value of a burial space are excluded from consideration as countable income or resources. When calculating the value of resources to be deemed to an applicant/recipient from his/her parent(s) or spouse, the value of spaces held by the parent(s)/spouse which are to be used for the burial of the applicant/recipient or any other member of the applicant/recipient's immediate family, including the deemer parent/spouse, must be excluded. The burial space exclusion is separate from, and in addition to, the burial fund exclusion.
(1) Burial space definitions: "Burial space" is defined as a(n) burial plot, gravesite, crypt, mausoleum, casket, urn, niche, or other repository customarily used for the deceased's bodily remains. A burial space also includes necessary and reasonable improvements or additions, such as vaults, headstones, markers, plaques, burial containers (e.g., caskets), arrangements for the opening and closing of a gravesite, and contracts for care and maintenance of the gravesite, sometimes referred to as endowment or perpetual care. Items that serve the same purpose are excluded once per individual, such as excluding a cemetery lot and a casket, but not a casket and an urn.
(2) Burial space contract: An agreement which represents the purchase of a burial space is defined as a contract with a burial provider for a burial space held for the eligible applicant/recipient or a member of his/her immediate family. Until all payments are made on the contract, the amounts paid are considered burial funds and no burial space exclusions apply. An eligible applicant/recipient's immediate family includes:
(a) the spouse;
(b) natural or adoptive parents;
(c) minor or adult children, including adoptive and stepchildren;
(d) siblings, including adoptive and stepsiblings; and
(e) spouse of any of the above relatives;
(f) if a relative's relationship to an applicant/recipient is by marriage only, the relationship ceases to exist upon the dissolution of the marriage.
(3) Burial space "held" for an applicant/recipient: A burial space is considered held for an applicant/recipient if:
(a) someone has title to or possesses a burial space intended for the use of the applicant/recipient or a member of his/her immediate family; or
(b) someone has a contract with a funeral service company for a specified burial space for the applicant/recipient or a member of his/her immediate family, such as an agreement which represents the individual's current right to the use of the items at the amount shown.
(c) until the purchase price is paid in full, a burial space is not considered "held for" an individual under an installment sales contract or similar device if:
( i ) the individual does not currently own the space;
(ii) the individual does not currently have the right to use the space; and
(iii) the seller is not currently obligated to provide the space.
C. Life estate exclusion: A life estate gives an applicant/recipient certain rights to real property. These rights determine how the resource is treated in determining eligibility for medicaid .
(1) Possession: An applicant/recipient has the right to live on the real property for the rest of his/her life. If it is his/her principal place of residence (home), the life estate is evaluated in accordance with Subsection E of Section 8.215.500.14.NMAC, exclusions for real property and home , and following subsections.
(2) Use and profit: An applicant/recipient has the right to use and obtain profit from the real property. If it is income producing property, such as a rental or farm, the life estate is evaluated as income producing property. See Subsection F of Section 8.215.500.14 NMAC, income-producing property exclusion , and following subsections.
(3) Sale of the life estate interest: An applicant/recipient has the right to sell his/her life estate interest. The value of this interest is less than the fair market value of the property and is similar to a lease because of the time frame involved. The value of the life estate is based on the age and life-expectancy of the applicant/recipient.
(4) Valuation of life estates: The "unisex life estate and remainder interest tables" are used to determine the value of a life estate. See Section 8.200.520.14 NMAC, resource exclusions . The value is computed by multiplying the current market value by the percentage reduction on the unisex table under the column for the applicant/recipient's age. If an applicant/recipient feels the value calculated based on this method is overstated, he/she can obtain a valuation of the life estate in the area for use as documentation of lesser value.
(5) Legal documentation establishing life estate: The legal document establishing a life estate may affect one or more of the rights discussed above. Joint ownership of a life estate may require the co-owner's approval for sale. See Section 8.215.500.13 NMAC, countable resources , and following subsections for criteria to use in evaluating the count ability of the resource.
D. Settlement exclusions:
(1) Agent orange settlement payments made to veterans or their survivors are excluded from consideration as resources.
(2) Payments made under the Radiation Exposure Compensation Act are excluded from consideration as resources.
(3) Payments by the remembrance, responsibility and the future foundation to individual survivors forced into slave labor by the Nazis are excluded as resources.
(4) Payments received from a state-administered fund established to aid victims of crime are excluded for nine months, beginning the month after the month of receipt.
E. Exclusions for real property and home: A home is any shelter used by an applicant/recipient or his/her spouse as the principal place of residence. The home includes any buildings and contiguous land used in the operation of the home. A home is not considered a countable resource while in use by the applicant/recipient as his/her principal place of residence. The home continues to be excluded during periods when the applicant/recipient resides in an acute care or long term care medical facility if the applicant/recipient, or his/her representative, states that the applicant/recipient intends to return to the home. If the applicant/recipient or his/her representative states the applicant/recipient does not intend to return to the home but the home is the residence of the applicant/recipient's spouse or dependent relative, the home is an excluded resource. If the applicant/recipient or his/her representative puts the home up for sale and it is not the primary residence of the applicant/recipient’s spouse or a dependent relative, the home is considered a countable resource.
F. Income-producing property exclusion: To be excluded from consideration as a countable resource, income-producing property that does not qualify as a bona fide business (e.g., rental property or mineral rights) must have an equity value of no more than six thousand dollars ($6,000) and an annual rate of return of at least six percent of the equity value. See Subparagraph (b) of Paragraph (1) of Subsection F of Section 8.215.500.14 NMAC, determination of rate of return , below if the equity value exceeds six thousand dollars ($6,000) but the rate of return is at least six percent annually. The six thousand dollars ($6,000) and six percent limitation does not apply to property used in a trade or bona fide business, or to property used by an applicant/recipient as an employee which is essential to the applicant/recipient's self-support (e.g., tools used in employment as a mechanic, property owned or being purchased in conjunction with operating a business). Existence of a bona fide business can be established by documentation such as business tax returns.
(1) Determination of rate of return: To calculate the annual rate of return for income producing property when the six thousand dollars ($6,000) and six percent limits apply, the previous year's income tax statement, or at least three months earnings is used to project the rate of return for the year.
(a) If the income is sporadic or has decreased from that needed to maintain a six percent rate of return for the coming year, the property is reevaluated at appropriate intervals.
(b) If the annual rate of return is at least six percent of the equity value but the equity exceeds six thousand dollars ($6,000), only the excess equity is a countable resource.
(c) If the annual rate of return is less than six percent but the usual rate of return is more, the property is excluded as a countable resource if all of the following conditions are met:
( i ) unforeseeable circumstances, such as a fire, cause a temporary reduction in the rate of return;
(ii) the previous year's rate of return, as documented by the income tax statement or several months receipts, is at least six percent; and
(iii) the property is expected to produce a rate of return of at least six percent six percent within 18 months of the end of the year in which the adverse circumstances occurred; the ISD worker records in the case narrative the plan of action which is expected to increase the rate of return.
(d) The ISD worker notifies the applicant/recipient in writing that the property is excluded based on its expected increase in return and that it will be reevaluated at the end of the 18 month grace period. When this period ends, the property must be producing an annual rate of at least six percent to continue to be excluded as a countable resource.
(2) Types of income-producing property: Income- producing property includes:
(a) a business, such as a farm or store, including necessary capital and operating assets such as land and buildings, inventory, or livestock; the property must be in current use or have been used with a reasonable expectation of resumed use within a year of its most recent use; the ISD worker must account for the cash actually required to operate the business; liquid business assets of any amount are excluded;
(b) non-business property includes rental property, leased property, land leased for its mineral rights and property producing items for home consumption; property which produces items solely for home use is assumed to be producing an annual rate of return of at least six percent;
(c) employment-related property, such as tools or equipment; the applicant/recipient must provide a statement from his/her employer to establish that tools or equipment are required for continued employment; if the applicant/recipient is self-employed, only those tools normally required to perform the job adequately are excluded; the applicant/recipient must obtain a statement from someone in the same line of self-employment to establish what is excludable.
G. Vehicle exclusion: The term "vehicle" includes any mode of transportation, such as a passenger car, truck or special vehicle. Included in this definition are vehicles which are unregistered, inoperable, or in need of repair. Vehicles used solely for purposes other than transportation, such as disassembly to resell parts, racing, or as an antique are not included in this definition. Recreational vehicles and boats are classified as personal effects and are evaluated under the household goods and personal effects exclusion. One vehicle is totally excluded regardless of value if it is used for transportation for the individual or a member of the individual’s household. Any other automobiles are considered to be Non-liquid resources. Equity in the other automobiles is counted as a resource.
H. Life insurance exclusion: The value of life insurance policies is not considered a countable resource if the total cumulative face value of all policies owned by the applicant/recipient does not exceed one thousand five hundred dollars ($1,500). A policy is considered to be "owned" by the applicant/recipient if the applicant/recipient is the only one who can surrender the policy for cash.
(1) Consideration of burial insurance and term insurance: Burial insurance and term insurance are not considered when computing the cumulative face value because this insurance is redeemable only upon death.
(2) Calculation when value exceeds limit: If the total cumulative face value of all countable life insurance policies owned by the applicant/recipient exceeds one thousand five hundred dollars ($1,500), the ISD worker:
(a) verifies the total cash surrender value of all policies and considers the total amount a countable resource; and
(b) informs the applicant/recipient that the insurance policies can be converted to term insurance or ordinary life insurance of lower face value at his/her option, if the cash surrender value, alone or in combination with other countable resources, exceeds the resource standard.
I. Produce for home consumption exclusion: The value of produce for home consumption is totally excluded.
J. Exclusion of settlement payments from the department of housing and urban development: Payments from the department of housing and urban development (HUD) as defined in Underwood v. Harris are excluded as income and resources. These one-time payments were made in the spring of 1980 to certain eligible tenants of subsidized housing (Section 236 of the National Housing Act).
(1) Segregation of payment: To be excluded as a resource, payments retained by an applicant/recipient must be kept separate. These payments must not be combined with any other countable resources.
(2) Income from segregated funds: Interest or dividend income received from segregated payment funds is not excluded from income, or, if retained, is not an excluded resource. This interest or dividend income must be kept separate from excludable payment funds.
K. Lump sum payments exclusion: SSI and social security lump sum payments for retroactive periods are excluded as countable resources for nine months after the month in which they are received. See Paragraph (4) of Subsection A of Section 8.215.500.16 NMAC, treatment of SSI or social security lump sum payments , for policy regarding SSI and social security lump sums which are placed into the ownership of a medicaid qualifying trust. Social security lump sum payments are considered infrequent income.
L. Home replacement exclusion: The value of a promissory note or similar installment sales contract which constitutes proceeds from the sale of an excluded home is excluded from countable resources if all of the following conditions are met:
(1) the note results from the sale of the applicant/recipient's home as described in Subsection E of Section 8.215.500.14 NMAC, exclusion for real property and home , and following subsections;
(2) within three months of receipt (execution) of the note, the applicant/recipient purchases a replacement home which meets the definition of a home in Subsection E of Section 8.215.500.14 NMAC, exclusion for real property and home , and following subsections; and
(3) all note-generated proceeds are reinvested in the replacement home within three months of receipt.
(4) Additional exclusions: In addition to excluding the value of the note itself, the down payment received from the sale of the former home, as well as that portion of any installment amount constituting payment on the principal are also excluded from countable resources.
(5) Failure to purchase another excluded home timely: If the applicant/recipient does not purchase another home which can be excluded under the provisions of Subsection E of Section 8.215.500.14 NMAC, exclusions for real property and home , and following subsections within three months, the value of the promissory note or similar installment sales contract received from the sale of an excluded home becomes a countable resource as of the first moment of the first day of the month following the month the note is executed. If the applicant/recipient purchases a replacement home after the expiration of the three month period, the value of the promissory note or similar installment sales contract becomes an excluded resource effective the month following the month of purchase of the replacement home provided that all other proceeds are fully and timely reinvested.
(6) Failure to reinvest proceeds timely: If the proceeds from the sale of an excluded home under a promissory note or similar installment sales contract are not reinvested fully within three months of receipt in a replacement home, the following resources become countable as of the first moment of the first day of the month following receipt of the payment:
(a) the fair market value of the note;
(b) the portion of the proceeds, retained by the individual, which was not timely reinvested; and
(c) the fair market value of the note remains a countable resource until the first moment of the first day of the month following the receipt of proceeds that are fully and timely reinvested in the replacement home; failure to reinvest proceeds for a period of time does not permanently preclude exclusion of the promissory note or installment sales contract; however, previously received proceeds that were not timely reinvested remain countable resources to the extent they are retained.
(7) Interest payments: If interest is received as part of an installment payment resulting from the sale of an excluded home under a promissory note or similar installment sales contract, the interest payments are considered countable unearned income in accordance with Paragraph (3) of Subsection C of Section 8.215.500.20 NMAC, interest on promissory note or sales contract .
(8) When the home replacement exclusion does not apply: If the home replacement exclusion does not apply, the market value of a promissory note or sales contract as well as the portion of the payment received on the principal are considered countable resources.
M. Household goods and personal effects exclusion: Household goods and personal effects are excluded if they meet one of the following four criteria. They are:
(1) items of personal property, found in or near the home, which are used on a regular basis; items may include but are not limited to: furniture, appliances, recreational vehicles (i.e. boats and RVs), electronic equipment (i.e. computers and television sets), and carpeting;
(2) items needed by the householder for maintenance, use and occupancy of the premises as a home; items may include but are not limited to: cooking and eating utensils, dishes, appliances, tools, and furniture.
(3) items of personal property ordinarily worn or carried by the individual; items may include but are not limited to: clothing, shoes, bags, luggage, personal jewelry including wedding and engagement rings, and personal care items;
(4) items otherwise having an intimate relation to the individual; items may include but are not limited to: prosthetic devices, educational or recreational items such as books or musical instruments, items of cultural or religious significance to an individual; or items required because of an individual’s impairment.
N. ABLE act exclusions:
( 1) For most federal means-tested programs:
(a) ABLE account balances are excluded.
(b) Limitation is the maximum amount that can be contributed under a state plan.
( 2) For the SSI program:
(a) ABLE account balances are excluded up to one hundred thousand dollars ($100,000).
(b) Amounts over one hundred thousand dollars ($100,000) count toward the two thousand dollars ($2,000) SSI resource limit.
(c) If an ABLE account balance exceeds one hundred thousand dollars ($100,000) by an amount that causes the recipient to exceed the SSI resource limit the recipient is ineligible for SSI.
O. Indian per capita: Public Law 97-458 (section 4) Amended Public Law 93-134, the Judgement Award Authorization Act, to require the exclusion of per capita payments under the Indian Judgement Fund Act of two thousand dollars ($2,000) or less. Initial purchases made with exempt payments distributed between January 1, 1982 and January 12, 1983, are excluded from resources to the extent that excluded funds were used.
[8. 215.500 .14 NMAC - Rp, 8.215.500.14 NMAC, 3/1/2018]
8.215.500.15 ASSET TRANSFERS:
A. Transfers of assets for less than fair market value by SSI applicants/recipients are considered only if/when an applicant/recipient becomes institutionalized. For medicaid categories using SSI resource determination methodology, transfers by non-institutionalized applicants/recipients are not considered a factor of eligibility.
B. Transfer of resources by an SSI recipient: An institutionalized SSI applicant/recipient who transfers resources without fair return may become ineligible for medicaid coverage of nursing home care for a specified period of time. See Section 8.281.500.14 NMAC and following subsections for information on resource transfer policies and penalties applicable to institutionalized applicants/recipients.
[8. 215.500 .15 NMAC - Rp, 8.215.500.15 NMAC, 3/1/2018]
8.215.500.16 TRUSTS: In some instances, an applicant/recipient with a trust can be eligible for SSI cash benefits but not be automatically eligible for medicaid . If the social security administration (SSA) determines that an SSI recipient has a trust, SSI notifies the human services department (HSD) of the existence of the trust. The recipient is then notified that the trust document must be submitted to and reviewed by HSD before medicaid eligibility is determined.
A. Medicaid qualifying trusts: A " medicaid -qualifying trust" (MQT) is a trust or similar legal device established prior to August 11, 1993, other than by will, by an applicant/recipient or spouse, under which the applicant/recipient may be the beneficiary of all or part of the payments from the trust. The distribution of trust payments is determined by one or more trustees who are permitted to exercise discretion with respect to the distribution of payments to the applicant/recipient. When the use of an attorney is solicited to establish a trust, the beneficiary of that trust is not exempt from the requirements of MQT provisions. Legal instruments such as trusts are almost always drafted by an attorney. It is the grantor him/herself who actually establishes of creates the trust when he/she signs or executes it.
(1) Amount deemed available from an MQT: The amount from an MQT that is deemed available to an applicant/recipient is the maximum amount that could be distributed to the applicant/ recipient, or for the care of the applicant/ recipient, regardless of restrictions imposed by the trust on the allowable use of the funds. If, for example, the trustee can make payments to a health care provider for medical services, the applicant/recipient beneficiary is considered to be receiving benefits from the trust even though these benefits are not paid directly to the beneficiary. This provision applies regardless of whether the MQT was set up for the purpose of qualifying for medicaid or whether the trust is irrevocable.
(2) Revocable trusts: Revocable trusts that limit access to the assets held in trust must be dissolved and the assets spent down before eligibility can be established.
(3) Beneficiary of trust lives in an ICF-MR: If the beneficiary of a trust is an applicant/recipient who is mentally retarded and resides in an intermediate care facility for the mentally retarded (ICF-MR), that applicant/recipient's trust is not considered an MQT if the trust or trust decree was established prior to April 7, 1986, and is solely for the benefit of that applicant/recipient.
(4) Treatment of SSI or social security lump sum payments: SSI or social security lump sum payments for retroactive periods which are placed into an MQT do not qualify for the nine month exclusion from countable resources.
B. Trusts creating medicaid eligibility: [RESERVED]
[8. 215.500 .16 NMAC - Rp, 8.215.500.16 NMAC, 3/1/2018]
8.215.500.17 DEEMING RESOURCES:
A. Deeming resources when an applicant/recipient lives with an ineligible spouse: If an eligible noninstitutionalized applicant/recipient lives in the same household with an ineligible spouse, the resources of the ineligible spouse are considered to belong to the applicant/recipient. The resource standard for a couple applies.
B. Deeming resources for minor applicant living with ineligible parent(s): If an applicant/recipient is a minor under 18 years of age, the resources of the parent(s) are deemed to the applicant/recipient if the parent(s) live in the same household.
(1) Computing deemed resources: To determine the amount of resources deemed to an applicant/recipient who is a minor, the following computation is made:
(a) determine the parent(s) resources;
(b) allow the parent(s) all the resource exclusions that an applicant/recipient receives; and
(c) remaining resources in excess of two thousand dollars ($2,000) for one parent or three thousand dollars ($2,000) for two parents are deemed to the eligible minor.
(2) Computing countable resources: The deemed resources are added to the applicant/recipient's own countable resources. The minor applicant/recipient is eligible if countable resources do not exceed resource standards.
[8. 215.500 .17 NMAC - Rp, 8.215.500.17 NMAC, 3/1/2018]
8.215.500.18 INCOME:
A. An applicant/recipient's gross countable monthly income must be less than the maximum allowable monthly standard for the applicable medicaid category. Income may be in the form of cash, checks, money orders, or in-kind, including personal property or food. If income is not received in the form of cash, the cash value of the item is determined and counted as income. Income is counted in the month received. Income is considered available throughout the month, regardless of when in the month it is received. The ISD worker verifies and documents all income.
B. Types of income: Countable income is the sum of unearned income or earned income, less disregards or exclusions, plus deemed income.
(1) Earned income: Earned income consists of the total gross income received by an individual for services performed as an employee or as a result of self-employment.
(a) Royalties earned in connection with the publication of the applicant/recipient's work and any honorarium/fees received for services rendered are considered earned income.
(b) The self-employed applicant/recipient must provide an estimate of his/her current income based on the tax return filed for the previous year or current records maintained in the regular course of business. The estimate of net earnings for the entire previous taxable year is prorated equally among all months of the current year, even if the business is seasonal.
( i ) Consideration is given to the applicant/recipient's explanation as to why he/she believes the estimated net earnings for the current year vary substantially from the information shown on his/her tax return for past years.
(ii) A satisfactory explanation is that the business suffered heavy loss or damage from fire, flood, burglary, serious illness or disability of the owner, or other such catastrophic events. Documentation must include copies of newspaper accounts or medical reports and must be filed in the case record to substantiate the need for a reduced estimate of current self-employment income.
(2) Unearned income: Unearned income consists of all other income (minus exclusions and disregards) that is not earned in the course of employment or self-employment.
(3) Deemed income: Deemed income is income which must be considered available to the assistance unit and counted in determining eligibility whether or not the income is actually made available. For household member(s) who are not members of the assistance unit but who have a support obligation to the assistance unit, income can only be deemed from a parent to his/her minor child(ren) who live in the same household and from one spouse to the other when both live in the same household.
C. Contributions to the able account:
(1) Contributions from any source to an ABLE account are not considered income to an SSI recipient.
(2) However:
(a) An SSI recipient’s earnings contributed to an ABLE account are still considered wages and counted (even if payroll deduction).
(b) Gifts to an SSI recipient to be deposited into an ABLE account are considered as income.
(c) Gifts made directly into an ABLE account are not income.
[8. 215.500 .18 NMAC - Rp, 8.215.500.18 NMAC, 3/1/2018]
8.215.500.19 INCOME STANDARDS: See 8.200.520 NMAC and following subsections for income standards applicable to the SSI-related medicaid categories.
A. Income exclusions: Income exclusions are applied before income disregards. Exclusions are applied in determining eligibility whether the income belongs to the applicant/recipient or to an individual from whom income is deemed.
B. Infrequent or irregular income: Exclude the first thirty dollars ($30) per calendar quarter of earned income; and the first sixty dollars ($60) per calendar quarter of unearned income. The following definitions apply.
(1) "Irregular income" is income received on an unscheduled or unpredictable basis.
(2) "Infrequent income" is income received only once during a calendar quarter from a single source and includes:
(a) proceeds of life insurance policies;
(b) prizes and awards;
(c) gifts;
(d) support and alimony;
(e) inheritances;
(f) interest per account, and royalties;
(g) one-time lump sum payments, such as social security or retroactive SSI.
(3) "Frequency" is evaluated for the calendar quarter (i.e., January - March, April - June, July - September, October - December) but the dollar amount is considered in the month received.
C. Foster care: Foster care payments are totally excluded if:
(1) the foster child is not eligible for SSI; and
(2) the child was placed in the applicant/recipient's home by a public or private nonprofit child placement or child care agency.
D. Domestic volunteer services exclusions: Payments to volunteers under domestic volunteer services (ACTION) programs are excluded from consideration as income in the eligibility determination process. These programs include the following:
(1) volunteers in service to America (VISTA);
(2) university year for action (UYA);
(3) special demonstration and volunteer programs;
(4) retired senior volunteer program (RSVP);
(5) foster grandparent program;
(6) senior companion program.
E. Census bureau employment: Wages paid by the census bureau for temporary employment related to the census are excluded from consideration as income in the eligibility determination process.
[8. 215.500 .19 NMAC - Rp, 8.215.500.19 NMAC, 3/1/2018]
8.215.500.20 UNEARNED INCOME:
A. Unearned income includes all income not earned in the course of employment or self-employment.
B. Income paid to one spouse is considered the income of that spouse. One-half the total income paid to a couple is considered available to each member of the couple.
(1) If payment is made in the name of either or both spouses and another party, only the applicant/recipient's proportionate share is considered available to him/her.
(2) If income is derived from property for which ownership is not established, such as unprobated property, one-half of the income is considered available to each member of a married couple.
C. Standards for unearned income: Unearned income is computed on a monthly basis. If there are no expenses incurred with the receipt of unearned income, such as annuities, pensions, retirement payments or disability benefits, the gross amount is considered countable unearned income.
(1) Social security overpayments: If the social security administration withholds an amount because of an overpayment, the gross social security payment amount is used to determine eligibility.
(2) Rental income: If an applicant/recipient has rental property, the ISD worker allows the cost of real estate taxes, maintenance and repairs, advertising, mortgage insurance and interest payments on the mortgage as deductions from the amount received as rent.
(3) Interest on promissory note or sales contract: The portion of the payment representing interest received from a promissory note or sales contract is considered unearned income. The market value of promissory notes or sales contracts and the portion of the payment representing payment of the principal are considered resources. See also Subsection L of Section 8.215.500.14 NMAC, home replacement exclusion .
D. Unearned income exclusions:
(1) Interest from an excluded burial fund: Interest from an excluded burial fund is not considered unearned income if the interest is applied toward the fund balance. If the interest is paid to the applicant/recipient, it is considered unearned income.
(2) Tax refunds and earned income tax credit: Tax refunds from any public agency for property taxes or taxes on food purchases are totally excluded. Any portion of a federal income tax return which constitutes an earned income tax credit is excluded.
(3) Grants, scholarships and fellowships: All grants, scholarships and fellowships used to pay tuition and fees at an educational institution, including vocational and technical schools, are totally excluded. Any portion of a grant, scholarship or fellowship used to pay any other expense, such as food, clothing or shelter, is not excluded.
(4) Veterans payments: Veterans aid and attendance (A&A) payments are excluded from unearned income for determination of eligibility.
(a) If an applicant/recipient receives an augmented VA payment as a veteran or veteran's widow or widower, the payment amount may include an increment for a dependent. If so, the VA must be contacted to provide documentation of the portion of the payment which represents the dependent's increment. When verified, this amount of the VA payment is considered the dependent's income.
(b) The portion of a veterans administration improved pension (VAIP) benefit intended for unreimbursed medical expenses is excluded for purposes of eligibility determination.
(5) Payments by a third party: Third party payments are excluded as income if made directly to the applicant/recipient's creditor.
(a) Third party payments may include mortgage payments by credit life or credit disability insurance and installment payments by a family member on a burial plot or prepaid burial contract.
(b) Interest from a burial contract that is automatically applied to the outstanding balance is excluded from unearned income. If the payment or interest is sent to the individual, it is counted as unearned income regardless of the sender's (third party's) intentions. This applies even if the sender specifies the purpose of the payment on the check.
(c) This provision does not apply if the signature of the creditor and the individual must both be present in order to negotiate the check (two-party check).
(6) Indian tribe per capita payments: Certain per capita payments are excluded from income and resources.
(a) Up to two thousand dollars two thousand dollars ($2,000) of per capita distributions of judgment funds to members of the confederated tribes of the Warm Springs Reservation are excluded except for funds held by Alaska native regional and village corporations (ANRVC) that are not held in trust by the secretary of the interior. ANRVC dividend distributions are not excluded from countable income under this exclusion (per Public Law 97-436 section 4, 98-64, and 100-580).
(b) All distributions to heirs of certain deceased Indians under the Old Age Assistance Claims Settlement Act except for per capita shares in excess of two thousand dollars ($2,000) (per Public Law 98-500 section 8).
(c) Up to two thousand dollars ($2,000) per year received by Indians that is derived from individual interests in trust or restricted lands (per Public Law 103-66 section 13736, 92-203, and 100-241).
(d) Up to two thousand dollars ($2,000) per year received by Indians that is derived from individual interests in trust or restricted lands (per Public Law 111-291).
(e) Amounts received by an individual as a lump sum or a periodic payment via the Cobell settlement cannot be counted as income in the month received or as a resource for a one year period beginning with the date of receipt (per Public Law 111-291 section 101).
(7) Plans for achieving self-support: Income derived from, or necessary to, an approved plan for achieving self-support for a blind or disabled applicant/recipient under 65 years of age is excluded.
(a) For an applicant/recipient who is blind or disabled and over 65 years of age, this exclusion applies only if he/she received medicaid for the month preceding his/her 65th birthday.
(b) The self-support plan must be in writing and contain the following:
( i ) designated occupational objective;
(ii) specification of any savings (resource) or earnings needed to complete the plan, such as amounts needed for purchase of equipment or for financial independence;
(iii) identification and segregation of any income saved to meet the occupational goal; and
(iv) designation of a time period for completing the plan and achieving the occupational goal.
(c) Plans for achieving self-support are developed by vocational rehabilitation counselors. If a self-support plan is not in place, the ISD worker makes a referral to the division of vocational rehabilitation (DVR).
(d) The ISD worker forwards the written plan and documentation to the MAD eligibility unit. The plan must be approved by that unit.
(e) An approved plan is valid for the following specified time periods:
( i ) initial period of no more than 18 months;
(ii) extension period of no more than 18 months;
(iii) final period of no more than 12 months; and
(iv) total period of no more than 48 months.
(8) Agent orange settlement payments: Agent orange settlement payments made to veterans or their survivors are excluded from consideration as income in determining eligibility.
(9) Radiation Exposure Compensation Act payments: Payments made under the Radiation Exposure Compensation Act are excluded from consideration as income in determining eligibility.
(10) Remembrance, responsibility and the future foundation: Payments to individual survivors forced into slave labor by the Nazis are excluded.
(11) Victims compensation payments: Payments made by a state-administered fund established to aid victims of crime are excluded from consideration as income in determining eligibility.
(12) SSI lump sums for retroactive periods: Supplemental security income (SSI) lump sum payments for retroactive periods are excluded from consideration as countable income in the month received.
(13) Life insurance and other burial benefits: Life insurance and other burial benefits are unearned income to the beneficiary (not the owner). The ISD worker must subtract the amount spent on the insured individual's last illness or burial up to one thousand five hundred dollars ($1,500). Any excess is counted as unearned income.
(14) One hundred percent state-funded assistance payment: Any one hundred percent state-funded assistance payment based on need, such as general assistance (GA), is excluded. Any interim payments made by a state or municipality from all state or local funds while an SSI application is pending are excluded.
(15) ABLE ACT distributions: Distributions from an ABLE account are excluded as income of the designated beneficiary. Qualified disability expenses (QDEs) are expenses related to the blindness or disability of the designated beneficiary and for the benefit of the designated beneficiary. The following (QDEs) are excluded:
(a) Housing related QDEs: mortgages (including house insurance), real property taxes, rent, heating fuel, gas, electricity, water, sewer, and garbage removal.
(b) Non-housing related QDEs: education, transportation, employment training and support, assistive technology and related services, health, prevention and wellness, financial management and administrative services, legal fees, expenses for ABLE account oversight and monitoring, funeral and burial, and basic living expenses.
(c) Non-qualified expenses.
(d) QDEs for non-housing: Distributions for other non-housing expenses are excluded if retained beyond the month received in their current ABLE account if the distribution is identifiable and is intended to eventually be expended for non-housing costs.
(e) Non-qualified expenses: N ot excluded under the ABLE Act are housing-related or other QDEs if retained by the beneficiary for two months.
[8. 215.500 .20 NMAC - Rp, 8.215.500.20 NMAC, 3/1/2018]
8.215.500.21 DEEMED INCOME:
A. Availability: Deemed income is income which must be considered available to members of an assistance unit regardless of whether the income is actually made available.
B. Situations in which deeming occurs: For household member(s) who are not members of the assistance unit but who have a support obligation to the assistance unit member(s), income can only be deemed from a parent(s) to his/her minor child(ren) who live in the same household and from one spouse to the other when both live in the same household.
C. Parent or spouse receiving benefits based on economic need: In a deeming situation where one parent or the spouse is receiving a needs benefit, the benefit plus all of the income of the spouse/parent who receives the benefit is excluded from the deeming process. This exclusion applies only to the income of the individual who receives the benefit.
(1) Needs benefit defined: "Needs benefit" is any benefit or assistance which is paid by a governmental agency on the basis of economic need.
(2) Consideration of household membership: Even if the income of one parent is excluded from the deeming process, the parent is considered a member of the household for purposes of determining the parental allocation. This does not apply to benefits received under the temporary assistance to needy families (TANF) program. No income is allocated to a parent or child if that parent or child is receiving TANF assistance.
D. Applicant living with ineligible spouse:
(1) If an applicant/recipient is living in the same household with an ineligible spouse, income may be deemed from the ineligible spouse to the applicant/recipient.
(2) The methodology described below does not apply to the qualified medicare beneficiaries (QMB) program. See Paragraph (1) of Subsection B of Section 8.240.500.15 NMAC for methodology applicable to the QMB program only.
(a) Evaluation of applicant's income: Determine the amount of income available to the applicant using only the applicant's own income and allow the twenty dollars ($20) disregard. If the applicant/recipient has earned income, the first sixty five dollars ($65) plus one-half of the remainder is also disregarded.
( i ) If an applicant/recipient's own income exceeds the income standard for an individual, the applicant/recipient is ineligible. No further calculation needs to be done.
(ii) If an applicant/recipient's countable income is less than the standard for an individual, determine the ineligible spouse's gross income.
(b) Evaluation of ineligible spouse's gross income: Determine the ineligible spouse's gross income (both earned and unearned). Subtract the twenty dollars ($20) general disregard plus the first sixty five dollars ($65) and one-half of the remainder from any earned income. If there are no children in the household, compare the ineligible spouse's countable income to one-half of the SSI federal benefit rate (FBR) for an individual not living in the household of others. If the ineligible spouse's countable income is less than one-half of the SSI FBR, no income is deemed from the ineligible spouse to the applicant/recipient. If the ineligible spouse's countable income equals or exceeds one-half of the SSI FBR, income is deemed from the ineligible spouse to the applicant.
E. Applicant living with ineligible spouse and children:
(1) A “child” is under 18 years of age or under 21 years of age if a full-time student at an accredited institution of learning.
(2) If there are children in the household, subtract a living allowance for each ineligible child from the ineligible spouse's countable income. The living allowance is one-half of the monthly SSI FBR for an individual not living in a household with others less any income attributable to the child. If the remaining amount is less than one-half of the SSI FBR, no income is deemed from the ineligible spouse to the applicant/recipient. If the remaining amount equals or exceeds one-half of the SSI FBR, income is deemed from the ineligible spouse to the applicant/recipient.
(3) Determination of countable income: Add the total gross unearned income of the ineligible spouse to the total gross unearned income of the applicant/recipient. The twenty dollars ($20) disregard is deducted from the combined total of the couple's unearned income. If the total unearned income is less than twenty dollars ($20), the remainder is deducted from the combined total of the couple's earned income. The first sixty five dollars ($65) and half (1/2) of the remainder is subtracted from the combined total of the couple's earned income. After all applicable disregards have been subtracted, the remaining earned and unearned income amounts are combined to arrive at the total countable income. If the total countable income is less than the income standard for a couple, the applicant/recipient is eligible.
F. Applicant child living with ineligible parents: A "child" applicant/recipient is under 18 years of age. The ISD worker determines the total gross monthly amount of parental income, both unearned and earned. The ISD worker applies appropriate income disregards to calculate the countable deemed income. See Section 8.200.520.18 NMAC, deemed income worksheet . If the deemed income plus the child's separate income exceeds the income standard for an applicant/recipient, the child is not eligible for that month.
G. Applicant/recipient parent and applicant/recipient child(ren): If a household is composed of an applicant/recipient parent and an applicant/recipient child(ren), the income is deemed from the ineligible spouse to the applicant/recipient spouse if appropriate. See Subsection B of Section 8.215.500.21 NMAC, deemed income .
(1) If there is enough total income to make the applicant/recipient parent ineligible, the remainder of the income is carried over to be deemed to the child(ren). Deemed income is divided equally among the applicant/recipient children.
(2) If the total countable income of the child, including the deemed income, is more than the applicable income standard, the child is ineligible.
[8. 215.500 .21 NMAC - Rp, 8.215.500.21 NMAC, 3/1/2018]
8.215.500.22 DISREGARDS: Income disregards are allowed as described below when applicable.
A. Child support payments: One-third of the amount of child support payments made to a child applicant/recipient is disregarded. The remainder is considered unearned income, subject to the appropriate disregards.
B. Twenty dollar disregard: The first twenty dollars ($20) of unearned or earned income received in a month is disregarded. This disregard is applied first to unearned income, then to earned income if the unearned income is less than twenty dollars ($20). If there is no unearned income, the entire twenty dollars ($20) is applied to the gross earned income. This disregard is not applicable to payments made to an applicant/recipient through a state or other government assistance program, or by a private charitable organization, where such payments are based on the applicant/recipient's need.
C. Additional earned income disregard: After disregarding the first twenty dollars ($20) as specified in Subsection B of Section 8.215.500.22 NMAC above, if appropriate, earned income of sixty-five ($65) per month plus one-half of the remainder is disregarded.
D. Work-related expenses of the blind or disabled: Work-related expenses of an employed applicant/recipient or couple who is/are legally blind or disabled are disregarded. This disregard is for earned income only. The dollar amount of expenses which may be disregarded must be items or services directly related to enabling a person to work and which are necessarily incurred by that individual because of a physical or mental disability or blindness. Such costs incurred must be reasonable. Expenses are disregarded when paid and must be verified.
(1) This disregard does not apply to an applicant/recipient who is blind and is 65 years of age or older, unless he/she was receiving SSI payments due to blindness or disability in the month before turning 65 or received payments under a state aid to the blind or disabled program.
(2) Types of work-related expenses which may be disregarded include:
(a) federal, state, and local income taxes;
(b) social security contributions;
(c) union dues;
(d) transportation costs, including actual cost of bus/taxi cab fare, or 15 cents per mile for private automobile;
(e) lunches;
(f) child care costs, if not otherwise provided;
(g) uniforms, tools, and other necessary equipment;
(h) special vehicle modifications to enable transportation to and from work, but not the cost of the vehicle itself;
( i ) attendants who may be hired for the purpose of taking applicant/recipient to and from work, and getting ready for work;
(j) durable medical equipment that is medically related and generally not useful in absence of the blindness or disability yet are necessary to attend and perform tasks in the work place;
(k) expenses for work related equipment which is impairment related and necessary for the individual to perform his/her tasks;
(l) prostheses necessary to perform work related tasks;
(m) design modifications related to blindness or disability that enable the applicant/recipient to leave home in order to attend work, or design modifications made to the work area of the home in the case where the applicant/recipient engages in a home based business; and
(n) special expenses necessary to enable an applicant/recipient who is blind or disabled to engage in employment, such as a seeing-eye dog, braille instructions, or instructions on using special equipment.
(3) If items or services above are purchased through an installment contract, the payments are disregarded. Should the item or service be a one time purchase, the purchase may be pro-rated over a 12 month period, or over the life of the contract.
(4) For items which are leased, the monthly payment would be disregarded.
E. Student earned income:
(1) This disregard applies only to a student's own earned income and includes all payments made as compensation for services, such as wages from employment or self-employment, or payments from programs such as neighborhood youth corps or work-study.
(2) This disregard is available in addition to any exclusions applied to grants, scholarships or fellowships and in addition to any other allowable disregards.
(3) Up to one thousand two hundred dollars ($1,200) per quarter, or a maximum of one thousand six hundred twenty dollars ($1,620) per calendar year, of the earned income of certain students may be disregarded. To qualify for this disregard, the applicant/recipient must meet all of the following requirements:
(a) under 22 years of age;
(b) unmarried;
(c) not the head of a household; and
(d) in regular attendance at a college or university for at least 12 semester hours or a school or vocational or technical training course for at least 20 hours per week.
[8. 215.500 .22 NMAC - Rp, 8.215.500.22 NMAC, 3/1/2018]
8.215.500.23 INCOME STANDARD: When computing an applicant/recipient's eligibility, the applicable income standard is that of the SSI-related category being applied for/received. See Section 8.200.520 NMAC and following subsections.
[8. 215.500 .23 NMAC - Rp, 8.215.500.23 NMAC, 3/1/2018]
HISTORY OF 8.215.500 NMAC: The material in this part was derived from that previously filed with the Commission of Public Records - State Records Center and Archives:
MAD Rule 860, SSI Methodology For Computation Of Countable Resources And Income, 3/17/1990.
MAD Rule 860, SSI Methodology For Computation Of Countable Resources And Income, 3/21/1990.
MAD Rule 860, SSI Methodology For Computation Of Countable Resources And Income, 4/24/1991.
MAD Rule 860, SSI Methodology For Computation Of Countable Resources And Income, 6/19/1992.
MAD Rule 861, Resources - SSI Methodology For Computation Of Countable Resources And Income, 3/18/1993.
MAD Rule 861, Resources - SSI Methodology For Computation Of Countable Resources And Income, 12/29/1994.
MAD Rule 862, Income - SSI Methodology For Computation Of Countable Resources And Income, 3/18/1993.
MAD Rule 864, Potential Income Or Resources - SSI Methodology For Computation Of Countable Resources And Income, 3/18/1993.
MAD Rule 866, Deeming Income, 11/16/1994.
History of Repealed Material:
8.215.500 NMAC, Medicaid Eligibility Supplemental Security Income (SSI) Methodology - Income And Resource Standards f iled 2/15/2001) - Repealed effective 3/1/2018.
TITLE 8 SOCIAL SERVICES
CHAPTER 215 MEDICAID ELIGIBILITY - SUPPLEMENTAL SECURITY INCOME (SSI) METHODOLOGY
PART 600 BENEFIT DESCRIPTION
8.215.600.1 ISSUING AGENCY: New Mexico Health Care Authority.
[8.215.600.1 NMAC - Rp, 8.215.600.1 NMAC, 1/1/2019; A,7/1/2024]
8.215.600.2 SCOPE: The rule applies to the general public .
[8.215.600.2 NMAC - Rp, 8.215.600.2 NMAC, 1/1/2019]
8.215.600.3 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.
[8.215.600.3 NMAC - Rp, 8.215.600.3 NMAC, 1/1/2019; A, 7/1/2024]
8.215.600.4 DURATION: Permanent.
[8.215.600.4 NMAC - Rp, 8.215.600.4 NMAC, 1/1/2019]
8.215.600.5 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.
[8.215.600.5 NMAC - Rp, 8.215.600.5 NMAC, 1/1/2019]
8.215.600.6 OBJECTIVE: The objective of these regulations is to provide eligibility policy and procedures for the medicaid program.
[8.215.600.6 NMAC - Rp, 8.215.600.6 NMAC, 1/1/2019]
8.215.600.7 DEFINITIONS: [ RESERVED ]
8.215.600.8 [ RESERVED ]
8.215.600.9 GENERAL BENEFIT COVERAGE: Medicaid coverage for services based on determinations made using the SSI methodology varies based on the category of eligibility. For applicants/recipients who are eligible for SSI, full medicaid coverage for services is available. If applicants/recipients are eligible for medicare coverage, medicaid covers medicare premium amounts.
[8.215.600.9 NMAC - Rp, 8.215.600.9 NMAC, 1/1/2019]
8.215.600.10 SSI RETROACTIVE BENEFIT COVERAGE: Retroactive medicaid coverage is provided in accordance with 8.200.400.14 NMAC.
[8.215.600.10 NMAC - Rp, 8.215.600.10 NMAC, 1/1/2019]
8.215.600.11 CHANGES IN ELIGIBILITY: A case is closed, with provision of advance notice when the recipient becomes ineligible. If a recipient dies, the case is closed the following month.
[8.215.600.11 NMAC - Rp, 8.215.600.11 NMAC, 1/1/2019]
HISTORY OF 8.215.600 NMAC:
Pre NMAC History: The material in this part was derived from that previously filed with the State Records Center.
MAD Rule 860, SSI Methodology for Computation of Countable Resources and Income, filed 3/7/1989.
MAD Rule 860, SSI Methodology for Computation of Countable Resources and Income, filed 3/21/1990.
MAD Rule 860, SSI Methodology for Computation of Countable Resources and Income, filed 4/24/1991.
MAD Rule 860, SSI Methodology for Computation of Countable Resources and Income, filed 6/19/1992.
MAD Rule 861, Resources - SSI Methodology for Computation of Countable Resources and Income, filed 3/18/1993.
MAD Rule 861, Resources - SSI Methodology for Computation of Countable Resources and Income, filed 12/29/1994.
MAD Rule 862, Income - SSI Methodology for Computation of Countable Resources and Income, filed 3/18/1993.
MAD Rule 864, Potential Income or Resources - SSI Methodology for Computation of Countable Resources and Income, filed 3/18/1993.
MAD Rule 866, Deeming Income, filed 11/16/1994.
History of Repealed Material:
MAD Rule 860, SSI Methodology for Computation of Countable Resources and Income, filed 6/19/1992 - Repealed effective 2/1/1995.
MAD Rule 861, Resources - SSI Methodology for Computation of Countable Resources and Income, filed 12/29/1994 - Repealed effective 2/1/1995.
MAD Rule 862, Income - SSI Methodology for Computation of Countable Resources and Income, filed 3/18/1993- Repealed effective 2/1/1995.
MAD Rule 864, Potential Income or Resources - SSI Methodology for Computation of Countable Resources and Income, filed 3/18/1993 - Repealed effective 2/1/1995.
MAD Rule 866, Deeming Income, filed 11/16/1994 - Repealed effective 2/1/1995.
8.215.600 NMAC - Benefit Description filed 9/3/2013 - Repealed effective 1/1/2019.
TITLE 8 SOCIAL SERVICES
CHAPTER 231 MEDICAID ELIGIBILITY - INFANTS OF MOTHERS WHO ARE MEDICAID ELIGIBLE (CATEGORY 031)
PART 400 RECIPIENT POLICIES
8.231.400.1 ISSUING AGENCY: New Mexico Health Care Authority.
[8.231.400.1 NMAC - Rp, 8.231.400.1 NMAC, 10/1/2017; A,7/1/2024]
8.231.400.2 SCOPE: The rule applies to the general public .
[8.231.400.2 NMAC - Rp, 8.231.400.2 NMAC, 10/1/2017]
8.231.400.3 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.
[8.231.400.3 NMAC - Rp, 8.231.400.3 NMAC, 10/1/2017; A, 7/1/2024]
8.231.400.4 DURATION: Permanent
[8.231.400.4 NMAC - Rp, 8.231.400.4 NMAC, 10/1/2017]
8.231.400.5 EFFECTIVE DATE: October 1, 2017, unless a later date is cited at the end of a section.
[8.231.400.5 NMAC - Rp, 8.231.400.5 NMAC, 10/1/2017]
8.231.400.6 OBJECTIVE: The objective of these regulations is to provide eligibility policy and procedures for the medicaid program.
[8.231.400.6 NMAC - Rp, 8.231.400.6 NMAC, 10/1/2017]
8.231.400.7 DEFINITIONS: [ RESERVED ]
8.231.400.8 MISSION: To transform lives. Working with our partners, we design and deliver innovative, high quality health and human services that improve the security and promote independence for New Mexicans in their communities.
[8.231.400.8 NMAC - Rp, 8.231.400.8 NMAC, 10/1/2017; A, 1/1/2022]
8.231.400.9 NEWBORN - CATEGORY 031: The New Mexico medicaid program covers infants for 13 months born to mothers who are eligible for and receiving New Mexico medicaid at the time of the child's birth including during a period of retroactive eligibility. Mothers eligible to receive emergency medical services for non-citizens (EMSNC) at the time of labor and delivery are considered to meet the standard of medicaid eligibility for the mother.
[8.231.400.9 NMAC - Rp, 8.231.400.9 NMAC, 10/1/2017; A, 1/1/2022]
8.231.400.10 BASIS FOR DEFINING THE GROUP (42 CFR 435.177):
A. Eligibility: HSD provides medicaid to children from birth through the month of the child's first birthday without application if, for the date of the child's birth, the child's mother was eligible for and received covered services under:
(1) the medicaid state plan (including during a period of retroactive eligibility under 42 CFR 435.915) regardless of whether payment for services for the mother is limited to services necessary to treat an emergency medical condition, as defined in section 1903(v)(3) of the Act and 8.285.400.10 NMAC under the emergency medical services for non-citizens (EMSNC) program.
(2) the child is deemed to have applied and been determined eligible under the medicaid state plan effective as of the date of birth, and remains eligible regardless of changes in circumstances through the month of the child's first birthday, unless the child dies or ceases to be a resident of the state or the child's representative requests a voluntary termination of eligibility.
B. Medicaid identification number: The medicaid identification number of the mother serves as the child's identification number, and all claims for covered services provided to the child may be submitted and paid under such number, unless and until the state issues the child a separate identification number. HSD will issue a separate medicaid identification number for the child prior to the effective date of any termination of the mother's eligibility or prior to the date of the child's first birthday, whichever is sooner, except that HSD will issue a separate medicaid identification number in the case of a child born to a mother:
(1) whose coverage is limited to services necessary for the treatment of an emergency medical condition, consistent with 42 CFR 435.139 or 435.350 and 8.285.400.10 NMAC under the EMSNC program; or
(2) who received medicaid in another state on the date of birth.
[8.231.400.10 NMAC - Rp, 8.231.400.10 NMAC, 10/1/2017; A, 1/1/2022]
8.231.400.11 GENERAL RECIPIENT REQUIREMENTS: [RESERVED]
[8.231.400.11 NMAC - Rp, 8.231.400.11 NMAC, 10/1/2017]
8.231.400.12 USE OF SOCIAL SECURITY NUMBER: The infant is not required to have a social security number as a condition of eligibility.
[8.231.400.12 NMAC - Rp, 8.231.400.12 NMAC, 10/1/2017]
8.231.400.13 CITIZENSHIP: An eligible newborn is considered to have met the citizenship and identity requirements.
[8.231.400.13 NMAC - Rp, 8.231.400.13 NMAC, 10/1/2017]
8.231.400.14 RESIDENCE: To be eligible for medicaid , an applicant/recipient must be physically present in New Mexico on the date of application or final determination of eligibility and must have demonstrated intent to remain in the state. A temporary absence from the state does not prevent eligibility. A temporary absence exists if the applicant/recipient leaves the state for a specific purpose with a time-limited goal, and intends to return to New Mexico when the purpose is accomplished.
[8.231.400.14 NMAC - Rp, 8.231.400.14 NMAC, 10/1/2017]
8.231.400.15 SPECIAL RECIPIENT RESPONSIBILITIES: [RESERVED]
[8.231.400.15 NMAC - Rp, 8.231.400.15 NMAC, 10/1/2017]
8.231.400.16 AGE: An applicant/recipient newborn is eligible for medicaid under this category from birth through the month of the child's first birthday.
[8.231.400.16 NMAC - Rp, 8.231.400.16 NMAC, 10/1/2017]
8.231.400.17 RECIPIENT RIGHTS AND RESPONSIBILITIES: An applicant/recipient is responsible for establishing his/her eligibility for medicaid . As part of this responsibility, the applicant/recipient must provide required information and documents or take the actions necessary to establish eligibility. Failure to do so must result in a decision that eligibility does not exist. An applicant/recipient must also grant the human services department (HSD) permission to contact other persons, agencies or sources of information which are necessary to establish eligibility.
[8.231.400.17 NMAC - Rp, 8.231.400.17 NMAC, 10/1/2017]
8.231.400.18 ASSIGNMENT OF SUPPORT: Assignment of child support rights is not required for applicants/recipients eligible for category 031.
[8.231.400.18 NMAC - Rp, 8.231.400.18 NMAC, 10/1/2017]
HISTORY OF 8.231.400 NMAC:
Pre-NMAC History: The material in this part was derived from that previously filed with the State Records Center.
ISD 290.1000, Medical Assistance for Woman and Children, filed 11/13/1984.
ISD FA 830, Medical Assistance for Woman and Children and AFDC Related Groups, filed 2/10/1988.
MAD Rule 830, Medical Assistance for Women and Children and AFDC - Related Groups, filed 8/11/1988.
MAD Rule 830, Medical Assistance for Women and Children and AFDC - Related Groups; filed 9/8/1988.
MAD Rule 830, Medical Assistance for Women and Children and AFDC - Related Groups; filed 9/30/1988.
MAD Rule 830, Medical Assistance for Women and Children and AFDC - Related Groups; filed 12/1/1988.
MAD Rule 830, Medical Assistance for Women and Children and AFDC - Related Groups; filed 3/31/1989.
MAD Rule 830, Medical Assistance for Women and Children and AFDC - Related Groups; filed 6/8/1989.
MAD Rule 830, Medical Assistance for Women and Children and AFDC - Related Groups; filed 12/28/1989.
MAD Rule 830, Medical Assistance for Women and Children and AFDC - Related Groups; filed 12/29/1989.
MAD Rule 830, Medical Assistance for Women and Children and AFDC - Related Groups; filed 3/1/1991.
MAD Rule 830, Medical Assistance for Women and Children and AFDC - Related Groups; filed 6/5/1992.
History of Repealed Material:
MAD Rule 830, Medical Assistance for Women and Children and AFDC - Related Groups; filed 6/5/1992 - Repealed effective 2/1/1995.
8.231.400 NMAC, Recipient Policies, (filed 12/10/2007) - Repealed effective 10/1/2017.
NMAC History:
8.231.400 NMAC, Recipient Policies (filed 12/10/2007) was replaced by 8.231.400 NMAC, Recipient Policies, effective 10/1/2017.
TITLE 8 SOCIAL SERVICES
CHAPTER 231 MEDICAID ELIGIBILITY - INFANTS OF MOTHERS WHO ARE MEDICAID ELIGIBLE (CATEGORY 031)
PART 500 INCOME AND RESOURCE STANDARDS
8.231.500.1 ISSUING AGENCY: New Mexico Health Care Authority.
[8.231.500.1 NMAC - Rp, 8.231.500.1 NMAC, 10/1/2017; A, 7/1/2024]
8.231.500.2 SCOPE: The rule applies to the general public .
[8.231.500.2 NMAC - Rp, 8.231.500.2 NMAC, 10/1/2017]
8.231.500.3 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 human services department 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.
[8.231.500.3 NMAC - Rp, 8.231.500.3 NMAC, 10/1/2017; A,7/1/2024]
8.231.500.4 DURATION: Permanent.
[8.231.500.4 NMAC - Rp, 8.231.500.4 NMAC, 10/1/2017]
8.231.500.5 EFFECTIVE DATE: October 1, 2017, unless a later date is cited at the end of a section.
[8.231.500.5 NMAC - Rp, 8.231.500.5 NMAC, 10/1/2017]
8.231.500.6 OBJECTIVE: The objective of these regulations is to provide eligibility policy and procedures for the medicaid program.
[8.231.500.6 NMAC - Rp, 8.231.500.6 NMAC, 10/1/2017]
8.231.500.7 DEFINITIONS: [ RESERVED ]
8.231.500.8 [ RESERVED ]
8.231.500.9 NEED DETERMINATION:
[8.231.500.9 NMAC - Rp, 8.231.500.9 NMAC, 10/1/2017]
8.231.500.10 RESOURCE STANDARDS: Resources are not a factor in the eligibility determination for category 031.
[8.231.500.10 NMAC - Rp, 8.231.500.10 NMAC, 10/1/2017]
8.231.500.11 INCOME STANDARDS: Income is not a factor in the eligbility determination for category 031.
[8.231.500.11 NMAC - Rp, 8.231.500.11 NMAC, 10/1/2017]
HISTORY OF 8.231.500 NMAC:
Pre-NMAC History: The material in this part was derived from that previously filed with the State Records Center.
ISD 290.1000, Medical Assistance for Woman and Children, filed 11/13/1984.
ISD FA 830, Medical Assistance for Woman and Children and AFDC Related Groups, filed 2/10/1988.
MAD Rule 830, Medical Assistance for Women and Children and AFDC - Related Groups, filed 8/11/1988.
MAD Rule 830, Medical Assistance for Women and Children and AFDC - Related Groups; filed 9/8/1988.
MAD Rule 830, Medical Assistance for Women and Children and AFDC - Related Groups; filed 9/30/1988.
MAD Rule 830, Medical Assistance for Women and Children and AFDC - Related Groups; filed 12/1/1988.
MAD Rule 830, Medical Assistance for Women and Children and AFDC - Related Groups; filed 3/31/1989.
MAD Rule 830, Medical Assistance for Women and Children and AFDC - Related Groups; filed 6/8/1989.
MAD Rule 830, Medical Assistance for Women and Children and AFDC - Related Groups; filed 12/28/1989.
MAD Rule 830, Medical Assistance for Women and Children and AFDC - Related Groups; filed 12/29/1989.
MAD Rule 830, Medical Assistance for Women and Children and AFDC - Related Groups; filed 3/1/1991.
MAD Rule 830, Medical Assistance for Women and Children and AFDC - Related Groups; filed 6/5/1992.
History of Repealed Material:
MAD Rule 830, Medical Assistance for Women and Children and AFDC - Related Groups; filed 6/5/1992 - Repealed effective 2/1/1995.
8.231.500 NMAC, Income and Resource Standards (filed 12/10/2007) - Repealed effective 10/1/2017.
NMAC History:
8.231.500 NMAC, Income and Resource Standards (filed 12/10/2007) was replaced by 8.231.500 NMAC, Income and Resource Standards (filed 12/10/2007) effective 10/1/2017 .
TITLE 8 SOCIAL SERVICES
CHAPTER 231 MEDICAID ELIGIBILITY - INFANTS OF MOTHERS WHO ARE MEDICAID OR MEDICAL ASSISTANCE PROGRAM ELIGIBLE
PART 600 BENEFIT DESCRIPTION
8.231.600.1 ISSUING AGENCY: New Mexico Health Care Authority.
[8.231.600.1 NMAC - Rp, 8.231.600.1 NMAC, 1/1/2019; A, 7/1/2024]
8.231.600.2 SCOPE: The rule applies to the general public .
[8.231.600.2 NMAC - Rp, 8.231.600.2 NMAC, 1/1/2019]
8.231.600.3 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 Section 27-1-12 et seq., NMSA 1978. 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.
[8.231.600.3 NMAC - Rp, 8.231.600.3 NMAC, 1/1/2019; A, 7/1/2024]
8.231.600.4 DURATION: Permanent.
[8.231.600.4 NMAC - Rp, 8.231.600.4 NMAC, 1/1/2019]
8.231.600.5 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.
[8.231.600.5 NMAC - Rp, 8.231.600.5 NMAC, 1/1/2019]
8.231.600.6 OBJECTIVE: The objective of this rule is to provide specific instructions when determining eligibility for the medicaid program and other health care programs. Processes for establishing and maintaining this category of eligibility are found in the affordable care general provision chapters located at 8.291.400 NMAC through 8.291.430 NMAC.
[8.231.600.6 NMAC - Rp, 8.231.600.6 NMAC, 1/1/2019]
8.231.600.7 DEFINITIONS: [RESERVED]
8.231.600.8 MISSION: To transform lives. Working with our partners, we design and deliver innovative, high quality health and human services that improve the security and promote independence for New Mexicans in their communities.
[8.231.600.8 NMAC - Rp, 8.231.600.8 NMAC, 1/1/2019; A, 1/1/2022]
8.231.600.9 BENEFIT DESCRIPTION: An applicant or recipient who is eligible for medicaid under this category is eligible to receive the full range of medicaid services.
[8.231.600.9 NMAC - Rp, 8.231.600.9 NMAC, 1/1/2019]
8.231.600.10 BENEFIT DETERMINATION:
A. Medical service providers must give the name and case number of the New Mexico medicaid eligible mother and the name, birth date, sex of the newborn, and the name of the hospital where the birth occurred to local county income support division (ISD) office. Within three days after receipt of this information, the income support specialist (ISS):
(1) determines if the mother was eligible for New Mexico medicaid at the time of birth or if the birth and delivery was covered by emergency medical services to undocumented non-citizens (EMSNC);
(2) registers the newborn for medicaid on the system; a signed application is not required;
(3) provides eligibility information to the hospital; and
(4) notifies the mother that a signed application is necessary to establish the newborn’s eligibility for temporary assistance for needy families (TANF), if applicable.
B. Processing time limit: All applications must be processed within 45 days from the date of application. The time limit begins on the day the signed application is received. Applications must be acted upon and notice of approval, denial or delay sent out within the required time limit. The ISS explains the time limit and that the applicant may request an administrative hearing if the application pends longer than the time limit allows.
[8.231.600.10 NMAC - Rp, 8.231.600.10 NMAC, 1/1/2019; A, 1/1/2022]
8.231.600.11 ONGOING BENEFITS: A newborn remains eligible for assistance under Category 031 from birth through the month of the child’s first birthday as long as the newborn remains in New Mexico.
[8.231.600.11 NMAC - Rp, 8.231.600.12 NMAC, 1/1/2019]
8.231.600.12 RETROACTIVE BENEFIT COVERAGE: Retroactive medicaid coverage is provided in accordance with Subsection H of 8.200.400.14 NMAC.
[8.231.600.12 NMAC - Rp, 8.231.600.13 NMAC, 1/1/2019]
8.231.600.13 CHANGE IN ELIGIBILITY: If the newborn is placed on MAD Category 400 or 420 and then loses eligibility for either of these categories, the newborn can still be eligible for Category 031 if he meets Category 031 requirements for the remainder of the 12 month period. A new application is not required
[8.231.600.13 NMAC - Rp, 8.231.600.14 NMAC, 1/1/2019]
8.231.600.14 PERIODIC REDETERMINATIONS OF ELIGIBILITY (42 CFR 435.117( d)) : A redetermination of eligibility must be completed on behalf of the children described in this provision in accordance with 8.291.410.19 NMAC.
[8.231.600.14 NMAC - Rp, 8.231.600.14 NMAC, 1/1/2019]
8.231.600.15 ENUMERATION AND CITIZENSHIP:
A. HSD requires, as a condition of eligibility, that each individual (including children) seeking medicaid furnish each of his or her social security numbers (SSN) per paragraph (a) of 42 CFR 435.910 and 8.200.410.10 NMAC. HSD will request an SSN at renewal if not already provided.
B. Newborns who were initially eligible for medicaid as deemed newborns are considered to have provided satisfactory documentation of citizenship, identity, and age.
[8.231.600.15 NMAC - Rp, 8.231.600.15 NMAC, 1/1/2019]
HISTORY OF 8.231.600 NMAC:
Pre-NMAC History: The material in this part was derived from that previously filed with the State Records Center:
ISD 290.1000, Medical Assistance for Woman and Children, filed 11/13/1984.
ISD FA 830, Medical Assistance for Woman and Children and AFDC Related Groups, filed 2/10/1988.
MAD Rule 830, Medical Assistance for Women and Children and AFDC - Related Groups, filed 8/11/1988.
MAD Rule 830, Medical Assistance for Women and Children and AFDC - Related Groups, filed 9/8/1988.
MAD Rule 830, Medical Assistance for Women and Children and AFDC - Related Groups, filed 9/30/1988.
MAD Rule 830, Medical Assistance for Women and Children and AFDC - Related Groups, filed 12/1/1988.
MAD Rule 830, Medical Assistance for Women and Children and AFDC - Related Groups, filed 3/31/1989.
MAD Rule 830, Medical Assistance for Women and Children and AFDC - Related Groups, filed 6/8/1989.
MAD Rule 830, Medical Assistance for Women and Children and AFDC - Related Groups, filed 12/28/1989.
MAD Rule 830, Medical Assistance for Women and Children and AFDC - Related Groups, filed 12/29/1989.
MAD Rule 830, Medical Assistance for Women and Children and AFDC - Related Groups, filed 3/1/1991.
MAD Rule 830, Medical Assistance for Women and Children and AFDC - Related Groups, filed 6/5/1992.
History of Repealed Material:
MAD Rule 830, Medical Assistance for Women and Children and AFDC - Related Groups, filed 6/5/1992 - Repealed effective 2/1/1995.
8.231.600 NMAC, Benefit Description, filed 12/10/2007 - Repealed 1/1/2014.
8.231.600 NMAC, Benefit Description, filed 12/2/2013 - Repealed effective 10/1/2017.
8.231.600 NMAC, Benefit Description, filed 9/14/2017 - Repealed effective 1/1/2019.
NMAC History:
8.231.600 NMAC, Benefit Description, filed 12/2/2013 was replaced by 8.231.600 NMAC, Benefit Description, effective 10/1/2017.
8.231.600 NMAC, Benefit Description, filed 9/14/2017 was replaced by 8.231.600 NMAC, Benefit Description, effective 1/1/2019.
TITLE 8 SOCIAL SERVICES
CHAPTER 234 MEDICAID ELIGIBILITY - SSI INELIGIBILITY - DUE TO INCOME OR RESOURCES FROM A NON-CITIZEN SPONSOR
PART 400 RECIPIENT REQUIREMENTS
8.234.400.1 ISSUING AGENCY: New Mexico Health Care Authority.
[8.234.400.1 NMAC - Rp, 8.234.400.1 NMAC, 1/1/2014; A, 7/1/2024]
8.234.400.2 SCOPE: The rule applies to the general public .
[8.234.400.2 NMAC - Rp, 8.234.400.2 NMAC, 1/1/2014]
8.234.400.3 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.
[8.234.400.3 NMAC - Rp, 8.234.400.3 NMAC, 1/1/2014; A, 7/1/2024]
8.234.400.4 DURATION: Permanent.
[8.234.400.4 NMAC - Rp, 8.234.400.4 NMAC, 1/1/2014]
8.234.400.5 EFFECTIVE DATE: January 1, 2014, unless a later date is cited at the end of a section.
[8.234.400.5 NMAC - Rp, 8.234.400.5 NMAC, 1/1/2014]
8.234.400.6 OBJECTIVE: The objective of this rule is to provide specific instructions when determining eligibility for the medicaid program and other health care programs. Generally, applicable eligibility rules are detailed in the medical assistance division (MAD) eligibility, 8.200 NMAC, Medicaid Eligibility – General Recipient Policies . Processes for establishing and maintaining medicaid eligibility are detailed in the income support division (ISD) general provisions, 8.100 NMAC, General Provisions for Public Assistance Programs .
[8.234.400.6 NMAC - Rp, 8.234.400.6 NMAC, 1/1/2014]
8.234.400.7 DEFINITIONS: [ RESERVED ]
8.234.400.8 MISSION: To transform lives. Working with our partners we design and deliver innovative, high quality health and human services that improve the security and promote independence for New Mexicans in their communities.
[8.200.400.8 NMAC - N, 1/1/2014; A, 1/1/2022 ]
8.234.400.9 MEDICAID ELIGIBILITY FOR INDIVIDUALS INELIGIBILE FOR SSI DUE TO DEEMED INCOME OR RESOURCES FROM A NON-CITIZEN SPONSOR - CATEGORY 034:
A. An individual must meet specific eligibility requirements. These include:
(1) an individual meets the social security administration (SSA) definitions of aged, blind, or disabled and is ineligible for supplemental security income (SSI) solely because of deemed income or resource considered available from a non-citizen sponsor;
(2) an individual who meets the eligibility requirements pursuant to 8.200.410 NMAC and 8.200.420 NMAC for citizenship or non-citizen status, enumeration, residence; non-concurrent receipt of assistance, and applications for other benefits;
(3) an applicant or recipient must assign medical support rights to HSD and agree to cooperate with third party liability responsibilities pursuant to 8.200.430 NMAC; and
(4) appropriate to the budget group size, countable income must be less than the SSI federal benefit rate (FBR) income pursuant to 8.200.520 NMAC, 8.215 NMAC and 8.234.500 NMAC.
B. Individuals may have other creditable health insurance coverage.
C. An individual who is an inmate of a public institution is not eligible pursuant to 8.200.410 NMAC.
[8.234.400.9 NMAC - Rp, 8.234.400.9 NMAC, 1/1/2014; A, 1/1/2022]
8.234.400.10 [ RESERVED ]
8.234.400.11 ENUMERATION: Refer to 8.200.410.10 NMAC.
[8.234.400.11 NMAC - Rp, 8.234.400.11 NMAC, 1/1/2014]
8.234.400.12 CITIZENSHIP: Refer to 8.200.410.11 NMAC.
[8.234.400.12 NMAC - Rp, 8.234.400.12 NMAC, 1/1/2014]
8.234.400.13 RESIDENCE: Refer to 8.200.410.12 NMAC.
[8.234.400.13 NMAC - Rp, 8.234.400.13 NMAC, 1/1/2014]
8.234.400.14 [ RESERVED ]
8.234.400.15 SSI STATUS:
A. An applicant or re-determining recipient for Category 034 must meet all other SSI eligibility standards, including:
(1) applicant or re-determining recipient’s own income and resources must be below SSI standards;
(2) nonconcurrent receipt of assistance;
(3) residence;
(4) aged, blind, or disabled status; and
(5) citizenship or permanent non-citizen status.
B. See 8.215.500.11 NMAC and 8.215.500.18 NMAC for information on SSI income and resource standards.
[8.234.400.15 NMAC - Rp, 8.234.400.15 NMAC, 1/1/2014; A, 1/1/2022]
8.234.400.16 RECIPIENT RIGHTS AND RESPONSIBILITIES: Refer to 8.200.430 NMAC.
[8.234.400.16 NMAC - Rp, 8.234.400.16 NMAC, 1/1/2014]
8.234.400.17 BASIS FOR DEFINING THE ASSISTANCE UNIT AND BUDGET GROUP: At the time of application, an applicant shall identify everyone who is to be considered for inclusion in the assistance unit and budget group. The composition of the assistance unit and budget group is based on the relationship of the household members. Each member of the assistance unit and budget group, including an unborn child, is counted as one in the household size.
[8.234.400.17 NMAC - N, 1/1/2014]
8.234.400.18 ASSISTANCE UNIT : The assistance unit includes the applicant and may include others in the household who are determined eligible.
[8.234.400.18 NMAC - N, 1/1/2014]
8.234.400.19 BUDGET GROUP: The budget group includes all members of the assistance unit. Additional budget group members include individuals who live in the household with the assistance unit and have a financial obligation of support.
A. Except for an SSI recipient, the following individuals have a financial obligation of support for medicaid eligibility:
(1) spouses: married individuals as defined under applicable New Mexico state law (New Mexico recognizes common law and same sex marriages established in other states); and
(2) parents for children: there is a presumption that a child born to a married woman is the child of the spouse, or if the individual established parentage by some other legally recognized process.
B. The following individuals do not have a financial obligation of support for medicaid eligibility:
(1) an SSI recipient to the assistance unit;
(2) a f ather of the unborn child who is not married to the pregnant woman;
(3) a stepparent to a stepchild;
(4) a grandparent to a grandchild;
(5) a legal guardian or conservator of a child;
(6) a non-citizen sponsor to the assistance unit; and
(7) a sibling to a sibling.
[8.234.400.19 NMAC - N, 1/1/2014; A, 1/1/2022]
8.234.400.20 LIVING IN THE HOME:
A. Living in the home with a relative: To be included in the assistance unit, a child must be living, or considered to be living, in the home of:
(1) a natural or an adoptive parent; there is a presumption that a child born to a married woman is the child of the spouse, or if the individual established parentage by some other legally recognized process ; or
(2) a specified relative who is related within the fifth degree of relationship by blood, marriage or adoption and assumes responsibility for the day-to-day care and control of the child; the determination of whether an individual functions as the specified relative shall be made by the specified relative unless other information known to the worker clearly indicates otherwise.
B. A child considered to be living in the home: A child is considered to be part of the assistance unit as evidenced by the child's customary physical presence in the home. If a child is living with more than one household, the following applies:
(1) when the child is actually spending more time with one household than the other, the child would be determined to be living with the household with whom the child spends the most time; and
(2) when the child is actually spending equal amounts of time with each household, the child shall be considered to be living with the household who first applies for medicaid enrollment.
C. Extended living in the home: An individual may be physically absent from the home for longer or shorter periods of time and be a member of the assistance unit and budget group.
(1) Extended living in the home includes:
(a) when an individual is attending college or a boarding school; or
(b) when an individual is receiving treatment in a Title XIX medicaid facility (including institutionalized when meeting a nursing facility (NF) level of care (LOC) and intermediate care facilities for individuals with an intellectual disability (ICF-IID) LOC.
(2) When an individual has been a member of the assistance unit, eligibility for another medicaid eligibility category, such as long term care medicaid , should be evaluated. Until a determination of eligibility for another category can be made, the individual is considered to be living with the budget group.
D. Temporary absence - extended living in the home: An individual may be physically absent from the home and be a member of the assistance unit and budget group. These other temporary absences include:
(1) an individual not living in the home due to an emergency who is expected to return to the household within 60 calendar days, continues to be a member of the household;
(2) a child removed from the home of a parent or a specified relative by a child protective services agency (tribal, bureau of Indian affairs, or children, youth and families department), until an adjudicatory custody hearing takes place; if the adjudicatory hearing results in custody being granted to some other entity, the child will be removed from the assistance unit; or
(3) a child residing in a detention center:
(a) continues to be a member of the household if he or she resides fewer than 60 calendar days who is either adjudicated or not adjudicated as an inmate of a public institution; or
(b) the individual is not eligible for medicaid enrollment if he or she resides 60 calendar days or more as an adjudicated inmate of a public institution pursuant to 8.200.410 NMAC.
[8.234.400.20 NMAC - N, 1/1/2014]
HISTORY OF 8.234.400 NMAC:
History of Repealed Material:
8.234.400 NMAC, Recipient Policies, filed 9-3-13 - Repealed effective 1/1/2014.
TITLE 8 SOCIAL SERVICES
CHAPTER 234 MEDICAID ELIGIBILITY - SSI INELIGIBILITY - DUE TO INCOME OR RESOURCES FROM A NON-CITIZEN SPONSOR
PART 500 INCOME AND RESOURCE STANDARDS
8.234.500.1 ISSUING AGENCY: New Mexico Health Care Authority.
[8.234.500.1 NMAC - Rp, 8.234.500.1 NMAC, 1/1/2014; A, 7/1/2024]
8.234.500.2 SCOPE: The rule applies to the general public.
[8.234.500.2 NMAC - Rp, 8.234.500.2 NMAC, 1/1/2014]
8.234.500.3 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.
[8.234.500.3 NMAC - Rp, 8.234.500.3 NMAC, 1/1/2014 ; A, 7/1/2024 ]
8.234.500.4 DURATION: Permanent.
[8.234.500.4 NMAC - Rp, 8.234.500.4 NMAC, 1/1/2014]
8.234.500.5 EFFECTIVE DATE: January 1, 2014, unless a later date is cited at the end of a section.
[8.234.500.5 NMAC - Rp, 8.234.500.5 NMAC, 1/1/2014]
8.234.500.6 OBJECTIVE: The objective of this rule is to provide specific instructions when determining eligibility for the medicaid program and other health care programs. Generally, applicable eligibility rules are detailed in the medical assistance division (MAD) eligibility policy manual, specifically 8.200 400 NMAC, General Medicaid Eligibility . Processes for establishing and maintaining MAD eligibility are detailed in the income support division (ISD) general provisions policy manual, 8.100 NMAC, General Provisions for Public Assistance Programs .
[8.234.500.6 NMAC - Rp, 8.234.500.6 NMAC, 1/1/2014]
8.234.500.7 DEFINITIONS: [ RESERVED ]
8.234.500.8 MISSION: To transform lives. Working with our partners, we design and deliver innovative, high quality health and human services that improve the security and promote independence for New Mexicans in their communities.
[8.234.500.8 NMAC - N, 1/1/2014; A, 1/1/2022]
8.234.500.9 NEED DETERMINATION: An individual's financial need is based on meeting supplemental security income (SSI) federal benefit rate (FBR) income and resource methodology pursuant to 8.215.500 NMAC.
[8.234.500.9 NMAC - Rp, 8.234.500.9 NMAC, 1/1/2014]
8.234.500.10 RESOURCE STANDARDS: T he resource standards for establishing eligibility are described in 8.215.500 NMAC. The resources of a non-citizen sponsor are not considered when determining eligibility.
[8.234.500.10 NMAC - Rp, 8.234.500.10 NMAC, 1/1/2014; A, 1/1/2022]
8.234.500.11 INCOME STANDARDS: T he income standards for establishing eligibility are described in 8.215.500 NMAC. The income of a non-citizen sponsor is not considered when determining eligibility.
[8.234.500.11 NMAC - Rp, 8.234.500.11 NMAC, 1/1/2014; A, 1/1/2022]
HISTORY OF 8.234.500 NMAC:
History of Repealed Material:
8.234.500 NMAC, Income and Resource Standards, filed 9/3/2013 - Repealed effective 1/1/2014.
TITLE 8 SOCIAL SERVICES
CHAPTER 234 MEDICAID ELIGIBILITY - SSI INELIGIBILITY - DUE TO INCOME OR RESOURCES FROM AN ALIEN SPONSOR
PART 600 BENEFIT DESCRIPTION
8.234.600.1 ISSUING AGENCY: New Mexico Health Care Authority.
[8.234.600.1 NMAC - Rp, 8.234.600.1 NMAC, 1/1/2014; A, 7/1/2024]
8.234.600.2 SCOPE: The rule applies to the general public .
[8.234.600.2 NMAC - Rp, 8.234.600.2 NMAC, 1/1/2014]
8.234.600.3 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 Section 27-1-12 et seq . NMSA 1978. 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.
[8.234.600.3 NMAC - Rp , 8.234.600.3 NMAC, 1/1/ 2014 ; A, 7/1/2024 ]
8.234.600.4 DURATION: Permanent.
[8.234.600.4 NMAC - Rp, 8.234.600.4 NMAC, 1/1/2014]
8.234.600.5 EFFECTIVE DATE: January 1, 2014, unless a later date is cited at the end of a section.
[8.234.600.5 NMAC - Rp, 8.234.600.5 NMAC, 1/1/2014]
8.234.600.6 OBJECTIVE: The objective of this rule is to provide specific instructions when determining eligibility for the medicaid program and other health care programs. Generally, applicable eligibility rules are detailed in the medical assistance division (MAD) eligibility policy manual, specifically 8.200.400 NMAC, General Medicaid Eligibility . Processes for establishing and maintaining MAD eligibility are detailed in the income support division (ISD) general provisions Chapter 8.100 NMAC, General Provisions for Public Assistance Programs .
[8.234.600.6 NMAC - Rp, 8.234.600.6 NMAC, 1/1/2014]
8.234.600.7 DEFINITIONS: [RESERVED]
8.234.600.8 MISSION: 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.
[8.234.600.8 NMAC - N, 1/1/2014]
8.234.600.9 BENEFIT DESCRIPTION: Under the eligibility Category 034, an eligible recipient receives the full range of medicaid covered services.
[8.234.600.9 NMAC - Rp, 8.234.600.9 NMAC, 1/1/2014]
8.234.600.10 BENEFIT DETERMINATION:
A. Income support division (ISD) determines initial and ongoing eligibility.
B. Up to three months of retroactive medicaid coverage is provided to an applicant who has received a medicaid covered service during the retroactive period and who would have met applicable eligibility criteria had they applied earlier. Eligibility for each retroactive month is determined separately. An application for retroactive medicaid enrollment must be made within 180 calendar days from the date of the medicaid application.
[8.234.600.10 NMAC - Rp, 8.234.600.10 NMAC, 1/1/2014]
8.234.600.11 INITIAL BENEFITS:
A. Move during eligibility determination: If an applicant moves to another county while the eligibility determination is pending, the county ISD office in which the application was originally registered shall transfer the case to the new responsible office.
B. Delays in eligibility determination: If an eligibility determination is not made within the time limit, the applicant is notified in writing of the reason for the delay. This notice also informs the applicant or re-determining recipient of the right to request an administrative hearing.
[8.234.600.11 NMAC - Rp, 8.234.600.11 NMAC, 1/1/2014]
8.234.600.12 PERIODIC REDETERMINATIONS OF ELIGIBILITY:
A. A re-determination of eligibility is made every 12 months.
B. All changes that may affect eligibility must be reported within 10 calendar days from the date of the change as detailed in 8.200.430 NMAC.
[8.234.600.12 NMAC - Rp, 8.234.600.12 NMAC, 1/1/2014]
8.234.600.13 SSI 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 [42 CFR 435.914].
A. Application for retroactive benefit coverage: Application for retroactive medicaid can be made by checking “yes” in the “application for retroactive medicaid payments” box on the application or re-determination of eligibility for medical assistance (MAD 381) form or by checking “yes” to the question “does anyone in your household have unpaid medical expenses in the last three months?” on the application for assistance (ISD 100 S) form. Applications for retroactive supplemental security income (SSI) medicaid benefits for recipients of SSI must be made by 180 days from the date of approval for SSI. Medicaid covered services which were furnished more than two years prior to approval are not covered.
B. Approval requirements: To establish retroactive eligibility, the income support specialist (ISS) must verify that all conditions of eligibility were met for each of the three retroactive months and that the applicant received medicaid covered services. Eligibility for each month is approved or denied on its own merits.
(1) Applicable benefit rate: The federal benefit rate (FBR) in effect during the retroactive months based on the applicant’s living arrangements is applicable for retroactive medicaid eligibility determinations. See 8.200.520.10 NMAC. If the applicant’s countable income in a given month exceed the applicable FBR, the applicant is not eligible for retroactive medicaid for that month. If the countable income is less that the FBR, the applicant is eligible on the factor of income for that month. A separate determination must be made for each of the three months in the retroactive period.
(2) Disability determination required: If a determination is needed of the date of onset of blindness or disability, the ISS must send a referral to disability determination services (ISD 305) to the disability determination unit.
C. Notice:
(1) Notice to applicant: The applicant must be informed if any of the retroactive months are denied.
(2) Recipient responsibility to notify provider: After the retroactive eligibility has been established, the ISS must notify the recipient that he or she is responsible for informing all providers with outstanding bills of the retroactive eligibility determination. If the recipient does not inform all providers and furnish verification of eligibility which can be used for billing and the provider consequently does not submit the billing within 120 days from the date of approval of retroactive coverage, the recipient is responsible for payment of the bill.
[8.234.600.13 NMAC - Rp, 8.234.600.13 NMAC, 1/1/2014]
HISTORY OF 8.234.600 NMAC:
History of Repealed Material:
8.234.600 NMAC, Benefit Description, filed 9/3/2013 - Repealed effective 1/1/2014.
TITLE 8 SOCIAL SERVICES
CHAPTER 240 MEDICAID ELIGIBILITY - QUALIFIED MEDICARE BENEFICIARIES (QMB) (CATEGORY 040)
PART 400 RECIPIENT POLICIES
8.240.400.1 ISSUING AGENCY: New Mexico Health Care Authority.
[8.240.400.1 NMAC - Rp 8.240.400.1 NMAC, 7/1/2024]
8.240.400.2 SCOPE: The rule applies to the general public .
[8.240.400.2 NMAC - Rp 8.240.400.2 NMAC, 7/1/2024]
8.240.400.3 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.
[8.240.400.3 NMAC - Rp 8.240.400.3 NMAC, 7/1/2024]
8.240.400.4 DURATION: Permanent.
[8.240.400.4 NMAC - Rp 8.240.400.4 NMAC, 7/1/2024]
8.240.400.5 EFFECTIVE DATE: July 1, 2024, unless a later date is cited at the end of a section.
[8.240.400.5 NMAC - Rp 8.240.400.5 NMAC, 7/1/2024]
8.240.400.6 OBJECTIVE: The objective of these regulations is to provide eligibility policy and procedures for the medicaid program.
[8.240.400.6 NMAC - Rp 8.240.400.6 NMAC, 7/1/2024]
8.240.400.7 DEFINITIONS: [ RESERVED ]
8.240.400.8 [ RESERVED ]
8.240.400.9 QUALIFIED MEDICARE BENEFICIARIES (QMB) - CATEGORY 040: To be eligible for the qualified medicare beneficiaries program (QMB), an applicant/recipient must be covered by medicare part A. Medicare part A is a free entitlement to social security beneficiaries who are 65 years of age or older or who have received social security disability payments for 24 months. Fully or currently insured workers, or their dependents, who have end-stage renal disease are also covered under medicare . Most applicants/recipients 65 years of age or older who do not receive free medicare part A can voluntarily enroll for hospital insurance coverage, with payment of a monthly premium. Voluntary enrollees must also enroll for supplementary medical insurance, medicare part B, and pay that premium, as well.
[8.240.400.9 NMAC - Rp 8.240.400.9 NMAC, 7/1/2024]
8.240.400.10 BASIS FOR DEFINING THE GROUP: Applicants/recipients eligible for medicaid coverage under any other category may be eligible for coverage under QMB. QMB eligibility affords two advantages when an applicant/recipient is already eligible for medicaid :
A. medicare premium part A is payable by medicaid ; and
B. medicaid receives federal matching funds for purchase of medicare part B.
[8.240.400.10 NMAC - Rp 8.240.400.10 NMAC, 7/1/2024]
8.240.400.11 GENERAL RECIPIENT REQUIREMENTS: [RESERVE]
[8.240.400.11 NMAC - Rp 8.240.400.11 NMAC, 7/1/2024]
8.240.400.12 ENUMERATION: Applicants/recipients must furnish their social security account number(s). QMB eligibility is denied or terminated if applicants/recipients fail to furnish their social security numbers.
[8.240.400.12 NMAC - Rp 8.240.400.12 NMAC, 7/1/2024]
8.240.400.13 CITIZENSHIP:
A. Refer to medical assistance program manual 8.200.410.11 NMAC.
B. Verification of citizenship: Citizenship determinations rendered by the social security administration (SSA) for SSI are final.
(1) Documentation of citizenship: Primary documentation of citizenship is a birth certificate. Secondary documentation includes:
(a) certificate of naturalization;
(b) citizenship certificate;
(c) other resident identification documents issued by the United States immigration and naturalization service, such as:
( i ) U.S. passport issued by the U.S. state department;
(ii) consular report of birth;
(iii) certification of birth issued by the U.S. state department, proof of marriage to a U.S. citizen before September 2, 1922, or a card of identity and registration of a U.S. citizen; or
(iv) official communication from an American foreign service post indicating that an applicant/recipient is registered as a United States citizen.
(2) Declaration of citizenship, nationality, or immigration status: As a condition of eligibility, medicaid requires a declaration by the applicant/recipient or by another person on behalf of a child or an applicant/recipient who is mentally incapacitated, which specifies whether the applicant/recipient is a citizen or national of the United States. If not, the declaration must state that the applicant/recipient is in satisfactory immigration status. Eligibility is not denied solely because an applicant/recipient cannot legally sign the declaration and the individual who is legally able to do so refuses to sign on the applicant/recipient’s behalf or to cooperate, as required.
[8.240.400.13 NMAC - Rp 8.240.400.13 NMAC, 7/1/2024]
8.240.400.14 RESIDENCE: An applicant/recipient must be physically present in New Mexico on the date of application or final determination of eligibility and have demonstrated intent to remain in the state. If the applicant/recipient does not have the present mental capacity to declare intent, the parent, guardian or adult child can assume responsibility for a declaration of intent. If there is no guardian or relative to assume responsibility for a declaration of intent, the state where the applicant/recipient is living is recognized as the state of residence. A temporary absence from the state does not prevent eligibility. A temporary absence exists if an applicant/recipient leaves the state for a specific purpose with a time-limited goal and intends to return to New Mexico when the purpose is accomplished.
[8.240.400.14 NMAC - Rp 8.240.400.14 NMAC, 7/1/2024]
8.240.400.15 NONCONCURRENT RECEIPT OF ASSISTANCE: A QMB applicant/recipient on buy-in in another state cannot be approved for QMB in New Mexico until the other state’s buy-in is terminated.
[8.240.400.15 NMAC - Rp 8.240.400.15 NMAC, 7/1/2024]
8.240.400.16 SPECIAL RECIPIENT REQUIREMENTS: There is no special recipient requirements such as age or disability for QMB.
[8.240.400.16 NMAC - Rp 8.240.400.16 NMAC, 7/1/2024]
8.240.400.17 RECIPIENT RIGHTS AND RESPONSIBILITIES: An applicant/recipient is responsible for establishing their eligibility for medicaid . As part of this responsibility, the applicant/recipient must provide required information and documents or take the actions necessary to establish eligibility. Failure to do so must result in a decision that eligibility does not exist. An applicant/recipient must also grant the HCA permission to contact other persons, agencies or sources of information which are necessary to establish eligibility.
[8.240.400.17 NMAC - Rp 8.240.400.17 NMAC, 7/1/2024]
8.240.400.18 ASSIGNMENTS OF MEDICAL SUPPORT: Refer to medical assistance program manual Subsection F of 8.200.420.12 NMAC.
[8.240.400.18 NMAC - Rp 8.240.400.18 NMAC, 7/1/2024]
8.240.400.19 REPORTING REQUIREMENTS: All medicaid recipients must report any change in their circumstances which can affect eligibility to the local income support division (ISD) office within 10 days of the change.
[8.240.400.19 NMAC - Rp 8.240.400.19 NMAC, 7/1/2024]
HISTORY OF 8.240.400 NMAC:
Pre-NMAC History: The material in this part was derived from that previously filed with the Commission of Public Records - State Records Center and Archives:
MAD Rule 840, Qualified Medicare Beneficiaries, filed 3/7/1989.
MAD Rule 840, Qualified Medicare Beneficiaries, filed 3/31/1989.
MAD Rule 840, Qualified Medicare Beneficiaries, filed 12/29/1989.
MAD Rule 840, Qualified Medicare Beneficiaries, filed 6/22/1990.
MAD Rule 840, Qualified Medicare Beneficiaries, filed 12/4/1990.
MAD Rule 840, Qualified Medicare Beneficiaries, filed 5/3/1991.
MAD Rule 840, Qualified Medicare Beneficiaries, filed 6/30/1992.
MAD Rule 840, Qualified Medicare Beneficiaries, filed 9/26/1994.
History of Repealed Material:
MAD Rule 840, Qualified Medicare Beneficiaries, filed 9/26/1994 - Repealed effective 2/1/1995.
8.240.400 NMAC - Recipient Policies (filed 6/13/2003) Repealed effective 7/1/2024.
Other : 8.240.400 NMAC - Recipient Policies (filed 6/13/2003) Replaced by 8.240.400 NMAC - Recipient Policies, effective 7/1/2024.
TITLE 8 SOCIAL SERVICES
CHAPTER 240 MEDICAID ELIGIBILITY - QUALIFIED MEDICARE BENEFICIARIES (QMB) (CATEGORY 040)
PART 500 INCOME AND RESOURCE STANDARDS
8.240.500.1 ISSUING AGENCY: New Mexico Health Care Authority.
[8.240.500.1 NMAC -Rp 8.240.500.1 NMAC, 7/1/2024]
8.240.500.2 SCOPE: The rule applies to the general public .
[8.240.500.2 NMAC -Rp 8.240.500.2 NMAC, 7/1/2024]
8.240.500.3 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.
[8.240.500.3 NMAC -Rp 8.240.500.3 NMAC, 7/1/2024]
8.240.500.4 DURATION: Permanent.
[8.240.500.4 NMAC -Rp 8.240.500.4 NMAC, 7/1/2024]
8.240.500.5 EFFECTIVE DATE: July 1, 2024, unless a later date is cited at the end of the section.
[8.240.500.5 NMAC -Rp 8.240.500.5 NMAC, 7/1/2024]
8.240.500.6 OBJECTIVE: The objective of this rule is to provide eligibility policy and procedures for the medicaid program.
[8.240.500.6 NMAC -Rp 8.240.500.6 NMAC, 7/1/2024]
8.240.500.7 DEFINITIONS: [ RESERVED ]
8.240.500.8 [ RESERVED ]
8.240.500.9 GENERAL NEED DETERMINATION: Applicants for, or recipients of, the qualified medicare beneficiaries (QMB) program must apply for and take all necessary steps to obtain any income or resources to which they may be entitled. Recipients of supplemental security income (SSI) or aid to families with dependent children (AFDC) who apply for QMB are excluded from this requirement. A victim of crime is not required to accept victim compensation payments from a state-administered fund established to aid crime victims as a condition of eligibility.
[8.240.500.9 NMAC -Rp 8.240.500.9 NMAC, 7/1/2024]
8.240.500.10 RESOURCE STANDARDS: The value of an applicant/recipient’s individual countable resources must not exceed the amount set forth in Section 8.200.510.14 NMAC, resource amounts for supplemental security income (SSI) related medicare savings programs (QMB and SLIMB/QI). The resource limit for an applicant couple is the amount set forth in Section 8.200.510.14 NMAC. An applicant/recipient with an ineligible spouse is eligible if the couple’s countable resources do not exceed the amount set forth in Section 8.200.510.14 NMAC, when resources are deemed. The resource determination is always made as of the first moment of the first day of the month. The applicant/recipient is ineligible for any month in which the countable resources exceed the current resource standard as of the first moment of the first day of the month. Changes in the amount of resources during a month do not affect eligibility for that month. See Section 8.215.500.13 NMAC, countable resources, and Section 8.215.500.14 NMAC, resource exclusions, for specific information on exclusions, disregards, and calculation of countable resources.
[8.240.500.10 NMAC -Rp 8.240.500.10 NMAC, 7/1/2024]
8.240.500.11 RESOURCE TRANSFERS: The social security administration excluded transfer of resources as a factor of eligibility for non-institutionalized SSI recipients. Transfer of resources is not a factor for consideration in categories that use SSI methodology in the eligibility determination.
[8.240.500.11 NMAC -Rp 8.240.500.11 NMAC, 7/1/2024]
8.240.500.12 TRUSTS: See Section 8.281.510 NMAC and following subsections.
[8.240.500.12 NMAC -Rp 8.240.500.12 NMAC, 7/1/2024]
8.240.500.13 INCOME STANDARDS: The income ceiling for QMB eligibility is one hundred percent of the federal income poverty guidelines. These guidelines are updated annually effective April 1st. See Section 8.200.520 NMAC, Income Standards . If the applicant is a minor child, income must be deemed from the parent(s). Income must be verified and documented in the case record. See Section 8.215.500.13 NMAC, countable resources , and Section 8.215.500.14 NMAC, resource exclusions , for specific information on exclusions, disregards, and calculation of countable income.
[8.240.500.13 NMAC -Rp 8.240.500.13 NMAC, 7/1/2024]
8.240.500.14 UNEARNED INCOME:
A. Unearned income exclusions: All social security and railroad retirement beneficiaries receive cost of living adjustments (COLAs) in January of each year. The ISD caseworker must disregard the COLA from January through March when (re)determining QMB eligibility. For redeterminations made in January, February and March and for new QMB applications registered in January, February or March, the ISD caseworker uses the December social security and railroad retirement benefit amounts. For QMB applications registered from April through December, total gross income including the new COLA figures are used to determine income and compared to the new April federal poverty levels. This exclusion does not apply to other types of income.
B. Evaluation of applicant/recipient’s income: The ISD caseworker determines the amount of income available to the applicant/recipient using only the applicant/recipient’s own income. A standard $20 disregard is allowed in accordance with Section 8.215.500.22 NMAC. The federal poverty level standard disregard is only given if the applicant/recipient lives with an ineligible spouse. See Section 8.240.500.15 NMAC for deemed income.
[8.240.500.14 NMAC -Rp 8.240.500.14 NMAC, 7/1/2024]
8.240.500.15 DEEMED INCOME:
A. Minor applicant/recipient living with parent( s ): If the applicant/recipient is a minor who lives with a parent(s), deemed income from the parent(s) must be considered in accordance with Section 8.215.500.21 NMAC, deemed income , and applicable subsections.
B. Applicant/recipient living with an ineligible spouse: If an applicant/recipient is living in the same household with an ineligible spouse, the income of the applicant/recipient and the income of the ineligible spouse must be considered in accordance with the following paragraphs.
(1) Evaluation of applicant/recipient’s income: The ISD caseworker determines the amount of income available to the applicant/recipient using only the applicant/recipient’s own income. Allow the standard $20 disregard in accordance with instructions in Subsection B of Section 8.215.500.22 NMAC of the medical assistance division policy manual. If the applicant/recipient has earned income, allow the earned income disregard as specified in Subsection C of Section 8.215.500.22 NMAC. From the combined total of the applicant/recipient’s remaining earned and unearned income, subtract up to the difference between one hundred percent of the federal income poverty level for two persons and one hundred percent of the federal income poverty level for one person. This is referred to as the FPL disregard. Compare the remaining countable income of the applicant/recipient to the individual income standard for the QMB program. If the applicant/recipient’s remaining countable income is greater than the individual standard, they are ineligible for the QMB program. If the applicant/recipient’s remaining countable income is less than the individual income standard, proceed to the following section.
(2) Evaluation of the ineligible spouse’s gross income: The ISD caseworker determines the total gross earned and unearned income of the ineligible spouse. From this combined amount, subtract a living allowance for any ineligible minor dependent child(ren) of either member of the couple who live(s) in the home. The deductible amount of the ineligible child(ren)’s living allowance cannot exceed the ineligible spouse’s total gross income. The amount of the living allowance for an ineligible child is determined by subtracting the child’s gross income from the figure which represents the difference between one hundred percent of the federal income poverty level for two persons and one hundred percent of the federal income poverty level for one person. A “child” must be under 18 years of age or under 21 years of age if a full-time student at an institution of learning.
(3) Determination of countable income for eligibility purposes: The ISD caseworker adds the gross unearned income of the applicant/recipient (without applying any disregards) to the gross unearned income of the ineligible spouse. The ISD caseworker then adds the total gross earned income of the applicant/recipient to the total gross earned income of the ineligible spouse. From the combined total gross earnings of the couple, the ISD caseworker subtracts one earned income disregard (the first $65 of the total earnings plus one half of the remainder). The resulting figure is the total combined countable earnings of the couple. Add the couple’s total combined countable earned income to their total gross unearned income. From this figure subtract the standard $20 disregard determined in accordance with Subsection B of Section 8.215.500.22 NMAC. Next, subtract the amount of the FPL disregard which the applicant/recipient was allowed. Finally, subtract the amount of the ineligible child(ren)’s living allowance which was calculated in Paragraph (2) of Subsection B of Section 8.240.500.14 NMAC. The resulting figure is the countable income of the couple. Compare it to the couple standard for QMB. If the countable income of the couple exceeds the couple standard, the applicant/recipient is ineligible for the QMB program. If the countable income of the couple is less than the couple standard, the applicant/recipient is eligible for the QMB program of the factor of income.
[8.240.500.15 NMAC -Rp 8.240.500.15 NMAC, 7/1/2024]
HISTORY OF 8.240.500 NMAC:
Pre-NMAC History: The material in this part was derived from that previously filed with the Commission of Public Records - State Records Center and Archives:
MAD Rule 840, Qualified Medicare Beneficiaries, filed 3/7/1989.
MAD Rule 840, Qualified Medicare Beneficiaries, filed 3/31/1989.
MAD Rule 840, Qualified Medicare Beneficiaries, filed 12/29/1989.
MAD Rule 840, Qualified Medicare Beneficiaries, filed 6/22/1990.
MAD Rule 840, Qualified Medicare Beneficiaries, filed 12/4/1990.
MAD Rule 840, Qualified Medicare Beneficiaries, filed 5/3/1991.
MAD Rule 840, Qualified Medicare Beneficiaries, filed 6/30/1992.
MAD Rule 840, Qualified Medicare Beneficiaries, filed 9/26/1994.
History of Repealed Material:
MAD Rule 840, Qualified Medicare Beneficiaries, filed 9/26/1994 - Repealed effective 2/1/1995.
8.240.500 NMAC - Income And Resource Standards (filed 6/25/2010) Repealed effective 7/1/2024.
Other: 8.240.500 NMAC - Income And Resource Standards (filed 6/25/2010) Replaced by 8.240.500 NMAC - Income And Resource Standards, effective 7/1/2024.
TITLE 8 SOCIAL SERVICES
CHAPTER 240 MEDICAID ELIGIBILITY - QUALIFIED MEDICARE BENEFICIARIES (QMB) (CATEGORY 040)
PART 600 BENEFIT DESCRIPTION
8.240.600.1 ISSUING AGENCY: New Mexico Health Care Authority.
[8.240.600.1 NMAC - Rp, 8.240.600.1 NMAC, 7/1/2024]
8.240.600.2 SCOPE: The rule applies to the general public .
[8.240.600.2 NMAC - Rp, 8.240.600.2 NMAC, 7/1/2024]
8.240.600.3 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. 191991). 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.
[8.240.600.3 NMAC - Rp, 8.240.600.3 NMAC, 7/1/2024]
8.240.600.4 DURATION: Permanent.
[8.240.600.4 NMAC - Rp, 8.240.600.4 NMAC, 7/1/2024]
8.240.600.5 EFFECTIVE DATE: July 1, 2024, unless a later date is cited at the end of a section.
[8.240.600.5 NMAC - Rp, 8.240.600.5 NMAC, 7/1/2024]
8.240.600.6 OBJECTIVE: The objective of these regulations is to provide eligibility policy and procedures for the medicaid program.
[8.240.600.6 NMAC - Rp, 8.240.600.6 NMAC, 7/1/2024]
8.240.600.7 DEFINITIONS: [ RESERVED ]
8.240.600.8 [ RESERVED ]
8.240.600.9 BENEFIT DESCRIPTION: For qualified medicare beneficiaries (QMB), medicaid covers payment of medicare premium amounts for Parts A and B and the coinsurance and deductibles on medicare -covered services. Medicaid does not pay for services which are not medicare benefits, services denied by medicare , or services furnished by providers who have not accepted medicare assignment. Reimbursement is made to providers of covered services and not directly to recipients.
[8.240.600.9 NMAC - Rp, 8.240.600.9 NMAC, 7/1/2024]
8.240.600.10 BENEFIT DETERMINATION: Application for QMB is made on the assistance application form. A separate application is not required if the recipient is receiving medicaid under another category. The income support specialist (ISS) must act on applications and send notice of action taken to the applicant within 45 days after the date of application. After the eligibility determination is made, notice of the approval or denial is sent to the applicant. If the application is denied, this notice includes the reason for the denial and an explanation of the recipient’s right to a hearing
[8.240.600.10 NMAC - Rp, 8.240.600.10 NMAC, 7/1/2024]
8.240.600.11 INITIAL BENEFITS: Eligibility begins the month after the month the case is approved. No retroactive coverage is available. Enrollment periods for medicare coverage: Individuals who are not entitled to free medicare Part A can purchase it. This is called “premium” or “conditional” Part A coverage. Applicants who are entitled to free medicare Part A may apply for QMB at any time. Enrollment for premium/conditional medicare Part A, is accepted by the social security administration (SSA) once a year, from January through March, with coverage starting in July. If a QMB applicant has an award letter or medicare card showing premium/conditional enrollment for July, the case can be approved in June with coverage beginning in July.
[8.240.600.11 NMAC - Rp, 8.240.600.11 NMAC, 7/1/2024]
8.240.600.12 ONGOING BENEFITS: A redetermination of eligibility conditions must be made at least every 12 months but no more frequently than every six months.
[8.240.600.12 NMAC - Rp, 8.240.600.12 NMAC, 7/1/2024]
8.240.600.13 RETROACTIVE BENEFITS: No retroactive medicaid benefits are available for applicants/recipients in this category.
[8.240.600.13 NMAC - Rp, 8.240.600.13 NMAC, 7/1/2024]
8.240.600.14 CHANGES IN ELIGIBILITY: A case is closed when the recipient becomes ineligible, with provision of advance notice. If a recipient dies, the case is closed the following month.
[8.240.600.14 NMAC - Rp, 8.240.600.14 NMAC, 7/1/2024]
HISTORY OF 8.240.600 NMAC:
Pre-NMAC History: The material in this part was derived from that previously filed with the State Records Center and Archives:
MAD Rule 840, Qualified Medicare Beneficiaries, filed 3/7/1989.
MAD Rule 840, Qualified Medicare Beneficiaries, filed 3/31/1989.
MAD Rule 840, Qualified Medicare Beneficiaries, filed 12/29/1989.
MAD Rule 840, Qualified Medicare Beneficiaries, filed 6/22/1990.
MAD Rule 840, Qualified Medicare Beneficiaries, filed 12/4/1990.
MAD Rule 840, Qualified Medicare Beneficiaries, filed 5/3/1991.
MAD Rule 840, Qualified Medicare Beneficiaries, filed 6/30/1992.
MAD Rule 840, Qualified Medicare Beneficiaries, filed 9/26/1994.
History of Repealed Material:
MAD Rule 840, Qualified Medicare Beneficiaries, filed 9/26/1994 - Repealed effective 2/1/1995.
8.240.600 NMAC - Benefit Description (filed 9/3/2013) Repealed effective 7/1/2024.
Other: 8.240.600 NMAC - Benefit Description (filed 9/3/2013) Replaced by 8.240.600 NMAC - Benefit Description effective 7/1/2024.
TITLE 8 SOCIAL SERVICES
CHAPTER 242 MEDICAL ASSISTANCE PROGRAM ELIGIBILITY - QUALIFIED DISABLED INDIVIDUALS WHOSE INCOME EXCEEDS QMB AND SLIMB
PART 400 RECIPIENT REQUIREMENTS
8.242.400.1 ISSUING AGENCY: New Mexico Health Care Authority.
[8.242.400.1 NMAC - Rp, 8.242.400.1 NMAC, 1/1/2014; A, 7/1/2024]
8.242.400.2 SCOPE: The rule applies to the general public .
[8.242.400.2 NMAC - Rp, 8.242.400.2 NMAC, 1/1/2014]
8.242.400.3 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 , Section 27-1-12 et seq . NMSA 1978. 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.
[8.242.400.3 NMAC - Rp , 8.242.400.3 NMAC, 1/1/ 2014 ; A, 7/1/2024 ]
8.242.400.4 Duration : Permanent.
[8.242.400.4 NMAC - Rp, 8.242.400.4 NMAC, 1/1/2014]
8.242.400.5 Effective Date : January 1, 2014, unless a later date is cited at the end of a section.
[8.242.400.5 NMAC - Rp, 8.242.400.5 NMAC, 1/1/2014]
8.242.400.6 Objective : The objective of this rule is to provide specific instructions when determining eligibility for the medicaid program and other health care programs. Generally, applicable eligibility rules are detailed in the medical assistance division (MAD) eligibility, 8.200 NMAC, Medicaid Eligibility - General Recipient Policies . Processes for establishing and maintaining medicaid eligibility are detailed in the income support division (ISD) general provisions 8.100 NMAC, General Provisions for Public Assistance Programs .
[8.242.400.6 NMAC - Rp, 8.242.400.6 NMAC, 1/1/2014]
8.242.400.7 DEFINITIONS: [RESERVED]
8.242.400.8 MISSION: 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.
[8.242.400.8 NMAC - N, 1/1/2014 ]
8.242.400.9 QUALIFIED DISABLED WORKING INDIVIDUALS (QD) - CATEGORY 050:
A. To qualify as a qualified disabled working individual (QD), an applicant or re-determining recipient must meet the following requirements:
(1) lose entitlement to free medicare Part A due to substantial gainful employment;
(2) continue to meet the social security administration (SSA) disability criteria; and
(3) be enrolled for premium Part A medicare .
B. The date of eligibility is based on the date of application and the date that all eligibility standards, including enrollment for medicare Part A, are met.
[8.242.400.9 NMAC - Rp, 8.242.400.9 NMAC, 1/1/2014]
8.242.400.10 [RESERVED]
8.242.400.11 ENUMERATION: An applicant or a re-determining recipient must have a social security number. Refer to 8.200.410.10 NMAC.
[8.242.400.11 NMAC - Rp, 8.242.400.11 NMAC, 1/1/2014]
8.242.400.12 CITIZENSHIP: Refer to 8.200.410.11 NMAC.
[8.242.400.12 NMAC - Rp, 8.242.400.12 NMAC, 1/1/2014]
8.242.400.13 RESIDENCE: An individual must be either be physically present in New Mexico on the date of his or her application or re-determination or on the eligibility determination date and intend to remain in the state. A temporary absence from the state does not preclude eligibility. A temporary absence is considered to exist when the eligible recipient leaves the state for a specific purpose with a time-limited goal, after accomplishment of which the eligible recipient intends to return to New Mexico. Refer to 8.200.410.12 NMAC.
[8.242.400.13 NMAC - Rp, 8.242.400.13 NMAC, 1/1/2014]
8.242.400.14 NONCONCURRENT RECEIPT OF ASSISTANCE: An applicant or re-determining recipient is not eligible for category 050 if he or she is eligible under another medical assistance division (MAD) category of eligibility or if receiving medicaid services from another state.
[8.242.400.14 NMAC - Rp, 8.242.400.14 NMAC, 1/1/2014]
8.242.400.15 [RESERVED]
8.242.400.16 AGE: A recipient must be under 65 years of age. When a recipient reaches 65 years of age he or she becomes entitled to free medicare Part A.
[8.242.400.16 NMAC - Rp, 8.242.400.16 NMAC, 1/1/2014]
8.242.400.17 RECIPIENT RIGHTS AND RESPONSIBILITIES: It is the responsibility of the applicant or re-determining recipient to provide the required information, documents or undertake the actions necessary for HSD to establish eligibility. The applicant or re-determining recipient must grant HSD permission to contact other persons, agencies or sources of information which are necessary in the establishment of eligibility. Failure of the applicant or re-determining recipient to provide or take action will result in an HSD action to deny eligibility. Refer to 8.200.430 NMAC.
[8.242.400.17 NMAC - Rp, 8.242.400.17 NMAC, 1/1/2014]
8.242.400.18 ASSIGNMENT OF SUPPORT: Assignment of medical support rights is not a factor of eligibility for this category, since medicaid coverage is limited to medicare Part A premium.
[8.242.400.18 NMAC - Rp, 8.242.400.18 NMAC, 1/1/2014]
8.242.400.19 REPORTING REQUIREMENTS: An applicant, re-determining, or eligible recipient must report any change in his or her circumstances which can affect his or her eligibility within 10 calendar days after the change to his or her local income support division (ISD) office. Refer to 8.200.430.19 NMAC.
[8.242.400.19 NMAC - Rp, 8.242.400.19 NMAC, 1/1/2014]
HISTORY OF 8.242.400 NMAC:
Pre-NMAC History: The material in this part was derived from that previously filed with the State Records Center:
MAD Rule 842.00, Qualified Disabled Working Individuals, filed 10/11/1990.
MAD Rule 842, Qualified Disabled Working Individuals, filed 6/30/1992.
MAD Rule 842, Qualified Disabled Working Individuals, filed 9/26/1994.
History of Repealed Material:
MAD Rule 842, Qualified Disabled Working Individuals, filed 9/26/1994 - Repealed effective 2/1/1995.
8.242.400 NMAC, Recipient Requirements, filed 9/3/2013 - Repealed effective 1/1/2014.
TITLE 8 SOCIAL SERVICES
CHAPTER 242 MEDICAL ASSISTANCE PROGRAM ELIGIBILITY - QUALIFIED DISABLED INDIVIDUALS WHOSE INCOME EXCEEDS QMB AND SLIMB
PART 500 INCOME AND RESOURCE STANDARDS
8.242.500.1 ISSUING AGENCY: New Mexico Health Care Authority.
[8.242.500.1 NMAC - Rp, 8.242.500.1 NMAC, 1/1/2014; A,7 /1/2024
8.242.500.2 SCOPE: The rule applies to the general public .
[8.242.500.2 NMAC - Rp, 8.242.500.2 NMAC, 1/1/2014]
8.242.500.3 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 Section 27-1-12 et seq . NMSA 1978. 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.
[8.242.500.3 NMAC - Rp , 8.242.500.3 NMAC, 1/1/ 2014; A,7/1/2024]
8.242.500.4 DURATION: Permanent.
[8.242.500.4 NMAC - Rp, 8.242.500.4 NMAC, 1/1/2014]
8.242.500.5 EFFECTIVE DATE: January 1, 2014, unless a later date is cited at the end of a section.
[8.242.500.5 NMAC - Rp, 8.242.500.5 NMAC, 1/1/2014]
8.242.500.6 OBJECTIVE: The objective of this rule is to provide specific instructions when determining eligibility for the medicaid program and other health care programs. Generally, applicable eligibility rules are detailed in the medical assistance division (MAD) eligibility policy manual, specifically 8.200.400 NMAC, General Medicaid Eligibility . Processes for establishing and maintaining medical assistance eligibility are detailed in the income support division (ISD) general provisions 8.100 NMAC, General Provisions for Public Assistance Programs .
[8.242.500.6 NMAC - Rp, 8.242.500.6 NMAC, 1/1/2014]
8.242.500.7 DEFINITIONS: [RESERVED]
8.242.500.8 MISSION: 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.
[8.242.500.8 NMAC - N, 1/1/2014]
8.242.500.9 NEED DETERMINATION: An applicant or a re-determining recipient for MAD eligibility Category 050 qualified disabled individuals (QD) must apply for and take all necessary actions to obtain any resources to which he or she may be entitled. See 8.215.500 NMAC.
[8.242.500.9 NMAC - Rp, 8.242.500.9 NMAC, 1/1/2014]
8.242.500.10 RESOURCE STANDARDS: The total value of an applicant or a re-determining recipient’s countable resources must not exceed $4,000. The resource limit for an applicant or re-determining recipient couple is $6,000. An applicant or a re-determining recipient with an ineligible spouse is eligible if the couple’s countable resources do not exceed $6,000 at the time resources are deemed. The resource determination is always made as of the first moment of the first day of the month. An applicant or a re-determining recipient is ineligible for any month in which countable resources exceed the current resource standard as of the first moment of the first day of the month. Changes in the value of countable resources during a month do not affect eligibility for that month.
[8.242.500.10 NMAC - Rp, 8.242.500.10 NMAC, 1/1/2014]
8.242.500.11 RESOURCE TRANSFERS: The social security administration (SSA) excluded transfer of resources as a factor of eligibility for a non-institutionalized recipient who receives supplemental security income (SSI) benefits. Transfer of resources is not a factor for consideration in categories that use SSI methodology in the eligibility determination.
[8.242.500.11 NMAC - Rp, 8.242.500.11 NMAC, 1/1/2014]
8.242.500.12 INCOME STANDARDS: The income ceiling for QD eligibility is 200 percent of the federal income poverty (FPL) guidelines. These guidelines are updated annually effective April 1. See 8.200.520 NMAC and 8.215.500 NMAC.
[8.242.500.12 NMAC - Rp, 8.242.500.12 NMAC, 1/1/2014]
8.242.500.13 UNEARNED INCOME: Unearned income exclusions: All social security and railroad retirement beneficiaries receive cost of living adjustments (COLAs) in January of each year. The income support specialist (ISS) must disregard the COLA from January through March when determining or re-determining QD eligibility. For re-determinations made in January, February and March or new QD applications registered in January, February or March, the ISS uses the December social security and railroad retirement benefit amounts. For QD applications registered from April through December, total gross income including the new COLA figures are used to determine income and compared to the new April FPL. This exclusion does not apply to other types of income.
[8.242.500.13 NMAC - Rp, 8.242.500.13 NMAC, 1/1/2014]
8.242.500.14 DEEMED INCOME: If an applicant or a re-determining recipient is married and lives with a spouse, deemed income from the spouse must be considered. See 8.215.500 NMAC.
[8.242.500.14 NMAC - Rp, 8.242.500.14 NMAC, 1/1/2014]
HISTORY OF 8.242.500 NMAC:
Pre-NMAC History: The material in this part was derived from that previously filed with the State Records Center:
MAD Rule 842.00, Qualified Disabled Working Individuals, filed 10/11/1990.
MAD Rule 842, Qualified Disabled Working Individuals, filed 6/30/1992.
MAD Rule 842, Qualified Disabled Working Individuals, filed 9/26/1994.
History of Repealed Material:
MAD Rule 842, Qualified Disabled Working Individuals, filed 9/26/1994 - Repealed effective 2/1/1995.
8.242.500 NMAC, Income and Resource Standards, filed 9/3/2013 - Repealed effective 1/1/2014.
TITLE 8 SOCIAL SERVICES
CHAPTER 242 MEDICAL ASSISTANCE PROGRAM ELIGIBILITY - QUALIFIED DISABLED INDIVIDUALS WHOSE INCOME EXCEEDS QMB AND SLIMB
PART 600 BENEFIT DESCRIPTION
8.242.600.1 ISSUING AGENCY: New Mexico Health Care Authority.
[8.242.600.1 NMAC - Rp, 8.242.600.1 NMAC, 1/1/2019; A, 7/1/2024]
8.242.600.2 SCOPE: The rule applies to the general public .
[8.242.600.2 NMAC - Rp, 8.242.600.2 NMAC, 1/1/2019]
8.242.600.3 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 Section 27-1-12 et seq., NMSA 1978. 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.
[8.242.600.3 NMAC - Rp, 8.242.600.3 NMAC, 1/1/2019; A, 7/1/2024]
8.242.600.4 DURATION: Permanent.
[8.242.600.4 NMAC - Rp, 8.242.600.4 NMAC, 1/1/2019]
8.242.600.5 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.
[8.242.600.5 NMAC - Rp, 8.242.600.5 NMAC, 1/1/2019]
8.242.600.6 OBJECTIVE: The objective of this rule is to provide specific instructions when determining eligibility for the medicaid program and other health care programs. Generally, applicable eligibility rules are detailed in the medical assistance division (MAD) eligibility policy manual, specifically 8.200.400 NMAC, General Medicaid Eligibility . Processes for establishing and maintaining MAD eligibility are detailed in the income support division (ISD) general provisions 8.100 NMAC, General Provisions for Public Assistance Programs .
[8.242.600.6 NMAC - Rp, 8.242.600.6 NMAC, 1/1/2019]
8.242.600.7 DEFINITIONS: [ RESERVED ]
8.242.600.8 [RESERVED]
[8.242.600.8 NMAC - Rp, 8.242.600.8 NMAC, 1/1/2019]
8.242.600.9 BENEFIT DESCRIPTION: For Category 050, medicaid coverage is limited to payment of the medicare Part A premium. No medicaid card is issued.
[8.242.600.9 NMAC - Rp, 8.242.600.9 NMAC, 1/1/2019]
8.242.600.10 BENEFIT DETERMINATION: Application for Category 050 is made on the assistance application form. Applications must be acted on and notice of action taken must be sent to the applicant within 45 days of receipt of the application.
[8.242.600.10 NMAC - Rp, 8.242.600.10 NMAC, 1/1/2019]
8.242.600.11 INITIAL BENEFITS: The effective date of eligibility for qualified disabled working individuals (QD) is based on the date of application and the date on which all eligibility criteria, including enrollment for medicare Part A, are met. Verification of the effective date of medicare Part A enrollment must be obtained from the social security administration (SSA). When the eligibility determination is made, notice of the approval or denial is sent to the applicant. If denied, this notice includes the reason for the denial and an explanation of rights to a hearing.
[8.242.600.11 NMAC - Rp, 8.242.600.11 NMAC, 1/1/2019]
8.242.600.12 ONGOING BENEFITS: A redetermination of eligibility must be made every 12 months.
[8.242.600.12 NMAC - Rp, 8.242.600.12 NMAC, 1/1/2019]
8.242.600.13 RETROACTIVE BENEFIT COVERAGE: Retroactive medicaid coverage is provided in accordance with 8.200.400.14 NMAC.
[8.242.600.13 NMAC - Rp, 8.242.600.13 NMAC, 1/1/2019]
8.242.600.14 CHANGES IN ELIGIBILITY: The case is closed when an eligible recipient becomes ineligible and is notified of the ineligibility in an advance notice. The case is closed in the month following the death of an eligible recipient.
[8.242.600.14 NMAC - Rp, 8.242.600.14 NMAC, 1/1/2019]
HISTORY OF 8.242.600 NMAC:
Pre-NMAC History: The material in this part was derived from that previously filed with the State Records Center:
MAD Rule 842.00, Qualified Disabled Working Individuals, filed 10/11/1990.
MAD Rule 842, Qualified Disabled Working Individuals, filed 6/30/1992.
MAD Rule 842, Qualified Disabled Working Individuals, filed 9/26/1994.
History of Repealed Material:
MAD Rule 842, Qualified Disabled Working Individuals, filed 9/26/1994 - Repealed effective 2/1/1995.
8.242.600 NMAC, Benefit Description, filed 9/3/2013 - Repealed effective 1/1/2014.
8.242.600 NMAC, Benefit Description, filed 12/2/2013 - Repealed effective 1/1/2019.
TITLE 8 SOCIAL SERVICES
CHAPTER 243 MEDICAID ELIGIBILITY - WORKING DISABLED INDIVIDUALS (WDI) (CATEGORY 043)
PART 400 RECIPIENT POLICIES
8.243.400.1 ISSUING AGENCY: New Mexico Health Care Authority.
[8.243.400.1 NMAC - Rp, 8.243.400.1 NMAC, 1/1/2019 ; A, 7/1/2024 ]
8.243.400.2 SCOPE: This rule applies to the general public .
[8.243.400.2 NMAC - Rp, 8.243.400.2 NMAC, 1/1/2019]
8.243.400.3 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 by the state human services department pursuant to state statute. See 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.
[8.243.400.3 NMAC - Rp , 8.243.400.3 NMAC, 1/1/ 2019 ; A, 7/1/2024 ]
8.243.400.4 DURATION: Permanent.
[8.243.400.4 NMAC - Rp, 8.243.400.4 NMAC, 1/1/2019]
8.243.400.5 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.
[8.243.400.5 NMAC - Rp, 8.243.400.5 NMAC, 1/1/2019]
8.243.400.6 OBJECTIVE: The objective of these regulations is to provide eligibility policy and procedures for the medicaid program.
[8.243.400.6 NMAC - Rp, 8.243.400.6 NMAC, 1/1/2019]
8.243.400.7 DEFINITIONS: [ RESERVED ]
8.243.400.8 MISSION: To transform lives. Working with our partners we design and deliver innovative, high quality health and human services that improve the security and promote independence for New Mexicans in their communities.
[8.243.400.8 NMAC - Rp, 8.243.400.8 NMAC, 1/1/2019; A, 1/1/2022]
8.243.400.9 WORKING DISABLED INDIVIDUALS (WDI) - CATEGORY 043: The working disabled individuals program covers:
A. disabled individuals who are employed; or
B. disabled individuals who have lost eligibility for supplemental security income (SSI) and medicaid due to initial receipt of social security disability insurance ( SSDI) and who are not yet qualified for medicare ; this group is referred to as “medigap”; once the medigap individual begins receiving medicare , they must become employed, as defined in Paragraph (1) of Subsection C of 8.243.400.10 NMAC, to retain their eligibility for WDI.
[8.243.400.9 NMAC - Rp, 8.243.400.9 NMAC, 1/1/2019]
8.243.400.10 BASIS FOR DEFINING THE GROUP: Individuals eligible for medicaid coverage under the working disabled individuals program (WDI) must meet the following requirements:
A. must meet the social security administration disability criteria without regard to “substantial gainful activity”, and
B. must have a recent attachment to the workforce.
C. Recent attachment to workforce defined: Medicaid for the working disabled individuals defines recent attachment to the workforce as either:
(1) having enough gross earnings in a quarter to meet social security administration’s definition of a qualifying quarter, see 8.200.520.20 NMAC; or
(2) having lost SSI and medicaid due to the initial receipt of SSDI benefits, and being within the 24-month waiting period for medicare .
[8.243.400.10 NMAC - Rp, 8.243.400.10 NMAC, 1/1/2019]
8.243.400.11 GENERAL RECIPIENT REQUIREMENTS: [ RESERVED ]
8.243.400.12 ENUMERATION: To be eligible an individual must report their social security account number(s) to the human services department (HSD). If an individual does not have a valid social security number, the individual must apply for one as a condition of medicaid eligibility. Applications for social security numbers can be made by completing an application form, and providing proof of application to local Income support division (ISD) offices.
[8.243.400.12 NMAC - Rp, 8.243.400.12 NMAC, 1/1/2019; A, 1/1/2022]
8.243.400.13 CITIZENSHIP: To be eligible for medicaid , an individual must be:
A. a citizen of the United States; or
B. a non-citizen who entered the United States prior to August 22, 1996, as one of the classes of non-citizens described in Subsection A of 8.200.410.11 NMAC, or a non-citizen who entered the United States as a qualified non-citizen on or after August 22, 1996, and who has met the five-year bar, or are exempt as listed in Subsection B of 8.200.410.11 NMAC.
C. Refer to 8.200.410.11 NMAC.
[8.243.400.13 NMAC - Rp, 8.243.400.13 NMAC, 1/1/2019; A, 1/1/2022]
8.243.400.14 RESIDENCE: To be eligible for medicaid , individuals must be living in New Mexico on the date of application or final determination of eligibility and have demonstrated intent to remain in the state.
A. Establishing residence: Residence in New Mexico is established by living in the state and carrying out the types of activities normally indicating residency, such as occupying a home, enrolling child(ren) in school, getting a state driver's license, or renting a post office box. An individual who is homeless is considered to have met the residence requirements if the individual intends to remain in the state.
B. Recipients receiving benefits out-of-state: Individuals who receive medical assistance in another state are considered residents of that state until the ISD staff receives verification from the other state agency indicating that it has been notified by an individual of the abandonment of residence in that state.
C. Abandonment: Residence is not abandoned by temporary absences. Temporary absences occur when recipients leave New Mexico for specific purposes with time-limited goals. Residence is considered abandoned when any of the following occurs:
(1) the individual leaves New Mexico and indicates that they intend to establish residence in another state;
(2) the individual leaves New Mexico for no specific purpose with no clear intention of returning;
(3) the individual leaves New Mexico and applies for financial, food or medical assistance in another state.
[8.243.400.14 NMAC - Rp, 8.243.400.14 NMAC, 1/1/2019; A, 1/1/2022]
8.243.400.15 NON-CONCURRENT RECEIPT OF ASSISTANCE: The individual may not be receiving assistance in another medicaid category with the exception of the qualified medicare beneficiaries (QMB) and specified low income medicare beneficiaries (SLIMB) programs. ISD staff will look at other categories of eligibility and make the appropriate eligibility determination, or referrals.
[8.243.400.15 NMAC - Rp, 8.243.400.15 NMAC, 1/1/2019]
8.243.400.16 AGE: The individual must be 18 years of age or older.
[8.243.400.16 NMAC - Rp, 8.243.400.16 NMAC, 1/1/2019]
8.243.400.17 DISABILITY: The individual must meet social security administration’s disability or blindness criteria, without regard to “substantial gainful activity”.
[8.243.400.17 NMAC - Rp, 8.243.400.17 NMAC, 1/1/2019]
8.243.400.18 RECIPIENT RIGHTS AND RESPONSIBILITIES: The individual is responsible for establishing their eligibility for medicaid . As part of this responsibility, the individual must provide required information and documents or take the actions necessary to establish eligibility. Failure to do so must result in a decision that eligibility does not exist. The individual must also grant the human services department (HSD) permission to contact other persons, agencies or sources of information which are necessary to establish eligibility.
[8.243.400.18 NMAC - Rp, 8.243.400.18 NMAC, 1/1/2019; A, 1/1/2022]
8.243.400.19 ASSIGNMENT OF MEDICAL SUPPORT: The individual must assign their right to medical support or other third party payments to the state.
A. Assignment of medical support rights occurs through the application for medicaid benefits.
B. Medicaid is not denied to an otherwise eligible individual solely because they cannot legally assign their own medical support rights and the party who is legally able to assign those rights refuses to assign or cooperate, as required by law.
[8.243.400.19 NMAC - Rp, 8.243.400.19 NMAC, 1/1/2019; A, 1/1/2022]
8.243.400.20 REPORTING REQUIREMENTS: An applicant/recipient is responsible to report changes affecting eligibility by the end of the calendar quarter in which the change took place.
[8.243.400.20 NMAC - Rp, 8.243.400.20 NMAC, 1/1/2019]
HISTORY OF 8.243.400 NMAC: [ RESERVED ]
History of Repealed Material:
8.243.400 NMAC - Recipient Policies, filed 12/13/2000 - Repealed effective 1/1/2019.
TITLE 8 SOCIAL SERVICES
CHAPTER 243 MEDICAID ELIGIBILITY - WORKING DISABLED INDIVIDUALS (WDI) (CATEGORY 043)
PART 500 INCOME AND RESOURCE STANDARDS
8.243.500.1 ISSUING AGENCY: New Mexico Health Care Authority (HCA).
[8.243.500.1 NMAC - N, 1/1/2001; A, 7/1/2024]
8.243.500.2 SCOPE: This rule applies to the general public.
[8.243.500.2 NMAC - N, 1/1/2001]
8.243.500.3 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 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 .
[8.243.500.3 NMAC - N, 1/1/2001 ; A, 7/1/2024]
8.243.500.4 DURATION: Permanent
[8.243.500.4 NMAC - N, 1/1/2001]
8.243.500.5 EFFECTIVE DATE: January 1, 2001, unless a later date is cited at the end of a section.
[8.243.500.5 NMAC - N, 1/1/2001]
8.243.500.6 OBJECTIVE: The objective of these regulations is to provide eligibility policy and procedures for the medicaid program.
[8.243.500.6 NMAC - N, 1/1/2001]
8.243.500.7 DEFINITIONS: [RESERVED]
8.243.500.8 [RESERVED]
8.243.500.9 WORKING DISABLED INDIVIDUALS: Income and resources are determined based on SSI methodology, except when deeming income from an ineligible spouse. See 8.215.500 NMAC. Individuals must meet all financial and non-financial eligibility criteria in the month(s) for which a determination of eligibility is made.
[8.243.500.9 NMAC - N, 1/1/2001; A, 6/1/2004]
8.243.500.10 RESOURCE STANDARDS: A “resource” is defined as cash or liquid assets and real or personal property which is owned and can be used either directly, or by sale or conversion, for the applicant’s/recipient’s support and maintenance. Resources may be liquid or non-liquid and may be excluded from the eligibility determination process under certain conditions.
A. A liquid resource is an asset, which can readily be converted to cash.
B. A non-liquid resource is an asset or property, which cannot readily be converted to cash.
[8.243.500.10 NMAC - N, 1/1/2001]
8.243.500.11 APPLICABLE RESOURCE STANDARDS: The resource determination is made as of the first moment of the first day of the month. For determination of continued eligibility, see Section 8.243.600.12 NMAC.
[8.243.500.11 NMAC - N, 1/1/2001]
8.243.500.12 COUNTABLE RESOURCES:
A. An individual’s countable resources must be less than $10,000.
B. Married individuals’ countable resources must be less than $15,000.
[8.243.500.12 NMAC - N, 1/1/2001]
8.243.500.13 RESOURCE EXCLUSIONS: Specified types of resources are excluded from the calculation of countable resources as described in 8.215.500.14 NMAC as follows:
A. Retirement funds: Internal revenue service-recognized retirement fund accounts are excludable resources in the eligibility determination so long as funds are not withdrawn from the account.
B. Examples of such retirement fund accounts include: PERA, ERA, an employer’s qualifying pension plan, 401(k) plan, civil service annuity, IRA, Roth IRA, KEOUGH plan, etc.
[8.243.500.13 NMAC - N, 1/1/2001]
8.243.500.14 RESOURCES TRANSFERS: See 8.215.500.15 NMAC.
[8.243.500.14 NMAC - N, 1/1/2001]
8.243.500.15 TRUSTS: See 8.281.510 NMAC and following subsections.
[8.243.500.15 NMAC - N, 1/1/2001; A, 10/1/2012]
8.243.500.16 DEEMING RESOURCES: If an eligible noninstitutionalized applicant/recipient lives in the same household with an ineligible spouse, resources are considered to belong to the applicant/recipient. The resource standard for a couple applies.
[8.243.500.16 NMAC - N, 1/1/2001]
8.243.500.17 INCOME:
A. Earned income consists of the total gross income received by an applicant/recipient for services performed as an employee or net income as a result of self-employment.
(1) Royalties earned in connection with the publication of the applicant’s/recipient’s work and any honoraria/fees received for services rendered are considered earned income.
(2) In any given calendar quarter, an applicant/recipient must have earnings equal to social security administration’s definition of a covered quarter. See 8.200.520.20 NMAC.
B. Unearned income consists of all other income (minus exclusions and disregards) that is not earned in the course of employment or self employment.
C. Deemed income is income which must be considered available to the applicant/recipient from the ineligible spouse when both live in the same household. Deemed income is counted in determining eligibility for the applicant/recipient.
[8.243.500.17 NMAC - N, 1/1/2001; A, 1/1/2002; A, 6/1/2004]
8.243.500.18 INCOME STANDARDS: The applicable income standard of countable earned income for this category is less than two hundred-fifty percent of the federal poverty level for a household size of one. See Subsection H of 8.200.520.11 NMAC. The applicant/recipient must meet two income tests to qualify for working disabled individuals. These are as follows:
A. TEST 1
(1) Determine applicant’s/recipient’s gross monthly earnings.
(2) Apply a $20.00 general disregard.
(3) Apply a $65.00 earned income disregard.
(4) Disregard ½ of the remainder of income.
(5) Disregard work-related expenses for the blind or disabled.
(6) If the countable earned income is less than two hundred-fifty percent of the applicable federal poverty level (FPL) for a household of one, the individual is eligible.
(7) If the countable earned income is less than two hundred-fifty percent of the applicable FPL for a household size of one, determine if there is an ineligible spouse and/or children in the household.
B. If applicant/recipient lives with an ineligible spouse, see 8.215.500.21 NMAC to determine if deeming income is applicable.
C. TEST 2
(1) Determine applicant’s/recipient’s gross unearned income.
(2) Add ineligible spouse’s deemable income, if applicable.
(3) Apply a $20.00 disregard.
(4) Subtract an amount equal to the current SSI federal benefit rate (FBR) for an individual. See 8.200.520.13 NMAC.
(5) Compare the total countable income to the SSI FBR for an individual or couple, as applicable.
(6) If the total countable income is less than the applicable SSI FBR, the individual is eligible.
D. Income exclusions: Income exclusions for the applicant/recipient are applied before income disregards. Exclusions are not applied to the income of the ineligible spouse from whom income may be deemed.
[8.243.500.18 NMAC - N, 1/1/2001; A, 6/1/2004; A, 3/14/2008]
8.243.500.19 UNEARNED INCOME
A. Standards for unearned income and exclusions: See 8.215.500.20.C. & D. NMAC.
B. Unearned income is computed on a monthly basis. If there are no expenses incurred with the receipt of unearned income, such as annuities, pensions, retirement payments or disability benefits, the gross amount is considered countable unearned income.
[8.243.500.19 NMAC - N, 1/1/2001]
8.243.500.20 DEEMED INCOME: [RESERVED]
[8.243.500.20 NMAC - N, 1/1/2001; Repealed, 6/1/2004]
8.243.500.21 DISREGARDS: Income disregards are allowed as described below when applicable.
A. Twenty dollar disregard: The first $20 of unearned or earned income received in a month is disregarded. This disregard is not applicable to payments made to an applicant/recipient through a state or other government assistance program, or by a private charitable organization, where such payments are based on the applicant’s/recipient's need.
B. Additional earned income disregard: If appropriate, earned income of $65 per month, plus one-half of the remainder is disregarded.
C. Work-related expenses defined: Work-related expenses of an employed applicant/recipient who is blind or disabled are disregarded. This disregard is applied to earned income only. Disregarded expenses must be for items or services directly related to enabling a person to work, and which are necessarily incurred by that individual because of a physical or mental disability or blindness. Such expenses are disregarded if not covered by other third party payers, including medicaid .
(1) Types of work-related expenses which may be disregarded include:
(a) federal, state, and local income taxes;
(b) social security contributions;
(c) union dues;
(d) transportation costs, including actual cost of bus or taxi cab fare, or 15 cents per mile for private automobile;
(e) lunches;
(f) child care costs, if not otherwise provided;
(g) uniforms, tools, and other necessary equipment;
(h) special vehicle modifications to enable transportation to and from work, but not the cost of the vehicle itself;
( i ) attendants who may be hired for the purpose of taking applicant/recipient to and from work, and getting ready for work;
(j) durable medical equipment that is medically related and generally not useful in absence of the blindness or disability yet, are necessary to attend and perform tasks in the work place;
(k) expenses for work related equipment, which is impairment related and necessary for the individual to perform his/her tasks;
(l) prostheses necessary to perform work related tasks.
(m) design modifications related to blindness or disability that enable the applicant/recipient to leave home in order to attend work, or design modifications made to the work area of the home in the case where the applicant/recipient engages in a home-based business;
(n) special expenses necessary to enable an applicant/recipient who is blind or disabled to engage in employment, such as a seeing-eye dog, braille instructions, or instructions on using special equipment and,
(o) health insurance premiums.
(2) If items or services above are purchased through an installment contract, the payments are disregarded. Should the item or service be a one-time purchase, the purchase may be pro-rated over a 12-month period, or over the life of the contract.
(3) If items are leased, the monthly payment would be disregarded.
D. NONDEDUCTIBLE ITEMS: The following items cannot be deducted from earned income:
(1) in-kind payments;
(2) expenses deducted under other provisions;
(3) expenses which will be reimbursed;
(4) life maintenance expenses; although not all-inclusive, life maintenance items include the following:
(a) meals consumed outside of work hours;
(b) self-care items (including items of cosmetic rather than work related nature);
(c) general educational development;
(d) deposits into retirement accounts intended as an IRA, Keogh, 401K, PERA or voluntary pensions;
(e) life insurance premiums;
(f) items furnished by others that are needed in order to work (the value of such items is not income), and
(g) expenses claimed on a self-employment tax return.
[8.243.500.21 NMAC - N, 1/1/2001]
HISTORY OF 8.243.500 NMAC: [RESERVED]
History of Repealed Material: [RESERVED]
TITLE 8 SOCIAL SERVICES
CHAPTER 243 MEDICAID ELIGIBILITY - WORKING DISABLED INDIVIDUALS (WDI) (CATEGORY 043)
PART 600 BENEFIT DESCRIPTION
8.243.600.1 ISSUING AGENCY: New Mexico Health Care Authority(HCA).
[8.243.600.1 NMAC - Rp, 8.243.600.1 NMAC, 1/1/2019 ; A, 7/1/2024]
8.243.600.2 SCOPE: This rule applies to the general public .
[8.243.600.2 NMAC - Rp, 8.243.600.2 NMAC, 1/1/2019]
8.243.600.3 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 Section 27-1-12 et seq ., NMSA 1978. 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.
[8.243.600.3 NMAC - Rp, 8.243.600.3 NMAC, 1/1/2019 ; A, 7/1/2024]
8.243.600.4 DURATION: Permanent.
[8.243.600.4 NMAC - Rp, 8.243.600.4 NMAC, 1/1/2019]
8.243.600.5 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.
[8.243.600.5 NMAC - Rp, 8.243.600.5 NMAC, 1/1/2019]
8.243.600.6 OBJECTIVE: The objective of these rules is to provide eligibility policy and procedures for the medical assistance programs.
[8.243.600.6 NMAC - Rp, 8.243.600.6 NMAC, 1/1/2019]
8.243.600.7 DEFINITIONS: [ RESERVED ]
8.243.600.8 [RESERVED]
[8.243.600.8 NMAC - Rp, 8.243.600.8 NMAC, 1/1/2019]
8.243.600.9 GENERAL BENEFIT DESCRIPTION: An individual who meets a medical assistance programs (MAP) category of eligibility for the working disabled individual program (WDI) is eligible to receive full state plan benefits.
[8.243.600.9 NMAC - Rp, 8.243.600.9 NMAC, 1/1/2019]
8.243.600.10 BENEFIT DETERMINATION: Completed applications must be acted upon and notice of approval, denial, or delay sent out within 60 days of the date of application. Individuals will have time limits explained, and be informed of the date by which the application should be processed.
[8.243.600.10 NMAC - Rp, 8.243.600.10 NMAC, 1/1/2019]
8.243.600.11 INITIAL BENEFITS: Eligibility begins the month of approval. When an eligibility determination is made, notice of the approval or denial is sent to the individual. If the application is denied, this notice includes the individual’s right to request a hearing.
[8.243.600.11 NMAC - Rp, 8.243.600.11 NMAC, 1/1/2019]
8.243.600.12 ONGOING BENEFITS: A re-determination of MAP eligibility is made every 12 months or at such time the MAP eligible recipient begins receiving medicare benefits.
[8.243.600.12 NMAC - Rp, 8.243.600.12 NMAC, 1/1/2019]
8.243.600.13 RETROACTIVE BENEFIT COVERAGE: Retroactive medicaid coverage is provided in accordance with 8.200.400.14 NMAC.
[8.243.600.13 NMAC - Rp, 8.243.600.13 NMAC, 1/1/2019]
8.243.600.14 CHANGES IN ELIGIBILITY: A case is closed, with provision of advance notice, when the MAP eligible recipient becomes ineligible. If a MAP eligible recipient dies, the case is closed the following month.
[8.243.600.14 NMAC - Rp, 8.243.600.14 NMAC, 1/1/2019]
HISTORY OF 8.243.600 NMAC: [ RESERVED ]
History of Repealed Material:
8.243.600 NMAC - Medicaid Eligibility - Working Disabled Individuals (WDI) (Category 043) - Benefit Description, filed 12/13/2000 Repealed effective 1/1/2019.
TITLE 8 SOCIAL SERVICES
CHAPTER 245 MEDICAID ELIGIBILITY - SPECIFIED LOW INCOME MEDICARE BENEFICIARIES (SLIMB) (CATEGORY 045)
PART 400 RECIPIENT POLICIES
8.245.400.1 ISSUING AGENCY: New Mexico Health Care Authority.
[8.245.400.1 NMAC - Rp 8.245.400.1 NMAC, 7/1/2024]
8.245.400.2 SCOPE: The rule applies to the general public .
[8.245.400.2 NMAC - Rp 8.245.400.2 NMAC, 7/1/2024]
8.245.400.3 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.
[8.245.400.3 NMAC - Rp 8.245.400.3 NMAC, 7/1/2024]
8.245.400.4 DURATION: Permanent.
[8.245.400.4 NMAC - Rp 8.245.400.4 NMAC, 7/1/2024]
8.245.400.5 EFFECTIVE DATE: July 1, 2024, unless a later date is cited at the end of a section.
[8.245.400.5 NMAC - Rp 8.245.400.5 NMAC, 7/1/2024]
8.245.400.6 OBJECTIVE: The objective of these regulations is to provide eligibility policy and procedures for the medicaid program.
[8.245.400.6 NMAC - Rp 8.245.400.6 NMAC, 7/1/2024]
8.245.400.7 DEFINITIONS: [ RESERVED ]
8.245.400.8 MISSION: To reduce the impact of poverty on people living in New Mexico and to assure low income and disabled individuals in New Mexico equal participation in the life of their communities.
[8.245.400.8 NMAC - Rp 8.245.400.8 NMAC, 7/1/2024]
8.245.400.9 SPECIFIED LOW INCOME MEDICARE BENEFICIARIES (SLIMB) - CATEGORY 045: To be eligible for category 045, an applicant/recipient must be covered by medicare part A. The part A insurance is a free entitlement to social security beneficiaries who are 65 years of age or older or who have received social security disability payments for 24 months. Fully or currently insured workers, or their dependents, with end-stage renal disease are also covered under medicare .
[8.245.400.9 NMAC - Rp 8.245.400.9 NMAC, 7/1/2024]
8.245.400.10 BASIS FOR DEFINING THE GROUP: Specified low income medicare beneficiaries (SLIMB) are individuals who would be qualified medicare beneficiaries (QMBs) but for the fact that their income exceeds the income levels established for QMB. Income eligibility for the SLIMB is at least one hundred percent of the federal income poverty level, but less than one hundred twenty percent.
[8.245.400.10 NMAC - Rp 8.245.400.10 NMAC, 7/1/2024]
8.245.400.11 [ RESERVED ]
8.245.400.12 ENUMERATION: SLIMB applicants/recipients must furnish their social security account number(s). SLIMB eligibility must be denied or terminated for applicants/recipients who fail to furnish social security numbers.
[8.245.400.12 NMAC - Rp 8.245.400.12 NMAC, 7/1/2024]
8.245.400.13 CITIZENSHIP AND IDENTITY: Individuals entitled to or receiving medicare already meet citizenship and identity requirements.
[8.245.400.13 NMAC - Rp 8.245.400.13 NMAC, 7/1/2024]
8.245.400.14 RESIDENCE: To be eligible for SLIMB, an applicant/recipient must be physically present in New Mexico on the date of application or final determination of eligibility and must have demonstrated intent to remain in the state. A temporary absence from the state does not prevent eligibility. A temporary absence exists when an applicant/recipient leaves the state for a specific purpose with a time-limited goal and intends to return to New Mexico when the purpose is accomplished.
[8.245.400.14 NMAC - Rp 8.245.400.14 NMAC, 7/1/2024]
8.245.400.15 NONCONCURRENT RECEIPT OF ASSISTANCE: SLIMB applicants on buy-in in another state cannot be approved for the New Mexico SLIMB program until buy-in from the other state is terminated.
[8.245.400.15 NMAC - Rp 8.245.400.15 NMAC, 7/1/2024]
8.245.400.16 SPECIAL RECIPIENT REQUIREMENTS: Applicants/recipients for SLIMB eligibility must meet the specified age or disability requirements to be eligible for medicare part A. There is no age requirement for SLIMB eligibility.
[8.245.400.16 NMAC - Rp 8.245.400.16 NMAC, 7/1/2024]
8.245.400.17 RECIPIENT RIGHTS AND RESPONSIBILITIES: An applicant/recipient is responsible for establishing his/her eligibility for medicaid . As part of this responsibility, the applicant/recipient must provide required information and documents or take the actions necessary to establish eligibility. Failure to do so must result in a decision that eligibility does not exist. An applicant/recipient must also grant the HCA permission to contact other persons, agencies or sources of information which are necessary to establish eligibility.
[8.245.400.17 NMAC - Rp 8.245.400.17 NMAC, 7/1/2024]
8.245.400.18 ASSIGNMENT OF SUPPORT: Assignment of medical support: As a condition of eligibility, applicants for or recipients of benefits must do the following, 42 CFR Section 433.146; Subsection G of Section 27-2-28 NMSA 1978 (Repl. Pamp. 1991):
A. assign individual rights to medical support and payments to the HCA the assignment authorizes HCA to pursue and make recoveries from liable third parties on behalf of a recipient;
B. assign the rights to medical support and payments of other individuals eligible for medicaid , for whom they can legally make an assignment; and
C. assign their individual rights to any medical care support available under an order of a court or an administrative agency.
[8.245.400.18 NMAC - Rp 8.245.400.18 NMAC, 7/1/2024]
8.245.400.19 REPORTING REQUIREMENTS: Medicaid recipients must report any change in their circumstances which may affect eligibility within 10 days after the change to the local income support division (ISD) office.
[8.245.400.19 NMAC - Rp 8.245.400.19 NMAC, 7/1/2024]
HISTORY OF 8.245.400 NMAC:
Pre-NMAC History: The material in this part was derived from that previously filed with the State Records Center:
MAD Rule 843, Specified Low Income Medicare Beneficiaries, filed 9/26/1994.
History of Repealed Material:
MAD Rule 843, Specified Low Income Medicare Beneficiaries, filed 9/26/1994 - Repealed effective 2/1/1995.
8.245.400 NMAC - Recipient Policies (filed 11/16/2009) Repealed effective 7/1/2024.
Other: 8.245.400 NMAC - Recipient Policies (filed 11/16/2009) Replaced by 8.245.400 NMAC - Recipient Policies effective 7/1/2024.
TITLE 8 SOCIAL SERVICES
CHAPTER 245 MEDICAID ELIGIBILITY - SPECIFIED LOW INCOME MEDICARE BENEFICIARIES (SLIMB) (CATEGORY 045)
PART 500 INCOME AND RESOURCE STANDARDS
8.245.500.1 ISSUING AGENCY: New Mexico Health Care Authority.
[8.245.500.1 NMAC - Rp 8.245.500.1 NMAC, 7/1/2024]
8.245.500.2 SCOPE: The rule applies to the general public .
[8.245.500.2 NMAC - Rp 8.245.500.2 NMAC, 7/1/2024]
8.245.500.3 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.
[8.245.500.3 NMAC - Rp 8.245.500.3 NMAC, 7/1/2024]
8.245.500.4 DURATION: Permanent.
[8.245.500.4 NMAC - Rp 8.245.500.4 NMAC, 7/1/2024]
8.245.500.5 EFFECTIVE DATE: July 1, 2024, unless a later date is cited at the end of a section.
[8.245.500.5 NMAC - Rp 8.245.500.5 NMAC, 7/1/2024]
8.245.500.6 OBJECTIVE: The objective of this rule is to provide eligibility policy and procedures for the medicaid program.
[8.245.500.6 NMAC - Rp 8.245.500.6 NMAC, 7/1/2024]
8.245.500.7 DEFINITIONS: [ RESERVED ]
8.245.500.8 MISSION: 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.
[8.245.500.8 NMAC - Rp 8.245.500.8 NMAC, 7/1/2024]
8.245.500.9 NEED DETERMINATION: SLIMB applicants/recipients must apply for and take all necessary steps to obtain any resources to which they may be entitled.
[8.245.500.9 NMAC - Rp 8.245.500.9 NMAC, 7/1/2024]
8.245.500.10 RESOURCE STANDARDS: The value of an applicant/recipient’s countable resources must not exceed the amount set forth in 8.200.510.14 NMAC, resource amounts for supplemental security income (SSI) related medicare savings programs (QMB and SLIMB/QI1). The resource limit for an applicant couple cannot exceed the amount for a couple set forth in 8.200.510.14 NMAC. An applicant/recipient with an ineligible spouse is eligible if the couple’s countable resources do not exceed the amount set forth in 8.200.510.14 NMAC, when resources are deemed. A resource determination is always made as of the first moment of the first day of the month. An applicant/recipient is ineligible for any month in which the countable resources exceed the current resource standard as of the first moment of the first day of the month. Changes in the amount of resources during a month do not affect eligibility for that month. See 8.215.500.13 NMAC, countable resources, and 8.215.500.14 NMAC, resource exclusions , for information on exclusions, disregards, and countable resources.
[8.245.500.10 NMAC - Rp 8.245.500.10 NMAC, 7/1/2024]
8.245.500.11 RESOURCE TRANSFERS: The social security administration excluded transfer of resources as a factor of eligible for non-institutionalized SSI recipients. Transfer of resources is not a factor for consideration in the medicare savings programs.
[8.245.500.11 NMAC - Rp 8.245.500.11 NMAC, 7/1/2024]
8.245.500.12 TRUSTS: See 8.281.510 NMAC and following subsections.
[8.245.500.12 NMAC - Rp 8.245.500.12 NMAC, 7/1/2024]
8.245.500.13 INCOME STANDARDS: Income standards for this category are at least one hundred percent but no more than one hundred twenty percent of the federal income poverty guidelines. The federal income poverty guidelines are adjusted annually, effective April 1. See 8.200.520 NMAC, Income Standards , and 8.215.500.19 NMAC, Income Standards , for information on exclusions, disregards, and countable income. Verification of income must be documented in the case file.
[8.245.500.13 NMAC - Rp 8.245.500.13 NMAC, 7/1/2024]
8.245.500.14 UNEARNED INCOME: Unearned income exclusions: All social security and railroad retirement beneficiaries receive cost of living adjustments (COLAs) in January of each year. The ISD caseworker must disregard the COLA from January through March when (re)determining SLIMB eligibility. For redeterminations made in January, February and March and for new SLIMB applications registered in January, February, or March, the ISD caseworker uses the December social security and railroad retirement benefit amounts. For SLIMB applications registered from April through December, total gross income including the new COLA figures are used to determine income and compared to the new April federal poverty levels. This exclusion does not apply to other types of income.
[8.245.500.14 NMAC - Rp 8.245.500.14 NMAC, 7/1/2024]
8.245.500.15 DEEMED INCOME: If an applicant/recipient is a minor who lives with a parent(s), deemed income from the parent(s) must be considered. If an applicant/recipient is married and lives with a spouse, deemed income from the spouse must be considered. See 8.215.500.21 NMAC, Deemed Income, for information on deemed income.
[8.245.500.15 NMAC - Rp 8.245.500.15 NMAC, 7/1/2024]
HISTORY OF 8.245.500 NMAC:
Pre-NMAC History: The material in this part was derived from that previously filed with the State Records Center:
MAD Rule 843, Specified Low Income Medicare Beneficiaries, filed 9/26/94.
History of Repealed Material :
MAD Rule 843, Specified Low Income Medicare Beneficiaries, filed 9/26/1994 - Repealed effective 2/1/1995.
8 .245.500 NMAC - Income And Resource Standards (filed 11/16/2009) Repealed effective 7/1/2024.
Other : 8.245.500 NMAC - Income And Resource Standards (filed 11/16/2009) Replaced by 8.245.500 NMAC - Income And Resource Standards effective 7/1/2024.
TITLE 8 SOCIAL SERVICES
CHAPTER 245 MEDICAID ELIGIBILITY - SPECIFIED LOW INCOME MEDICARE BENEFICIARIES (SLIMB) (CATEGORY 045)
PART 600 BENEFIT DESCRIPTION
8.245.600.1 ISSUING AGENCY: New Mexico Health Care Authority.
[8.245.600.1 NMAC - Rp, 8.245.600.1 NMAC, 1/1/2019; A, 7/1/2024]]
8.245.600.2 SCOPE: The rule applies to the general public .
[8.245.600.2 NMAC - Rp, 8.245.600.2 NMAC, 1/1/2019]
8.245.600.3 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 (HCA) 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 HCA as a single, unified department to administer laws and exercise functions relating to health care facility licensure and health care purchasing and regulation.
[8.245.600.3 NMAC - Rp, 8.245.600.3 NMAC, 1/1/2019; A, 7/1/2024]
8.245.600.4 DURATION: Permanent.
[8.245.600.4 NMAC - Rp, 8.245.600.4 NMAC, 1/1/2019]
8.245.600.5 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.
[8.245.600.5 NMAC - Rp, 8.245.600.5 NMAC, 1/1/2019]
8.245.600.6 OBJECTIVE: The objective of these regulations is to provide eligibility policy and procedures for the medicaid program.
[8.245.600.6 NMAC - Rp, 8.245.600.6 NMAC, 1/1/2019]
8.245.600.7 DEFINITIONS: [ RESERVED ]
8.245.600.8 [RESERVED]
[8.245.600.8 NMAC - Rp, 8.245.600.8 NMAC, 1/1/2019]
8.245.600.9 BENEFIT DESCRIPTION: Most individuals 65 or older receive free medicare part A. Those who do not receive free part A can voluntarily enroll for hospital insurance coverage and pay the monthly premium. Medicaid does not pay the medicare part A monthly premium for this category of recipients. Voluntary enrollees for premium/conditional medicare part A must enroll for supplementary medical insurance, medicare part B, and pay that premium also. After an application for SLIMB benefits is approved, medicaid begins to pay the medicare part B premium. Applicants/recipients eligible for medicaid coverage under another medicaid category may also be eligible for SLIMB. SLIMB eligibility allows the state to receive federal matching funding for the purchase of medicare part B. Since payment of the medicare part B premium is the only benefit, no medicaid card is issued and there is no interaction with the medicaid claims processing contractor.
[8.245.600.9 NMAC - Rp, 8.245.600.9 NMAC, 1/1/2019]
8.245.600.10 BENEFIT DETERMINATION: Application for SLIMB is made on the assistance application form. Applications are acted on and notice of action taken is sent to the applicant within 45 days of the application. Determination of SLIMB eligibility for current recipients of medicaid is made without a separate application. Recipients of supplemental security income (SSI) or qualified medicare beneficiaries are not eligible for SLIMB.
[8.245.600.10 NMAC - Rp, 8.245.600.10 NMAC, 1/1/2019]
8.245.600.11 INITIAL BENEFITS: Eligibility begins the month the case is approved. When an eligibility determination is made, notice of the approval or denial is sent to the applicant. If the application is denied, this notice includes the recipient’s right to request a hearing.
[8.245.600.11 NMAC - Rp, 8.245.600.11 NMAC, 1/1/2019]
8.245.600.12 ONGOING BENEFITS: A redetermination of eligibility is made every 12 months.
[8.245.600.12 NMAC - Rp, 8.245.600.12 NMAC, 1/1/2019]
8.245.600.13 RETROACTIVE BENEFIT COVERAGE: Retroactive medicaid coverage is provided in accordance with 8.200.400.14 NMAC.
[8.245.600.13 NMAC - Rp, 8.245.600.13 NMAC, 1/1/2019]
8.245.600.14 CHANGES IN ELIGIBILITY: A case is closed, with provision of advance notice, when the recipient becomes ineligible. If a recipient dies, the case is closed the following month.
[8.245.600.14 NMAC - Rp, 8.245.600.14 NMAC, 1/1/2019]
HISTORY OF 8.245.600 NMAC:
Pre-NMAC History: The material in this part was derived from that previously filed with the State Records Center:
MAD Rule 843, Specified Low Income Medicare Beneficiaries, filed 9/26/1994.
History of Repealed Material: MAD Rule 843, Specified Low Income Medicare Beneficiaries, filed 9/26/1994 - Repealed effective 2/1/1995.
8.245.600 NMAC - Specified Low Income Medicare Beneficiaries-Benefit Description, filed 11/16/2009 - Repealed effective 1/1/2019.
TITLE 8 SOCIAL SERVICES
CHAPTER 248 MEDICAID ELIGIBILITY - MEDICARE DRUG COVERAGE (CATEGORY 048)
PART 400 RECIPIENT POLICIES
8.248.400 .1 ISSUING AGENCY: New Mexico Health Care Authority.
[8.248.400.1 NMAC - Rp, 8.248.400.1 NMAC, 7/1/2024]
8.248.400 .2 SCOPE: The rule applies to the general public .
[8.248.400.2 NMAC - Rp, 8.248.400.2 NMAC, 7/1/2024]
8.248.400 .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 27-2-12 et. seq. NMSA 1978 (Repl. Pamp. 1991). The legal basis for the low-income subsidy (LIS) program is the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA), Public Law 108-173. 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.
[8.248.400.3 NMAC - Rp, 8.248.400.3 NMAC, 7/1/2024]
8.248.400 .4 DURATION: Permanent.
[8.248.400.4 NMAC - Rp, 8.248.400.4 NMAC, 7/1/2024]
8.248.400 .5 EFFECTIVE DATE: July 1, 2024, unless a later date is cited at the end of a section.
[8.248.400.5 NMAC - Rp, 8.248.400.5 NMAC, 7/1/2024]
8.248.400 .6 OBJECTIVE: The objective of these regulations is to provide eligibility policy and procedures for the medicare part D - low-income subsidy program.
[8.248.400.6 NMAC - Rp, 8.248.400.6 NMAC, 7/1/2024]
8.248.400 .7 DEFINITIONS: [ RESERVED ]
8.248.400 .8 [ RESERVED ]
8.248.400.9 LOW-INCOME SUBSIDY FOR MEDICARE PART D ELIGIBLES: Applicants/recipients who meet certain income and other non-financial requirements can be eligible for the low-income subsidy (LIS) under medicare part D.
[8.248.400.9 NMAC - Rp, 8.248.400.9 NMAC, 7/1/2024]
8.248.400.10 BASIS FOR DEFINING THE GROUP:
A. Medicare recipients who are eligible for part D medicare coverage under the MMA of 2003 may be eligible for the low-income subsidy program. Eligibility is based on financial criteria, both income and resources, of applicant and spouse (if any) for the appropriate family size.
B. Family size: The following persons are included in the family size:
(1) the applicant;
(2) the applicant's spouse, if living with the applicant; and
(3) any persons who are related by blood, marriage, or adoption, who are living with the applicant and spouse and who are dependent on the applicant or spouse for at least one half of their financial support.
[8.248.400.10 NMAC - Rp, 8.248.400.10 NMAC, 7/1/2024]
8.248.400.11 GENERAL RECIPIENT REQUIREMENTS:
A. Medicare: Applicants must be eligible for and receiving part A or part B medicare benefits.
B. Residence: To be eligible for the low-income subsidy, an applicant/recipient must be physically present in New Mexico on the date of application or final determination of eligibility and must have demonstrated intent to remain in the state. Eligibility for the low-income subsidy (LIS) will transfer to New Mexico if determined by the social security administration (SSA) in another state. If eligibility was determined by another state (not SSA), eligibility must be re-determined in New Mexico.
[8.248.400.11 NMAC - Rp, 8.248.400.11 NMAC, 7/1/2024]
8.248.400.12 SPECIAL RECIPIENT REQUIREMENTS: Applicants/recipients must be enrolled in a part D prescription drug plan (PDP) or a medicare advantage prescription drug (MA-PD) plan.
[8.248.400.12 NMAC - Rp, 8.248.400.12 NMAC, 7/1/2024]
8.248.400.13 RECIPIENT RIGHTS AND RESPONSIBILITIES: An applicant/recipient is responsible for establishing their eligibility for the LIS.
A. As part of this responsibility, the applicant/recipient must provide required information and documents or take the actions necessary to establish eligibility. Failure to do so must result in a decision that eligibility does not exist.
B. An applicant/recipient must also grant the HCA permission to contact other persons, agencies or sources of information that are necessary to establish eligibility.
C. An applicant can voluntarily withdraw an application any time prior to the determination of eligibility. The ISD office advises an applicant that withdrawing an application has no effect upon their right to apply for assistance in the future.
[8.248.400.13 NMAC - Rp, 8.248.400.13 NMAC, 7/1/2024]
8.248.400.14 REPORTING REQUIREMENTS: A LIS recipient must report to the local ISD office any change in their circumstances that might affect eligibility within 10 days of the change.
[8.248.400.14 NMAC - Rp, 07/01/2024]
HISTORY OF 8.248.400 NMAC: 8.248.400 NMAC - Recipient Policies (filed 1/13/2006) Repealed effective 7/1/2024.
Other: 8.248.400 NMAC - Recipient Policies (filed 1/13/2006) Replaced by 8.248.400 NMAC - Recipient Policies effective 7/1/2024.
TITLE 8 SOCIAL SERVICES
CHAPTER 248 MEDICAID ELIGIBILITY - MEDICARE DRUG COVERAGE (CATEGORY 048)
PART 500 INCOME AND RESOURCE STANDARDS
8.248.500.1 ISSUING AGENCY: New Mexico Health Care Authority.
[8.248.500.1 NMAC - Rp 8.248.500.1 NMAC, 7/1/2024]
8.248.500.2 SCOPE: The rule applies to the general public .
[8.248.500.2 NMAC - Rp 8.248.500.2 NMAC, 7/1/2024]
8.248.500.3 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 27-2-12 et. seq. NMSA 1978 (Repl. Pamp. 1991). The legal basis for the low-income subsidy (LIS) program is the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA), Public Law 108-173. 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.
[8.248.500.3 NMAC - Rp 07/01/2024]
8.248.500.4 DURATION: Permanent.
[8.248.500.4 NMAC - Rp 8.248.500.4 NMAC, 7/1/2024]
8.248.500.5 EFFECTIVE DATE: July 1, 2024, unless a later date is cited at the end of a section.
[8.248.500.5 NMAC - Rp 8.248.500.5 NMAC, 7/1/2024]
8.248.500.6 OBJECTIVE: The objective of these regulations is to provide eligibility policy and procedures for the medicare part D (drug benefit) - low income subsidy program.
[8.248.500.6 NMAC - Rp 8.248.500.6 NMAC, 7/1/2024]
8.248.500.7 DEFINITIONS: [ RESERVED ]
8.248.500.8 [ RESERVED ]
8.248.500.9 NEED DETERMINATION: This section describes the methodology to be used in determining countable resources and income for the low-income subsidy (LIS) program which is based in part on supplemental security income (SSI) methodology. These guidelines are used for initial and on-going eligibility for medicare beneficiaries enrolled in part A or part B medicare . LIS eligibility is determined prospectively. Applicants/recipients must meet, or expect to meet, all financial and non-financial eligibility criteria in the month for which a determination of eligibility is made.
[8.248.500.9 NMAC - Rp 8.248.500.9 NMAC, 7/1/2024]
8.248.500.10 APPLICATION PROCESS: The income support division (ISD) office is responsible for taking LIS applications from those individuals who do not want to submit their application to the social security administration either directly or through the ISD office.
A. Who does not have to apply: Certain groups of medicare beneficiaries who are also receiving medicaid do not have to apply for the LIS. These individuals are called "deemed eligible" and will automatically be put on the LIS:
(1) full-benefit dual eligibles, who are persons eligible for both medicare and have full medicaid benefits (including drug benefits);
(2) SSI recipients;
(3) medicare beneficiaries, who are participants in the medicare saving programs, which are: QMB, SLIMB, and QI-1;
(4) working disabled individuals (WDI) who are receiving medicare ;
(5) HCBW recipients who are receiving medicare ; and
(6) individuals screened for QMB, SLIMB, or QI-1 and determined eligible before the application for LIS is processed.
B. Who can apply: medicare beneficiaries who are not deemed eligible (See Paragraphs (1) through (6) above) and who insist on filing their application with the state rather than with social security administration (SSA).
[8.248.500.10 NMAC - Rp 8.248.500.10 NMAC, 7/1/2024]
8.248.500.11 RESOURCE STANDARDS: A "resource" is defined as cash and other assets that can be converted to cash within 20 days.
A. Resource determination: The resource determination is made as of the first moment of the first day of the month. An applicant/recipient is ineligible for any month in which their countable resources exceed the allowable resource standard as of the first moment of the first day of the month. Changes in the amount of countable resources during a month do not affect eligibility or ineligibility for that month.
B. Distinguishing between resources and income: Resources must be distinguished from income to avoid counting a single asset twice. As a general rule , ownership of a resource precedes the current month while income is received in the current month. Income held by an applicant/recipient until the following month becomes a resource.
[8.248.500.11 NMAC - Rp 8.248.500.11 NMAC, 7/1/2024]
8.248.500.12 APPLICABLE RESOURCE STANDARDS: The resource standard for the LIS is $10,000 for an individual and $20,000 for a couple. Resources belonging to other dependent family members are not considered.
A. Cash resources: The face value of cash, savings or checking accounts is considered in determining LIS eligibility.
(1) An applicant/recipient must provide verification of the value of all cash resources. The resource value of a bank account is customarily verified by a statement from the bank showing the account balance as of the first moment of the first day of the month in question. If an applicant/recipient cannot provide this verification, the ISD worker sends a bank or postal savings clearance to the appropriate institution(s).
(2) If the applicant/recipient can demonstrate that a check was written and delivered to a payee but not cashed by the payee prior to the first moment of the first day of the month, the amount of that check is subtracted from the applicant/recipient's checking account balance to arrive at the amount to be considered a countable resource.
B. Other resources: The value of other resources is evaluated according to the applicant/spouse's equity in the resource(s). The equity value of an item is defined as the price for which that item, minus any encumbrances, can reasonably be expected to sell on the open market in the particular geographic area. Other resources which can be converted to cash within 20 days include, but are not limited to: stocks, bonds, mutual fund shares, promissory notes, mortgages, whole life insurance policies, financial institution accounts (savings, checking, CDs, IRAs, 401(K) accounts, and annuities), and real property not contiguous with home property.
[8.248.500.12 NMAC - Rp 8.248.500.12 NMAC, 7/1/2024]
8.248.500.13 COUNTABLE RESOURCES: Before a resource can be considered countable, the three criteria listed below must be met.
A. Ownership interest: An applicant/recipient must have an ownership interest in a resource for it to be countable. The fact that an applicant/recipient has access to a resource, or has a legal right to use it, does not make it countable unless the applicant/recipient also has an ownership interest in it.
B. Legal right to convert resource to cash: An applicant/recipient must have the legal ability to spend the funds or to convert non-cash resources into cash.
(1) Physical possession of resource: The fact that an applicant/recipient does not have physical possession of a resource does not mean it is not their resource. If they have the legal ability to spend the funds or convert the resource to cash, the resource is considered countable. Physical possession of savings bonds is a legal requirement for cashing them.
(2) Unrestricted use of resource: An applicant/recipient is considered to have free access to the unrestricted use of a resource even if he can take those actions only through an agent, such as a representative payee or guardian.
(3) If there is a legal bar to the sale of a resource, such as a co-owner legally blocking the sale of jointly owned property, the resource is not countable. The applicant/recipient is not required to undertake litigation in order to accomplish the sale.
C. Legal ability to use a resource: If a legal restriction exists which prevents the use of a resource for the applicant/recipient's own support and maintenance, the resource is not countable.
D. Jointly-held account: If the applicant/spouse is the only subsidy claimant or subsidy recipient who is an account holder on a jointly held account, the state will presume that all of the funds in the account belong to the applicant/spouse. If more than one subsidy claimant or subsidy recipient are account holders, the state will presume that the funds in the account belong to those individuals in equal shares. If the applicant/spouse disagrees with the ownership presumption described in this subsection, they may rebut the presumption. Rebuttal is a procedure that permits an individual to furnish evidence and establish that some or all of the funds in the jointly-held account do not belong to them.
[8.248.500.13 NMAC - Rp 8.248.500.13 NMAC, 7/1/2024]
8.248.500.14 RESOURCE EXCLUSIONS: The following resources are not to be considered for purposes of determining LIS eligibility:
A. Applicant's home: A home is any property in which the applicant and spouse have an ownership interest and which serves as the applicant’s principal place of residence. There is no restriction on acreage of home property. This property includes the shelter in which an individual resides, the land on which the shelter is located, and any outbuildings.
B. Non-liquid resources, other than real property: These include, but are not limited to:
(1) household goods and personal effects;
(2) automobiles, trucks, tractors and other vehicles;
(3) machinery and livestock; and
(4) non-cash business property.
C. Property of a trade or business: Property of a trade or business that is essential to the applicant/spouse's means of self-support.
D. Non-business property: Non-business property that is essential to the applicant/spouse's means of self-support.
E. Stock in regional or village corporations: Stock in regional or village corporations held by natives of Alaska during the 20-year period in which the stock is inalienable pursuant to the Alaska Native Claims Settlement Act.
F. Whole life insurance: Whole life insurance owned by an individual (and spouse, if any) if the total face value of all the life insurance policies on any person does not exceed $1,500. When the total face value of all policies exceeds $1,500, the cash surrender value of all policies is countable.
G. Term life insurance: Term life insurance that has no cash surrender value.
H. Restricted, allotted Indian lands: Restricted, allotted Indian lands, if the Indian/owner cannot dispose of the land without the permission of other individuals, their tribe, or an agency of the federal government.
I. Payments or benefits: Payments or benefits provided under a federal statute other than title XVI of the act where exclusion is required by such statute.
J. Federal disaster relief: Federal disaster relief assistance received on account of a presidentially declared major disaster, including accumulated interest, or comparable state or local assistance.
K. Funds of $1,500: Funds of $1,500 for the individual and $1,500 for the spouse who lives with the individual if these funds are intended to be used for funeral or burial expenses of the individual and spouse.
L. Burial spaces: Burial spaces, including burial plots, gravesites, crypts, mausoleums, urns, niches, vaults, headstones, markers, plaques, burial containers, opening and closing of the gravesite, and other customary and tradition repositories for the deceased's bodily remains, for the applicant/spouse.
M. Retained retroactive SSI or social security: Retained retroactive SSI or social security benefits for nine months after the month they are received.
N. Certain housing assistance:
O. Refunds: Refunds of federal income taxes and advances made by an employer relating to an earned income tax credit for the month following the month of receipt, and refunds of child tax credits for nine months after the month they are received.
P. Payments: Payments received as compensation incurred or losses suffered as a result of a crime (victims' compensation payments), for nine months beginning with the month following the month of receipt.
Q. Relocation assistance: Relocation assistance for a state or local government, for nine months, beginning with the month following the month of receipt.
R. Dedicated financial institution accounts: Dedicated financial institution accounts consisting of past-due benefits for an SSI-eligible individual under age 18.
S. Gifts: A gift to, or for the benefit of, an individual who has not attained 18 years of age and who has a life-threatening condition, from an organization described in section 501(c)(3) of the internal revenue code of 1986 which is exempt from taxation under Section 501(a) of such code. The resource exclusion applies to any in-kind gift that is not converted to cash, or to a cash gift that does not exceed $2,000.
T. Funds received: Funds received from a government or nongovernmental agency, program, or health insurance policy whose purpose is to provide medical care or medical services or social services and conserved to pay for medical or social services.
[8.248.500.14 NMAC - Rp 8.248.500.14 NMAC, 7/1/2024]
8.248.500.15 INCOME STANDARDS: Income is anything the applicant/spouse receives in cash or in-kind that can be used to meet their needs for food or shelter. The gross income of the applicant, and their spouse if living together, but not dependent family members, will be considered. However, dependent family members will be counted in the family size.
[8.248.500.15 NMAC - Rp 8.248.500.15 NMAC, 7/1/2024]
8.248.500.16 EARNED INCOME:
A. Earned income: Earned income consists of the following types of payments:
(1) wages counted at the earliest of: when received, when credited to the person employed, or when set aside for the employee's use;
(2) net earnings from self-employment counted on a taxable year basis; net losses, if any, are deducted from other earned income, but not from unearned income;
(3) payments for services performed in a sheltered workshop or work activities center counted when received or set aside for the employee’s use;
(4) royalties earned by an individual in connection with any publication of their work and any honoraria received for services rendered; and
(5) in-kind earned income is counted based on current market value. If the applicant/spouse receives an item that is not fully paid for and they are responsible for the balance, only the paid up value is income to the applicant.
B. Period under consideration: The period for which earned income is counted is, in 2006, the remainder of the calendar year, starting with the month of application for the subsidy. Adjust prospective earned income based on the number of months remaining in the calendar year. The income standard against which the income is measured should be adjusted to reflect the same number of months. For subsidy applications filed in 2005, eligibility cannot begin prior to January 1, 2006.
C. Earned income exclusions: Earned income exclusions apply in the order listed below:
(1) refund of federal income taxes and payments under the earned income tax credit;
(2) the first $30 of earned income per calendar quarter that is received too irregularly or infrequently to be counted as income;
(3) any portion of the $20 per month exclusion that has not been excluded from combined unearned income;
(4) $65 per month of the applicant/spouse’s earned income;
(5) for applicants who are under age 65 and receive a social security disability insurance benefit based on disability, sixteen and three-tenths percent of gross earnings for impairment related work expenses (IRWE);
(6) one half of the applicant/spouse’s remaining earned income; and
(7) for applicants who are under age 65 and receive a social security disability insurance benefit that is based on blindness, twenty-five percent of gross earnings for blind work expenses (BWE).
[8.248.500.16 NMAC - Rp 8.248.500.16 NMAC, 7/1/2024]
8.248.500.17 UNEARNED INCOME: Unearned income is all income that is not earned income. Unearned income is counted at the earliest of the following points: when received, when credited to the recipient, or when set aside for the recipient’s use.
A. Unearned income includes, but is not limited to:
(1) social security;
(2) railroad retirement;
(3) veterans benefits;
(4) temporary assistance for needy families (TANF);
(5) pensions;
(6) annuities;
(7) alimony and support payments;
(8) rents;
(9) workmen’s compensation;
(10) in-kind support and maintenance;
(11) death benefits;
(12) royalties not counted as earned income; and
(13) dividends and interest not otherwise excluded under SSI rules.
B. Unearned income disregards:
(1) In-kind support and maintenance is any food and shelter that is given to the applicant/spouse or received because someone else pays for it. This includes room, rent, mortgage payments, real property taxes, heating fuel, gas, electricity, water, sewage, and garbage collection services. The maximum amount of income countable for in-kind support and maintenance is limited to one third of the monthly SSI benefit rate for an individual or a couple, if the applicant’s spouse is counted, or the current market value of the support, whichever is lower.
(2) When benefits are reduced for overpayments or garnishments, count the gross benefit before deductions.
(3) If part of a payment reflects expenses the applicant/spouse incurred in getting the payment, such as legal fees, damages, or medical expenses, incurred because of an accident, reduce the payment by the amount of the expenses. Do not reduce the payment by the amount of personal income taxes owed on the payment.
(4) Subtract from veterans benefits any amount included in the payment for a dependent. If the applicant/spouse is the dependent, count the portion of the benefit attributable to the dependent if they reside with the veteran or receive their own separate payment from the department of veteran affairs.
(5) Subtract from death benefits the expenses of the deceased person’s last illness and death paid by the recipient.
C. Unearned income exclusions: The following types of unearned income are not considered for purposes of determining LIS eligibility:
(1) SSI benefits;
(2) any public agency’s refund of taxes on real property or food;
(3) need-based assistance wholly funded by a state or one of its subdivisions, including state supplementation of SSI benefits but not a federal/state grant program such as TANF;
(4) any portion of a grant, scholarship, fellowship, or gift used for paying tuition, fees, or other educational expenses; any portion set aside or used for food, clothing or shelter is countable;
(5) food which the applicant or their spouse raise if it is consumed by them or their household;
(6) assistance received under the Disaster Relief and Emergency Assistance Act and assistance provided under any federal statute because of a catastrophe which the president of the United States declares to be a major disaster;
(7) Alaska longevity bonus payments made to an individual who is a resident of Alaska and who, prior to October 1, 1985, met the 25-year residency requirement for receipt of such payments in effect prior to January 1, 1983, and was eligible for SSI;
(8) payments for providing foster care to a child who was placed in the applicant’s home by a public or private nonprofit child placement or child care agency;
(9) any interest earned on excluded burial funds and any appreciation in the value of an excluded burial arrangement which are left to accumulate and become part of the separate burial fund;
(10) home energy assistance (any assistance related to meeting the costs of heating or cooling a home);
(11) one-third of support payments made to or for the applicant by an absent parent if the applicant is a child;
(12) the first $20 of any unearned income in a month other than income in the form of in-kind support and maintenance received in the household of another and income based on need;
(13) housing assistance-any assistance paid with respect to a dwelling unit under:
(a) the United States Housing Act of 1937;
(b) the National Housing Act;
(c) Section 101 of the Housing and Urban Development Act of 1965;
(d) Title V of the Housing Act of 1949; or
(e) Section 202(h) of the Housing Act of 1959;
(14) any interest accrued on and left to accumulate as part of the value of an excluded burial space purchase agreement;
(15) gift of a domestic travel ticket received by the applicant or their spouse and not converted to cash;
(16) payments made to the applicant or their spouse from a fund established by the state to aid victims of crime;
(17) relocation assistance provided to the applicant or their spouse by the state or local government that is comparable to relocation assistance provided under title II of the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970;
(18) hostile fire pay received from one of the uniformed services;
(19) the first $60 of unearned income received per calendar quarter that is received too irregularly or infrequently to be counted as income; or
(20) any dividends or interest earned on countable resources, any dividends or interest earned on resources excluded under a federal statute other than the Social Security Act, and any dividends or interest excluded under the Social Security Protection Act of 2004.
[8.248.500.17 NMAC - Rp 8.248.500.17 NMAC, 7/1/2024]
8.248.500.18 DEEMED INCOME: Deeming income from a spouse to their minor child(ren) or from one spouse to the other spouse when living in the same household, does not apply.
[8.248.500.18 NMAC - Rp 8.248.500.18 NMAC, 7/1/2024]
8.248.500.19 TOTAL COUNTABLE INCOME: Countable income is the sum of unearned income or earned income for the individual or spouse less disregards or exclusions. Only one earned income exclusion ($65 plus one half of the remainder) is applied and one $20 disregard is applied if using income from both spouses.
[8.248.500.19 NMAC - Rp 8.248.500.19 NMAC, 7/1/2024]
HISTORY OF 8.248.500 NMAC: [ RESERVED ]
History of Repealed Material: 8.248.500 NMAC - Income And Resource Standards (filed 1/13/2006) Repealed effective 7/1/2024.
Other: 8.248.500 NMAC - Income And Resource Standards (filed 1/13/2006) Replaced by 8.248.500 NMAC - Income And Resource Standards effective 7/1/2024.
TITLE 8 SOCIAL SERVICES
CHAPTER 248 MEDICAID ELIGIBILITY - MEDICARE DRUG COVERAGE (CATEGORY 048)
PART 600 BENEFIT DESCRIPTION
8.248.600 .1 ISSUING AGENCY: New Mexico Health Care Authority.
[8.248.600.1 NMAC - Rp 8.248.600.1 NMAC, 7/1/2024]
8.248.600 .2 SCOPE: The rule applies to the general public .
[8.248.600.2 NMAC - Rp 8.248.600.2NMAC, 7/1/2024]
8.248.600 .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 27-2-12 et. seq.NMSA 1978 ( Repl. Pamp. 1991). The legal basis for the low-income subsidy (LIS) program is the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA), Public Law 108-173. 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.
[8.248.600.3 NMAC - Rp 8.248.600.3NMAC, 7/1/2024]
8.248.600 .4 DURATION: Permanent.
[8.248.600.4 NMAC - Rp 8.248.600.4NMAC, 7/1/2024]
8.248.600 .5 EFFECTIVE DATE: July 1, 2024, unless a later date is cited at the end of a section.
[8.248.600.5 NMAC - Rp 8.248.600.5NMAC, 7/1/2024]
8.248.600 .6 OBJECTIVE: The objective of these regulations is to provide eligibility policy and procedures for the medicare part D - low income subsidy program.
[8.248.600.6 NMAC - Rp 8.248.600.6NMAC, 7/1/2024]
8.248.600 .7 DEFINITIONS: [ RESERVED ]
8.248.600 .8 [ RESERVED ]
8.248.600.9 GENERAL BENEFIT DESCRIPTION: An individual or couple who is determined eligible for the low income subsidy (LIS) under part D of medicare , is eligible for financial assistance with the monthly premium, the yearly deductible, the per-prescription co-payment, and continuous coverage with no gap prior to reaching $3,600 in out-of-pocket spending. The financial assistance may be full or partial depending on the income, family size and resources of the beneficiary.
[8.248.600.9 NMAC - Rp 8.248.600.9NMAC, 7/1/2024]
8.248.600.10 BENEFIT DETERMINATION: Completed applications must be acted upon and notice of approval, denial, or delay sent out within 45 days of the date of application. The applicant will have time limits explained and be informed of the date by which the application should be processed.
[8.248.600.10 NMAC - Rp 8.248.600.10NMAC, 7/1/2024]
8.248.600.11 INITIAL BENEFITS: Eligibility is always prospective and begins the month of application, but not earlier than January 1, 2006. When an eligibility determination is made, notice of the approval or denial is sent to the individual. If the application is denied, the notice shall include reason for denial and the applicant's right to request a fair hearing.
[8.248.600.11 NMAC - Rp 8.248.600.11NMAC, 7/1/2024]
8.248.600.12 ONGOING BENEFITS: The applicant/recipient is responsible to report changes affecting eligibility within 10 days of when the change took place. A re-determination of eligibility is made every 12 months. If a LIS recipient/applicant becomes eligible for certain medicaid categories; SSI, QMB, SLIMB, QI-1, WDI, IC, and HCBW, they will still be eligible for LIS. CMS will notify the beneficiary that they are now deemed eligible, because of categorical relatedness and will take over the re-determination of eligibility on a yearly basis. A change notice will be sent to the LIS recipient. For the year 2006, all certification periods will end December 31, 2006. Effective January 1, 2007, the certification period will be 12 months from the month of application or re-certification.
[8.248.600.12 NMAC - Rp 8.248.600.12NMAC, 7/1/2024]
8.248.600.13 RETROACTIVE BENEFIT COVERAGE: There is no three month retroactive LIS coverage under this program. The subsidy is effective the beginning of the month of application or January 1, 2006, whichever is later.
[8.248.600.13 NMAC - Rp 8.248.600.13NMAC, 7/1/2024]
HISTORY OF 8.248.600 NMAC: [ RESERVED ]
History of Repealed Material: 8.248.600 NMAC - Benefit Description (filed 1/13/2006) Repealed effective 7/1/2024.
Other: 8.248.600 NMAC - Benefit Description (filed 1/13/2006) Replaced by 8.248.600 NMAC - Benefit Description effective 7/1/2024.
TITLE 8 SOCIAL SERVICES
CHAPTER 249 MEDICAL ASSISTANCE PROGRAM ELIGIBILITY - REFUGEE MEDICAL ASSISTANCE (RMA) PROGRAM
PART 400 RECIPIENT REQUIREMENTS
8.249.400.1 ISSUING AGENCY: New Mexico Health Care Authority (HCA).
[8.249.400.1 NMAC - Rp, 8.249.400.1 NMAC, 1/1/2014 ; A, 7/1/2024 ]
8.249.400.2 SCOPE: The rule applies to the general public .
[8.249.400.2 NMAC - Rp, 8.249.400.2 NMAC, 1/1/2014]
8.249.400.3 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 Section 27-1-12 et seq . NMSA 1978. 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.
[8.249.400.3 NMAC - Rp , 8.249.400.3 NMAC, 1/1/ 2014 ; A, 7/1/2024 ]
8.249.400.4 DURATION: Permanent.
[8.249.400.4 NMAC - Rp, 8.249.400.4 NMAC, 1/1/2014]
8.249.400.5 EFFECTIVE DATE: January 1, 2014, unless a later date is cited at the end of a section.
[8.249.400.5 NMAC - Rp, 8.249.400.5 NMAC, 1/1/2014]
8.249.400.6 OBJECTIVE: The objective of this rule is to provide specific instructions when determining eligibility for the medicaid program and other health care programs. Generally, applicable eligibility rules are detailed in the medical assistance division (MAD) eligibility policy manual 8.200 NMAC, Medicaid Eligibility - General Recipients Policies . Processes for establishing and maintaining medicaid eligibility are detailed in the income support division (ISD) general provisions policy manual 8.100 NMAC, General Provisions for Public Assistance Programs . Refugee medical assistance (RMA): The RMA offers health coverage for a refugee within the first twelve months from their date of entry to the United States (U.S.) when they do not qualify for other medicaid eligibility categories. An RMA eligible refugee has access to a benefit package that parallels the full medicaid services. This program is not funded by medicaid ; funds are provided through a grant under Title IV of the Immigration and Nationality Act. The purpose of this grant is to provide for the effective resettlement of a refugee and to assist him or her to achieve economic self-sufficiency as quickly as possible.
[8.249.400.6 NMAC - Rp, 8.249.400.6 NMAC, 1/1/2014; A, 1/1/2023]
8.249.400.7 DEFINITIONS: “Refugee” is an immigrant, who because of persecution or fear of persecution on account of race, religion or political opinion, fled from their home country and cannot return because of fear of persecution because of race, religion or political opinion.
[8.249.400.7 NMAC - N, 1/1/2014; A, 1/1/2023]
8.249.400.8 MISSION: To transform lives. Working with our partners, we design and deliver innovative, high quality health and human services that improve the security and promote independence for New Mexicans in their communities.
[8.249.400.8 NMAC - N, 1/1/2014; A, 1/1/2022]
8.249.400.9 REFUGEE MEDICAL ASSISTANCE ONLY - CATEGORY 049 AND 059:
A. A medicaid eligible refugee recipient must meet the following non-financial eligibility requirements:
(1) is ineligible for full medicaid coverage;
(2) is not a full-time student in an institution of higher education, except where enrollment is part of an individual employability plan for a refugee enrolled in the refugee cash assistance program;
(3) is in the U.S. fewer than twelve months and meets one of the following statuses:
(a) is admitted as a refugee under Section 207 of the Immigration and Nationality Act;
(b) is paroled into the U.S. as a refugee or asylee under Section 212 (d)(5) of the Immigration and Nationality Act;
(c) is granted asylum under Section 208 of the Immigration and Nationality Act;
(d) is admitted as an Amerasian immigrant from Vietnam through the orderly departure program, under Section 584 of the Foreign Operations Appropriations Act, incorporated in the fiscal year 1988 Continuing Resolution P.L. 100-212;
(e) is a Cuban-Haitian entrant who was admitted as a public interest parolee under Section 212 (d)(5) of the Immigration and Nationality Act;
(f) is certified as a victim of human trafficking by the federal office of refugee resettlement (ORR);
(g) is an eligible family member of a victim of human trafficking certified by ORR who has a T-2, T-3, T-4, or T-5 Visa;
(h) is admitted as a special immigrant from Iraq or Afghanistan under Section 101 (a)(27) of the Immigration and Nationality Act; or
( i ) is a lawful permanent resident (LPR) when the individual had previously met a status as listed in Subparagraphs (a) through (h) above;
(4) an individual who meets the following eligibility requirements pursuant to 8.200.410 NMAC and 8.200.420 NMAC of citizenship or non-citizen status, enumeration, residence, non-concurrent receipt of assistance and applications for other benefits;
(5) appropriate to the size of the budget group (not including the ineligible parent due to citizenship or non-citizen status or enumeration), countable gross income must be less than one hundred and eighty-five percent of the standard of need (SON) countable net income must be less than the SON pursuant to 8.200.520 NMAC and 8.202.500 NMAC; and
(6) an applicant or an eligible recipient may have other creditable health insurance coverage.
B. An eligible recipient may have other creditable health insurance coverage. If the eligible recipient has other creditable health insurance coverage, RMA is the second payor.
C. An individual who is an inmate of a public institution is not eligible pursuant to 8.200.410 NMAC .
[8.249.400.9 NMAC - Rp, 8.249.400.9 NMAC, 1/1/2014; A, 1/1/2022; A, 1/1/2023]
8.249.400.10 BASIS FOR DEFINING GROUP: At the time of application, an applicant or an eligible recipient and HSD shall identify everyone who is to be considered for inclusion in the assistance unit and budget group. Each member of the assistance unit and budget group, including each unborn child, is counted as one in the household size.
[8.249.400.10 NMAC - Rp, 8.249.400.10 NMAC, 1/1/2014]
8.249.400.11 [ RESERVED ]
8.249.400.12 ENUMERATION: Refer to 8.200.410.10 NMAC.
[8.249.400.12 NMAC - Rp, 8.249.400.12 NMAC, 1/1/2014]
8.249.400.13 CITIZENSHIP: Refer to 8.200.410.11 NMAC.
[8.249.400.13 NMAC - Rp, 8.249.400.13 NMAC, 1/1/2014]
8.249.400.14 RESIDENCE: Refer to 8.200.410.12 NMAC.
[8.249.400.14 NMAC - Rp, 8.249.400.14 NMAC, 1/1/2014]
8.249.400.15 [ RESERVED ]
8.249.400.16 [ RESERVED ]
8.249.400.17 AGE: Age is not an eligibility requirement.
[8.249.400.17 NMAC - Rp, 8.249.400.17 NMAC, 1/1/2014]
8.249.400.18 NON-CITIZEN SPONSORSHIP: The income support division (ISD) caseworker must notify the refugee’s sponsor or local affiliate which provided for the resettlement of the refugee, when a refugee applies for refugee medical assistance.
[8.249.400.18 NMAC - Rp, 8.249.400.18 NMAC, 1/1/2014; A, 1/1/2022]
8.249.400.19 RECIPIENT RIGHTS AND RESPONSIBILITIES: Refer to 8.200.430 NMAC.
[8.249.400.19 NMAC - Rp, 8.249.400.19 NMAC, 1/1/2014]
8.249.400.20 ASSIGNMENT OF SUPPORT:
A. Assignment of medical support: Refer to 8.200.420.12 NMAC.
B. Assignments of child support: Assignment of child support is not required for refugee medical assistance.
[8.249.400.20 NMAC - Rp, 8.249.400.20 NMAC, 1/1/2014]
8.249.400.21 REPORTING REQUIREMENTS: Refer to 8.200.430.19 NMAC.
[8.249.400.21 NMAC - Rp, 8.249.400.21 NMAC, 1/1/2014]
8.249.400.22 ELIGIBLE ASSISTANCE UNIT: The assistance unit includes individuals who apply for RMA and who are determined eligible. I ndividuals may be ineligible for refugee cash assistance and eligible for RMA. An eligible recipient of refugee cash assistance who is not eligible for full medicaid services is eligible for RMA.
[8.249.400.22 NMAC - N, 1/1/2014]
8.249.400.23 BUDGET GROUP: The budget group includes all members of the assistance unit. Additional budget group members include individuals who live in the household with the assistance unit and have a financial obligation of support.
A. Except for an supplemental security income (SSI) recipient, the following individuals have a financial obligation of support for medicaid eligibility:
(1) spouses: married individuals as defined under applicable New Mexico state law (New Mexico recognizes common law and same sex marriages established in other states); and
(2) parents for children: there is a presumption that a child born to a married woman is the child of the spouse, or if the individual established parentage by some other legally recognized process.
B. The following individuals do not have a financial obligation of support for medicaid eligibility:
(1) an SSI recipient to the assistance unit;
(2) a f ather of the unborn child who is not married to the pregnant woman;
(3) a stepparent to a stepchild;
(4) a grandparent to a grandchild;
(5) a legal guardian or a conservator of a child;
(6) a non-citizen sponsor to the assistance unit; and
(7) a sibling to a sibling.
C. Budget group earned income disregards and child care deductions vary based on the age group of the child. Refer to 8.232.500 NMAC.
[8.249.400.23 NMAC - N, 1/1/2014; A, 1/1/2022]
8.249.400.24 LIVING IN THE HOME
A. To be included in the assistance unit and budget group, an individual must be living, or considered to be living, in the budget group’s home.
B. A child considered to be living in the home: A child is considered to be part of the budget group as evidenced by the child's customary physical presence in the home. If a child is living with more than one household, the following applies:
(1) when the child is actually spending more time with one household than the other, the child would be determined to be living with the household with whom the child spends the most time; or
(2) when the child is actually spending equal amounts of time with each household, the child shall be considered to be living with the household who first applies for medicaid enrollment.
C. Extended living in the home: An individual may be physically absent from the home for longer or shorter periods of time and be a member of the assistance unit and budget group.
(1) Extended living in the home includes:
(a) when an individual is attending college or boarding school; or
(b) when an individual is receiving treatment in a Title XIX medicaid facility, including institutionalized when meeting a nursing facility (NF) level of care (LOC) and intermediate care facilities for individuals with an intellectual disability (ICF-IID) LOC.
(2) When an individual has been a member of the assistance unit, eligibility for another medicaid eligibility category, such as long term care medicaid , should be evaluated; until a determination of eligibility for another category can be made, the individual is considered to be living with the budget group.
D. Temporary absence such as extended living in the home: An individual may be physically absent from the home and be a member of the assistance unit and budget group. These other temporary absences include:
(1) an individual not living in the home due to an emergency, who is expected to return to the household within 60 calendar days, continues to be a member of the household;
(2) a child removed from the home of a parent or a specified relative by a child protective services agency (tribal, bureau of Indian affairs, or children, youth and families department), until an adjudicatory custody hearing takes place; if the adjudicatory hearing results in custody being granted to some other entity, the child will be removed from the assistance unit; or
(3) a child residing in a detention center:
(a) continues to be a member of the household if they reside fewer than 60 calendar days, regardless of adjudication as an inmate of a public institution; or
(b) is not eligible for medicaid enrollment if they reside 60 calendar days or more as an adjudicated inmate of a public institution pursuant to 8.200.410 NMAC.
[8.249.400.13 NMAC - N, 1/1/2014]
HISTORY OF 8.249.400 NMAC:
Pre-NMAC History: The material in this part was derived from that previously filed with the State Records Center:
MAD Rule 822, Refugee Medical Assistance, filed 5/22/1992.
History of Repealed Material:
MAD Rule 822 Refugee Medical Assistance, filed 5/22/1992 - Repealed effective 2/1/1995.
8.249.400 NMAC Recipient Policies, filed 9/3/2013 - Repealed effective 1/1/2014.
TITLE 8 SOCIAL SERVICES
CHAPTER 249 MEDICAL ASSISTANCE PROGRAM ELIGIBILITY - REFUGEE MEDICAL ASSISTANCE (RMA) PROGRAM
PART 500 INCOME AND RESOURCE STANDARDS
8.249.500.1 ISSUING AGENCY: New Mexico Health Care Authority (HCA).
[8.249.500.1 NMAC - Rp, 8.249.500.1 NMAC, 1/1/2014; A, 7/1/2024]
8.249.500.2 SCOPE: The rule applies to the general public .
[8.249.500.2 NMAC - Rp, 8.249.500.2 NMAC, 1/1/2014]
8.249.500.3 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 Section 27-1-12 et seq . NMSA 1978. 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.
[8.249.500.3 NMAC - Rp , 8.249.500.3 NMAC, 1/1/ 2014 ; A, 7/1/2024 ]
8.249.500.4 DURATION: Permanent.
[8.249.500.4 NMAC - Rp, 8.249.500.4 NMAC, 1/1/2014]
8.249.500.5 EFFECTIVE DATE: January 1, 2014, unless a later date is cited at the end of a section.
[8.249.500.5 NMAC - Rp, 8.249.500.5 NMAC, 1/1/2014]
8.249.500.6 OBJECTIVE: The objective of this rule is to provide specific instructions when determining eligibility for the medicaid program and other health care programs. Generally, applicable eligibility rules are detailed in the medical assistance division (MAD) eligibility policy manual, specifically 8.200.400 NMAC, General Medicaid Eligibility . Processes for establishing and maintaining MAD eligibility are detailed in the income support division (ISD) general provisions 8.100 NMAC, General Provisions for Public Assistance Programs .
[8.249.500.6 NMAC - Rp, 8.249.500.6 NMAC, 1/1/2014]
8.249.500.7 DEFINITIONS: [ RESERVED ]
8.249.500.8 MISSION: To transform lives. Working with our partners, we design and deliver innovative, high quality health and human services that improve the security and promote independence for New Mexicans in their communities.
[8.249.500.8 NMAC - N, 1/1/2014; A, 1/1/2022]
8.249.500.9 NEED DETERMINATION:
A. Financial need: The budget group’s eligibility is based on financial need. See Section 1931 of the Social Security Act, the rules in this chapter and in 8.200.520 NMAC.
B. Financial eligibility: Pursuant to Section 1931 of the Social Security Act, enacted by Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA), a new medicaid financial eligibility standard was created. Refugee medical assistance (RMA) uses this same standard.
(1) Income eligibility criteria: The income eligibility criteria for Category 049 are based on New Mexico’s aid to families with dependent children (AFDC) program as of July 16, 1996. This is defined as the standard of need (SON) used in AFDC as of July 16, 1996. A refugee can be eligible for Category 059 if income would be below AFDC after deducting medical expenses incurred and paid in that month. Eligibility for Category 059 is determined on a month-to-month basis.
(2) Less restrictive income and resource methodology: Pursuant to Section 1931 of the Social Security Act, as a state option, New Mexico may use income and resource eligibility methodologies that are less restrictive than the AFDC methodologies used as of July 16, 1996. This chapter defines less restrictive methodologies to be used by New Mexico for resources, countable and excluded earned or unearned income, available or unavailable income and income deductions or disregards.
C. Gross and net income tests: Determining financial need is a two-step process. When the countable gross or net income is exactly equal to the income eligibility standards, eligibility does not exist.
(1) Gross income test: The first step is determining the countable gross income of the budget group. Gross income includes all countable income before taking into account taxes or deductions. Only self employment deductions are allowed in the gross income test. The calculated gross income must be less than one hundred and eighty-five percent of the SON. If the budget group's income is more than one hundred and eighty-five percent of the SON, the assistance unit is not eligible.
(2) Net income test: The second step is determining the countable net income of the budget group. From the countable gross income in step one, deduct all allowable work related expenses (WRE) and unearned income deductions/disregards. The countable net income must be less than the SON appropriate to the budget group size. If the budget group's income is more than the SON, the assistance unit is not eligible.
[8.249.500.9 NMAC - Rp, 8.249.500.9 NMAC, 1/1/2014; A, 1/1/2022]
8.249.500.10 RESOURCE STANDARDS: Resources are not an eligibility factor.
[8.249.500.10 NMAC - Rp, 8.249.500.10 NMAC, 1/1/2014]
8.249.500.11 INCOME STANDARDS: Refer to 8.249.500.9 NMAC.
[8.249.500.11 NMAC - Rp, 8.249.500.11 NMAC, 1/1/2014]
8.249.500.12 INCOME ELIGIBILITY: Income consists of money received by a person whose income is considered available to the budget group as described in this chapter.
A. Income from a 30 day-period is used to determine eligibility. The 30-day period may be any consecutive 30-day period that is prior to the date of the application through the date of timely disposition. The applicant and the caseworker must agree on the 30-day period. Income from a terminated source is not counted.
B. Income received less frequently than monthly: If an amount of gross income is received less frequently than monthly, that amount is converted to a monthly amount to determine financial eligibility. The conversion is obtained by dividing the total income by the number of months the income is intended to cover. For the purposes of this calculation, a partial month is considered to be one full month. This includes, but is not limited to, income from sharecropping, farming, and self-employment. It includes contract income as well as income for a tenured teacher who may not have a contract.
C. Use of conversion factors: Whenever a full month's income is received on a weekly or biweekly basis, the income is converted to a monthly amount. Income is rounded down to the nearest whole dollar prior to application of the conversion factor. Weekly income is multiplied by four and biweekly income is multiplied by two.
[8.249.500.12 NMAC - N, 1/1/2014]
8.249.500.13 AVAILABLE INCOME:
A. Determination of eligibility for the assistance unit is made by considering income that is available to the assistance unit and budget group. The amount of countable income is determined using allowable income exemptions, deductions and disregards. The income of a budget group member who is not included in the assistance unit is deemed available to the assistance unit.
B. Available income includes:
(1) income received by the budget group;
(2) income received by someone not included in the budget group for someone included in the budget group and which is available to the budget group;
(3) income that is withheld as a result of a garnishment or wage withholding; and
(4) income withheld by a source at the request of a budget group member.
[8.249.500.13 NMAC - N, 1/1/2014]
8.249.500.14 UNAVAILABLE INCOME:
A. Individuals included in the budget group may have a legal right to income but not access to it; such income is not counted as available income:
(1) old age, survivors, and disability insurance (OASDI);
(2) railroad retirement benefits (RRB);
(3) veterans administration (VA) benefits:
(a) income available to veterans and their dependents from the VA as compensation for service-connected disability;
(b) pension for non-service connected disability;
(c) dependency and indemnity compensation; and
(d) death benefits paid from a government issue (GI) life insurance;
(4) unemployment compensation benefits (UCB);
(5) military allotments;
(6) worker’s compensation;
(7) pension, annuity, and retirement benefits;
(8) union benefits;
(9) lodge or fraternal benefits;
(10) real property income that is not earned income;
(11) shared shelter and utility payments when the budget group shares shelter with others:
(a) payments which exceed the budget group’s cost are considered income;
(b) payments which are less than the budget group’s cost are not considered; these are the others’ share of the shelter cost and are treated as pass-through payments;
(12) income from the sale of goods or property which are obtained in finished condition;
(13) child support payments received directly by the budget group and retained for its use;
(14) settlement payments which are received from worker’s compensation settlements, insurance claims, damage claims, litigation, trust distributions which are made on a recurring basis;
(15) individual Indian monies (IIM) payments received and distributed by the bureau of Indian affairs (BIA) as a trustee for an individual member of a tribe;
(16) bureau of Indian affairs (BIA) or tribal general assistance (GA) payments; and
(17) income that is not listed as available in this chapter where the budget group cannot gain access to the income; this includes wages withheld by an employer that refuses to pay.
B. Individuals may receive payment of funds “passed through” the individual for the benefit of someone other than themselves. Such pass through payments are not considered available.
C. A recipient of supplemental security income (SSI) is not part of the budget group. His other income is not considered available to the budget group.
D. Non-citizen sponsor deeming is not applicable pursuant to 8.200.410 NMAC.
[8.249.500.14 NMAC - N, 1/1/2014; A, 1/1/2022]
8.249.500.15 EARNED INCOME: Includes all wages, salaries, tips, and other employee pay from employment and net earnings from self-employment.
[8.249.500.15 NMAC - N, 1/1/2014]
8.249.500.16 EARNED INCOME DEDUCTIONS/DISREGARDS:
A. Self employment : Certain self-employment deductions allowed by the federal internal revenue service (IRS) are allowed in the net and gross income test.
(1) Self-employment income will be annualized for income projection purposes. If the IRS Form 1040 has been filed, the previous year’s tax return is used to anticipate future income, if no significant changes in circumstances have occurred. An alternative method of income anticipation should be used when the amount of self employment income reported on tax returns would no longer be a good indicator of expected income, i.e., loss of cattle or crops due to disease.
(2) If tax returns are used for annualized projected income, self-employment expenses listed on the return are allowable except:
(a) the mileage allowance is the New Mexico department of finance and administration (DFA) rate as detailed in 2.42.2 NMAC unless proof that the actual expense is greater; and
(b) no deduction is allowed for rent or purchase of the place of business if the individual operates the business out of his or her residence, unless the individual can demonstrate that the expense has been allowed under federal income tax guidelines.
(3) The following deductions are not allowed:
(a) depreciation;
(b) personal business and entertainment expenses;
(c) personal transportation to and from work;
(d) purchase of capital equipment; and
(e) payments on the principal of loans for capital assets or durable goods.
B. WRE income disregards: The WRE disregard of $120 and one third of the remaining balance is disregarded from earned income during the net income test.
C. Child care expenses:
(1) To be eligible for a child care deduction, the child receiving the care must be:
(a) a dependent of the employed person;
(b) younger than 13; and
(c) included in the budget group.
(2) Standards: Actual costs of child care, not to exceed the applicable limits set forth below are deducted from earnings. The amount to be deducted depends upon whether the person is employed full or part-time and the age of the child. Full-time employment is considered to be 30 hours or more of employment per week; part time is any employment of less than 30 hours per week.
(a) up to $200 per month per child if the person is employed full-time and the child is under age two;
(b) up to $100 per month per child if the person is employed part-time and the child is under age two;
(c) up to $175 per month per child if the person is employed full-time and the child’s age is two through12; and
(d) up to $87.50 per month per child if the person is employed part-time and the child’s age is two through 12.
(3) Third party child care payments: Child care costs paid by third parties directly to the child care provider cannot be used as child care deductions. Such payments are classified as vendor payments and are not counted as income. If such payments do not meet the full cost of child care, the difference between the deduction and the vendor payment is the amount allowed, up to the stated child care deductions in Paragraph (2) of Subsection C of 8.249.500.16 NMAC. If the third party child care payments are made to the budget group, the payments would be treated as pass through payments and not counted.
[8.249.500.16 NMAC - N, 1/1/2014; A, 1/1/2022]
8.249.500.17 UNEARNED INCOME: Unearned income includes benefits, pensions, etc.
A. The following types of unearned income are counted:
(1) old age, survivors, and disability insurance (OASDI);
(2) railroad retirement benefits (RRB);
(3) veterans administration (VA) benefits:
(a) income available to veterans and their dependents from the VA as compensation for service-connected disability;
(b) pension for non-service connected disability;
(c) dependency and indemnity compensation; and
(d) death benefits paid from a government issue (GI) life insurance;
(4) unemployment compensation benefits (UCB);
(5) military allotments;
(6) worker’s compensation;
(7) pension, annuity, and retirement benefits;
(8) union benefits;
(9) lodge or fraternal benefits;
(10) real property income that is not earned income;
(11) shared shelter and utility payments when the budget group shares shelter with others:
(a) payments which exceed the budget group’s cost are considered income;
(b) payments which are less than the budget group’s cost are not considered; these are the others’ share of the shelter cost and are treated as pass-through payments;
(12) income from the sale of goods or property which are obtained in finished condition;
(13) child support payments received directly by the budget group and retained for its use;
(14) settlement payments which are received from worker’s compensation settlements, insurance claims, damage claims, litigation, trust distributions which are made on a recurring basis;
(15) individual Indian monies (IIM) payments received and distributed by the bureau of Indian affairs (BIA) as a trustee for an individual member of a tribe; and
(16) bureau of Indian affairs (BIA) or tribal general assistance (GA) payments.
B. The following types of unearned income are not considered in determining eligibility:
(1) cash assistance from HSD or a tribal entity;
(2) supplemental nutritional assistance program (SNAP);
(3) low income home energy assistance program (LIHEAP);
(4) foster care or adoption subsidy;
(5) supplemental security income (SSI);
(6) Child Nutrition and National School Lunch Act;
(7) nutrition programs for the elderly, including meals on wheels and lunches at senior citizen’s centers;
(8) bona fide loans from private individuals and commercial institutions as well as loans for the purpose of educational assistance;
(9) work study funds paid by an educational institution, when the purpose is to assist with educational expenses, regardless of the actual use of the funds;
(10) domestic volunteers compensation or any other payments made to or on behalf of volunteers under the Domestic Volunteers Services Act of 1973 including:
(a) volunteers in service to America (VISTA);
(b) university year for action (UYA);
(c) special volunteer programs (SVP);
(d) retired senior volunteer program (RSVP);
(e) foster grandparents program (FGP);
(f) older American community service program (OACSP);
(g) service corps of retired executives (SCORE); and
(h) active corps of executives (ACE);
(11) state and federal income tax returns;
(12) American Indian payments including:
(a) per capita payments distribution of tribal funds to an Indian tribe member by the tribe or by the secretary of the United States department of the interior;
(b) interest derived from retained per capita payments (if kept separately identifiable); and
(c) tribal land claims payments settled by means of case payments;
(13) Job Training Partnership Act of 1982 (JTPA) payments made to dependent children;
(14) Title II Uniform Relocation Assistance and Real Property Acquisition Act of 1970 payments;
(15) supportive service payments made for reimbursement of transportation, child care, or training related expenses under NMW work programs, tribal work programs, and other employment assistance programs;
(16) division of vocational rehabilitation (DVR) training payments made by the for training expenses;
(17) gifts, donations or contribution from other agencies which are intended to meet needs not covered as a benefit; to be exempt, the payment must:
(a) be paid under the auspices of an organization or non-profit entity; and
(b) be for a specific identified purpose, to supplement not duplicate covered benefits for the intended beneficiary of the donation/contribution;
(18) educational loans and grants intended for educational expenses; regardless of actual utilization of the funds;
(19) agent orange settlement fund payments or any fund established pursuant to the agent orange product liability litigation settlement;
(20) radiation exposure compensation settlement fund payments;
(21) Nazi victim payments made to individuals per P.L. 103-286, August 1, 1994; and
(22) vendor payments made on behalf of a budget group member when an individual or organization outside the budget group uses its own funds to make a direct payment to a budget group’s service provider.
[8.249.500.17 NMAC - N, 1/1/2014]
HISTORY OF 8.249.500 NMAC:
Pre-NMAC History: The material in this part was derived from that previously filed with the State Records Center:
MAD Rule 822, Refugee Medical Assistance, filed 5/22/1992.
History of Repealed Material:
MAD Rule 822 Refugee Medical Assistance, filed 5/22/1992 - Repealed effective 2/1/1995.
8.249.500 NMAC, Income and Resource Standards, filed 3/25/2010 - Repealed effective 1/1/2014.
TITLE 8 SOCIAL SERVICES
CHAPTER 249 MEDICAL ASSISTANCE PROGRAM ELIGIBILITY - REFUGEE MEDICAL ASSISTANCE (RMA) PROGRAM
PART 600 BENEFIT DESCRIPTION
8.249.600.1 ISSUING AGENCY: New Mexico Health Care Authority (HCA).
[8.249.600.1 NMAC - Rp, 8.249.600.1 NMAC, 1/1/2019; A, 7/1/2024]
8.249.600.2 SCOPE: The rule applies to the general public .
[8.249.600.2 NMAC - Rp, 8.249.600.2 NMAC, 1/1/2019]
8.249.600.3 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 Section 27-1-12 et seq ., NMSA 1978. 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.
[8.249.600.3 NMAC - Rp , 8.249.600.3 NMAC, 1/1/ 2019 ; A, 7/1/2024 ]
8.249.600.4 DURATION: Permanent.
[8.249.600.4 NMAC - Rp, 8.249.600.4 NMAC, 1/1/2019]
8.249.600.5 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.
[8.249.600.5 NMAC - Rp, 8.249.600.5 NMAC, 1/1/2019]
8.249.600.6 OBJECTIVE: The objective of this rule is to provide specific instructions when determining eligibility for the medicaid program and other health care programs. Generally, applicable eligibility rules are detailed in the medical assistance division (MAD) eligibility policy manual, specifically 8.200.400 NMAC, General Medicaid Eligibility . Processes for establishing and maintaining MAD eligibility are detailed in the income support division (ISD) general provisions 8.100 NMAC, General Provisions for Public Assistance Programs .
[8.249.600.6 NMAC - Rp, 8.249.600.6 NMAC, 1/1/2019]
8.249.600.7 DEFINITIONS: [ RESERVED ]
8.249.600.8 [RESERVED]
[8.249.600.8 NMAC – Rp, 8.249.600.8 NMAC, 1/1/2019]
8.249.600.9 BENEFIT DESCRIPTION: Refugee medical assistance ( RMA) offers health coverage for refugees within the first twelve months from their date of entry to the United States, when they do not qualify for medicaid . RMA eligible refugees have access to a benefit package that parallels the full coverage medicaid benefit package. This program is not funded by medicaid . RMA is funded through a grant under Title IV of the Immigration and Nationality Act. The purpose of this grant is to provide for the effective resettlement of refugees and to assist them to achieve economic self-sufficiency as quickly as possible. Refer to 8.100.100 NMAC.
[8.249.600.9 NMAC - Rp, 8.249.600.9 NMAC, 1/1/2019; A, 1/1/2023]
8.249.600.10 BENEFIT DETERMINATION: Application for refugee medical assistance is made on the assistance application form. The application is acted on and notice of the action sent to the applicant within 45 days of the date of application.
[8.249.600.10 NMAC - Rp, 8.249.600.10 NMAC, 1/1/2019]
8.249.600.11 INITIAL BENEFITS:
A. Approval or denial of application: After the eligibility determination is made, the income support specialist (ISS) sends notice to the applicant or applicant group. The denial notice contains information on the reason for the denial and explanation of appeal rights to the applicant(s).
B. Date of eligibility: Eligibility starts with the first day of the month of application after all eligibility requirements are met. The twelve-month period begins with the month the refugee enters the United States, as documented by the immigration and naturalization service (INS) (form I-94). For cases involving children born in the United States, the child’s eligibility period expires when the refugee parent who arrived last in the United States has been in this country for twelve months.
[8.249.600.11 NMAC - Rp, 8.249.600.11 NMAC, 1/1/2019; A, 1/1/2023]
8.249.600.12 ONGOING BENEFITS: No periodic review is required, since coverage is limited to a maximum of twelve months from the date of entry into the United States.
[8.249.600.12 NMAC - Rp, 8.249.600.12 NMAC, 1/1/2019; A, 1/1/2023]
8.249.600.13 RETROACTIVE BENEFIT COVERAGE: Retroactive medicaid coverage is provided in accordance with 8.200.400.14 NMAC.
[8.249.600.13 NMAC - Rp, 8.249.600.13 NMAC, 1/1/2019]
8.249.600.14 CASE CLOSURES: Cases are closed when refugee medical assistance recipients no longer meet eligibility standards or after the twelve-month eligibility period expires, whichever comes first.
[8.249.600.14 NMAC - Rp, 8.249.600.14 NMAC, 1/1/2019; A, 1/1/2023]
8.249.600.15 CHANGES AND REDETERMINATIONS OF ELIGIBILITY:
A. A re-determination of eligibility is not required.
B. Changes in income are not reportable. Reported income changes are not acted upon.
C. A refugee who received medicaid for eleven or fewer months during the RMA period is eligible for RMA for any remaining months in the twelve-month RMA period. Eligibility for RMA is determined without a new eligibility determination or application.
D. Residence changes must be reported within 10 days after the change for individuals placed in a public institution or those individuals moving out of New Mexico. Refer to 8.200.450 NMAC.
[8.249.600.15 NMAC – Rp, 8.249.600.15 NMAC, 1/1/2019; A, 1/1/2023]
HISTORY OF 8.249.600 NMAC:
Pre-NMAC History: The material in this part was derived from that previously filed with the State Records Center:
MAD Rule 822, Refugee Medical Assistance, filed 5/22/1992.
History of Repealed Material:
MAD Rule 822, Refugee Medical Assistance, filed 5/22/1992 - Repealed effective 2/1/1995.
8.249.600 NMAC, Benefit Description, filed 9/3/2013 - Repealed effective 1/1/2014.
8.249.600 NMAC - Benefit Description, filed 12/2/2013 - Repealed effective 1/1/2019.
TITLE 8 SOCIAL SERVICES
CHAPTER 250 MEDICAL ASSISTANCE PROGRAM ELIGIBILITY – QUALIFIED INDIVIDUALS WHOSE INCOME EXCEEDS QMB AND SLIMB
PART 400 RECIPIENT REQUIREMENTS
8.250.400.1 ISSUING AGENCY: New Mexico Health Care Authority.
[8.250.400.1 NMAC - Rp, 8.250.400.1 NMAC, 1/1/2014; A, 7/1/2024]
8.250.400.2 SCOPE: The rule applies to the general public .
[8.250.400.2 NMAC - Rp, 8.250.400.2 NMAC, 1/1/2014]
8.250.400.3 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 Section 27-1-12 et seq ., NMSA 1978. 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.
[8.250.400.3 NMAC - Rp , 8.250.400.3 NMAC, 1/1/2014 ; A, 7/1/2024]
8.250.400.4 DURATION: Permanent.
[8.250.400.4 NMAC - Rp, 8.250.400.4 NMAC, 1/1/2014]
8.250.400.5 EFFECTIVE DATE: January 1, 2014, unless a later date is cited at the end of a section.
[8.250.400.5 NMAC - Rp, 8.250.400.5 NMAC, 1/1/2014]
8.250.400.6 OBJECTIVE: The objective of this rule is to provide specific instructions when determining eligibility for the medicaid program and other health care programs. Generally, applicable eligibility rules are detailed in the medical assistance division (MAD) eligibility, 8.200 NMAC, Medicaid Eligibility – General Recipient Policies Processes for establishing and maintaining medicaid eligibility are detailed in the income support division (ISD) general provisions, 8.100 NMAC, General Provisions for Public Assistance Programs .
[8.250.400.6 NMAC - Rp, 8.250.400.6 NMAC, 1/1/2014]
8.250.400.7 DEFINITIONS: [ RESERVED ]
8.250.400.8 MISSION: To transform lives. Working with our partners, we design and deliver innovative, high quality health and human services that improve the security and promote independence for New Mexicans in their communities.
[8.250.400.8 NMAC - Rp, 8.250.400.8 NMAC, 1/1/2014; A, 1/1/2022]
8.250.400.9 QUALIFIED INDIVIDUALS 1 (QI1s) - CATEGORY 042: Medical assistance division (MAD) pays the monthly medicare Part B insurance premium for eligible recipients with income between one hundred and twenty percent and one hundred and thirty-five percent of the federal poverty level (FPL) who are not otherwise eligible for another medical assistance program category of eligibility (QI1s). A QI1 recipient must be covered by medicare Part A. The Part A insurance is a free entitlement to social security beneficiaries who are 65 years of age or older or who have received social security disability payments for 24 months. Fully or currently insured workers, or their dependents, with end-stage renal disease are also covered under medicare . Eligible recipients will be served on a first come, first served basis, contingent upon availability of federal funds. Eligibility will be offered to individuals on a yearly basis. After 1998, eligible recipients currently enrolled in the program will get the first opportunity to continue to receive benefits under this program.
[8.250.400.9 NMAC - Rp, 8.250.400.9 NMAC, 1/1/2014; A, 1/1/2022]
8.250.400.10 BASIS FOR DEFINING THE GROUP: QI1s are individuals who would be qualified medicare beneficiaries (QMB) but for the fact that their income exceeds the income levels established for QMB and specified low income medicare beneficiaries (SLIMB). Income eligibility for the QI1s is at least one hundred and twenty percent of the FPL, but less than one hundred thirty-five percent. The state of New Mexico (the state) will permit all individuals to apply for assistance during a calendar year beginning 1998. However, because of the capped allotments, the state shall limit the number of participants in QI1s selected in a calendar year so that the aggregate amount of benefits provided to such individuals in the calendar year is estimated not to exceed the state’s allocation for the fiscal year ending in that calendar year. The state shall select QI1s on a first-come, first-served basis (in the order in which they apply). For calendar years after 1998, the state shall give preference to individuals who were QI1s, QMBs, SLIMBs, or qualified disabled working individuals (QDWI) in the last month of the previous year and who continue to be or become QI1s.
[8.250.400.10 NMAC - Rp, 8.250.400.10 NMAC, 1/1/2014; A, 1/1/2022]
8.250.400.11 [ RESERVED ]
8.250.400.12 ENUMERATION: QI1 applicants or re-determining recipients must furnish their social security numbers (SSN). QI1 eligibility shall be denied or terminated for applicants or re-determining recipients who fail to furnish social security numbers.
[8.250.400.12 NMAC - Rp, 8.250.400.12 NMAC, 1/1/2014]
8.250.400.13 CITIZENSHIP:
A. Undocumented non-citizens cannot purchase medicare coverage and, therefore, are not eligible for QI1 benefits. To be eligible for QI1 an applicant or re-determining recipient must be one of the following:
(1) a citizen of the United States; or
(2) a non-citizen who entered the United States prior to August 22, 1996, as one of the classes of non-citizens described in 8.200.410 NMAC or a non-citizen who entered the United States as a qualified non-citizen on or after August 22, 1996, and who has met the five year bar listed in 8.200.410 NMAC.
B. Verification of citizenship: Individuals entitled to or receiving medicare already meet citizenship and identity requirements.
[8.250.400.13 NMAC - Rp, 8.250.400.13 NMAC, 1/1/2014; A, 1/1/2022]
8.250.400.14 RESIDENCE: An individual must physically present in New Mexico on the date of his or her application or re-determination or on the eligibility determination date and intends to remain in the state. If the applicant or re-determining recipient does not have the present mental capacity to declare intent, the parent, guardian, or adult child can assume responsibility for a declaration of intent. If there is no guardian or relative to assume responsibility for a declaration of intent, the state in which the applicant or re-determining recipient is living is recognized as the state of residence. A temporary absence from the state does not preclude eligibility. A temporary absence is considered to exist when the eligible recipient leaves the state for a specific purpose with a time-limited goal, after the accomplishment of which the eligible recipient intends to return to New Mexico. Refer to 8.200.410.12 NMAC.
[8.250.400.14 NMAC - Rp, 8.250.400.14 NMAC, 1/1/2014]
8.250.400.15 NONCONCURRENT RECEIPT OF ASSISTANCE: An applicant or re-determining recipient is not eligible for Category 042 if he or she is eligible under another medical assistance category of eligibility or if receiving medicaid services from another state.
[8.250.400.15 NMAC - Rp, 8.250.400.15 NMAC, 1/1/2014]
8.250.400.16 SPECIAL RECIPIENT REQUIREMENTS: An applicant or re-determining recipient for QI1 eligibility must meet the specified age or disability requirements to be eligible for medicare Part A.
[8.250.400.16 NMAC - Rp, 8.250.400.16 NMAC, 1/1/2014]
8.250.400.17 RECIPIENT RIGHTS AND RESPONSIBILITIES: It is the responsibility of the applicant or re-determining recipient to provide the required information, documents or undertake the actions necessary for HSD to establish eligibility. The applicant or re-determining recipient must grant HSD permission to contact other persons, agencies or sources of information which are necessary in the establishment of eligibility. Failure of the applicant or re-determining recipient to provide or take action will result in a HSD action to deny eligibility.
[8.250.400.17 NMAC - Rp, 8.250.400.17 NMAC, 1/1/2014]
8.250.400.18 [ RESERVED ]
8.250.400.19 REPORTING REQUIREMENTS: An applicant, re-determining or eligible recipient must report any change in his or her circumstances which can affect his or her eligibility within 10 calendar days after the change to his or her local income support division (ISD) office. Refer to 8.200.430.19 NMAC.
[8.250.400.19 NMAC - Rp, 8.250.400.19 NMAC, 1/1/2014]
HISTORY OF 8.250.400 NMAC:
History of Repealed Material:
8.250.400 NMAC, Recipient Policies, filed 11/16/2009 - Repealed effective 1/1/2014.
TITLE 8 SOCIAL SERVICES
CHAPTER 250 MEDICAL ASSISTANCE PROGRAM ELIGIBILITY - QUALIFIED DISABLED INDIVIDUALS
PART 500 INCOME AND RESOURCE STANDARDS
8.250.500.1 ISSUING AGENCY: New Mexico Health Care Authority.
[8.250.500.1 NMAC - Rp, 8.250.500.1 NMAC, 1/1/2014; A, 7/1/2024]
8.250.500.2 SCOPE: The rule applies to the general public .
[8.250.500.2 NMAC - Rp, 8.250.500.2 NMAC, 1/1/2014]
8.250.500.3 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 Section 27-1-12 et seq . NMSA 1978. 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.
[8.250.500.3 NMAC - Rp , 8.250.500.3 NMAC, 1/1/2014 ; A, 7/1/2024 ]
8.250.500.4 DURATION: Permanent.
[8.250.500.4 NMAC - Rp, 8.250.500.4 NMAC, 1/1/2014]
8.250.500.5 EFFECTIVE DATE: January 1, 2014, unless a later date is cited at the end of a section.
[8.250.500.5 NMAC - Rp, 8.250.500.5 NMAC, 1/1/2014]
8.250.500.6 OBJECTIVE: The objective of this rule is to provide specific instructions when determining eligibility for the medicaid program and other health care programs. Generally, applicable eligibility rules are detailed in the medical assistance division (MAD) eligibility policy manual, specifically 8.200.400 NMAC, General Medicaid Eligibility . Processes for establishing and maintaining MAD eligibility are detailed in the income support division (ISD) general provisions 8.100 NMAC, General Provisions for Public Assistance Programs .
[8.250.500.6 NMAC - Rp, 8.250.500.6 NMAC, 1/1/2014]
8.250.500.7 DEFINITIONS: [RESERVED]
8.250.500.8 MISSION: 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.
[8.250.500.8 NMAC - Rp, 8.250.500.8 NMAC, 1/1/2014]
8.250.500.9 QUALIFIED INDIVIDUALS 1 (QI1s) - CATEGORY 042: Medical assistance division ( MAD) pays the monthly medicare Part B insurance premium for qualified individuals (QI1s) with income between 120 percent and 135 percent of the federal poverty level and who are not otherwise eligible for another MAD category of eligibility. Eligible recipients will be served on a first come, first served basis, contingent upon availability of federal funds. Eligibility will be offered to individuals on a yearly basis. After 1998, eligible recipients currently enrolled in the program will get the first opportunity to continue to receive benefits.
[8.250.500.9 NMAC - N, 1/1/2014]
8.250.500.10 NEED DETERMINATION: An applicant or a re-determining recipient for the medical MAD eligibility Category 042 QI1s must apply for and take all necessary actions to obtain any resources to which he or she may be entitled. See 8.215.500 NMAC.
[8.250.500.10 NMAC - Rp, 8.250.500.9 NMAC, 1/1/2014]
8.250.500.11 RESOURCE STANDARDS: The value of an applicant or re-determining recipient’s countable resources must not exceed the amount set forth in 8.200.510 NMAC. The resource limit for an applicant or re-determining recipient couple is cannot exceed the amount for a couple set forth in 8.200.510 NMAC. An applicant or re-determining recipient with an ineligible spouse is eligible if the couple’s countable resources do not exceed the amount set forth in 8.200.510 NMAC, when resources are deemed. A resource determination is always made as of the first moment of the first day of the month. An applicant or re-determining recipient is ineligible for any month in which the countable resources exceed the current resource standard as of the first moment of the first day of the month. Changes in the amount of resources during a month do not affect eligibility for that month. See 8.215.500 NMAC for information on exclusions, disregards, and countable resources.
[8.250.500.11 NMAC - Rp, 8.250.500.10 NMAC, 1/1/2014]
8.250.500.12 RESOURCE TRANSFERS: The social security administration excluded transfer of resources as a factor of eligibility for a non-institutionalized recipient who receives supplemental security income (SSI) benefits. Transfer of resources is not a factor for consideration in categories that use SSI methodology in the eligibility determination.
[8.250.500.12 NMAC - Rp, 8.250.500.11 NMAC, 1/1/2014]
8.250.500.13 TRUSTS: See 8.281.510 NMAC.
[8.250.500.13 NMAC - Rp, 8.250.500.12 NMAC, 1/1/2014]
8.250.500.14 INCOME STANDARDS: Income standards for this category are at least 120 percent but less than 135 percent of the federal income poverty guidelines. The federal income poverty guidelines are adjusted annually, effective April 1. See 8.200.520 NMAC and 8.215.500 for information on exclusions, disregards and countable income. Verification of income must be documented in the case file.
[8.250.500.14 NMAC - Rp, 8.250.500.13 NMAC, 1/1/2014]
8.250.500.15 UNEARNED INCOME EXCLUSIONS: All social security and railroad retirement beneficiaries receive cost of living adjustments (COLAs) in January of each year. The ISD caseworker must disregard the COLA from January through March when determining or re-determining QI1s eligibility. For re-determinations made in January, February and March and for new QI1 applications registered in January, February or March, the ISD caseworker uses the December social security and railroad retirement benefit amounts. For QI1 applications registered from April through December, total gross income including the new COLA figures are used to determine income and compared to the new April federal poverty levels. This exclusion does not apply to other types of income.
[8.250.500.15 NMAC - Rp, 8.250.500.14 NMAC, 1/1/2014]
8.250.500.16 DEEMED INCOME: If an applicant or re-determining recipient is a minor who lives with a parent(s), deemed income from the parent(s) must be considered. If an applicant or re-determining recipient is married and lives with a spouse, deemed income from the spouse must be considered. See 8.215.500 NMAC for information on deemed income.
[8.250.500.16 NMAC - Rp, 8.250.500.15 NMAC, 1/1/2014]
HISTORY OF 8.250.500 NMAC:
History of Repealed Material:
8.250.500 NMAC, Income and Resource Standards, filed 11/16/2009 - Repealed effective 1/1/2014.
TITLE 8 SOCIAL SERVICES
CHAPTER 250 MEDICAID ELIGIBILITY - QUALIFIED INDIVIDUALS WHOSE INCOME EXCEEDS QMB AND SLIMB (CATEGORY 045)
PART 600 BENEFIT DESCRIPTION
8.250.600.1 ISSUING AGENCY: New Mexico Health Care Authority.
[8.250.600.1 NMAC - Rp, 8.250.600.1 NMAC, 1/1/2019; A, 7/1/2024]
8.250.600.2 SCOPE: The rule applies to the general public .
[8.250.600.2 NMAC - Rp, 8.250.600.2 NMAC, 1/1/2019]
8.250.600.3 STATUTORY AUTHORITY: New Mexico Statutes Annotated, 1978, (Chapter 27, Articles 1 and 2) authorizes the state to administer the medicaid program. Section 4732 of the 1997 Balanced Budget Act creates a separate group of eligible individuals, to be known as qualified individuals 1 (QI1s), with income between one hundred twenty percent and one hundred thirty-five percent of the federal poverty level. The benefit is limited to the payment of the monthly medicare part B insurance premium. Funding is available under one hundred percent federal block grant money. 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.
[8.250.600.3 NMAC - Rp , 8.250.600.3 NMAC, 1/1/2019 ; A, 7/1/2024]
8.250.600.4 DURATION: Permanent.
[8.250.600.4 NMAC - Rp, 8.250.600.4 NMAC, 1/1/2019]
8.250.600.5 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.
[8.250.600.5 NMAC - Rp, 8.250.600.5 NMAC, 1/1/2019]
8.250.600.6 OBJECTIVE: The objective of the qualified individuals 1 (QI1s) eligibility is for New Mexico medicaid to provide the payment of the monthly medicare part B insurance premium for individuals with income between one hundred twenty percent and one hundred thirty-five percent of the federal poverty level and who are not otherwise receiving medicaid under any other category of eligibility. Individuals will be served on a first come, first served basis, contingent upon availability of federal funds. Eligibility will be offered to individuals on a yearly basis. After 1998, individuals currently enrolled in the program will get the first opportunity to continue to receive benefits under this program.
[8.250.600.6 NMAC - Rp, 8.250.600.6 NMAC, 1/1/2019]
8.250.600.7 DEFINITIONS: [ RESERVED ]
8.250.600.8 [RESERVED]
[8.250.600.8 NMAC - Rp, 8.250.600.8 NMAC, 1/1/2019]
8.250.600.9 BENEFIT DESCRIPTION: Most individuals 65 or older receive free medicare part A. Those who do not receive free part A can voluntarily enroll for hospital insurance coverage and pay the monthly premium. Medicaid does not pay the medicare part A monthly premium for this category of recipients. Voluntary enrollees for premium/conditional medicare part A must enroll for supplementary medical insurance, medicare part B, and pay that premium also. After an application for QI benefits is approved, medicaid begins to pay the medicare part B premium. Applicants/recipients eligible for QI1 coverage under another medicaid category may not be eligible for QI1. QI1 eligibility is funded by limited block grant funding beginning in 1998 and ending when the congressional extension period expires. Since payment of the medicare part B premium is the only benefit, no medicaid card is issued.
[8.250.600.9 NMAC - Rp, 8.250.600.9 NMAC, 1/1/2019]
8.250.600.10 BENEFIT DETERMINATION: Application for QI1 is made on the assistance application form. Applications are acted on and notice of action taken is sent to the applicant within 45 days of the application.
[8.250.600.10 NMAC - Rp, 8.250.600.10 NMAC, 1/1/2019]
8.250.600.11 INITIAL BENEFITS: Eligibility begins the month the case is approved. When an eligibility determination is made, notice of the approval or denial is sent to the applicant. If the application is denied, this notice includes the recipient’s right to request a hearing.
[8.250.600.11 NMAC - Rp, 8.250.600.11 NMAC, 1/1/2019]
8.250.600.12 ONGOING BENEFITS: A redetermination of eligibility is made every 12 months.
[8.250.600.12 NMAC - Rp, 8.250.600.12 NMAC, 1/1/2019]
8.250.600.13 RETROACTIVE BENEFIT COVERAGE: Retroactive medicaid coverage is provided in accordance with 8.200.400.14 NMAC.
[8.250.600.13 NMAC - Rp, 8.250.600.13 NMAC, 1/1/2019]
8.250.600.14 CHANGES IN ELIGIBILITY: A case is closed, with provision of advance notice, when the recipient becomes ineligible. If a recipient dies, the case is closed effective the following month.
[8.250.600.14 NMAC - Rp, 8.250.600.14 NMAC, 1/1/2019]
HISTORY OF 8.250.600 NMAC: [ RESERVED ]
History of Repealed Material:
8.250.600 NMAC - Benefit Description, filed 11/16/2009 - Repealed effective 1/1/2019.
TITLE 8 SOCIAL SERVICES
CHAPTER 252 MEDICAID ELIGIBILITY - BREAST AND CERVICAL CANCER PROGRAM (CATEGORY 052)
PART 400 RECIPIENT POLICIES
8.252.400.1 ISSUING AGENCY: New Mexico Health Care Authority.
[8.252.400.1 NMAC - Rp 8.252.400.1 NMAC, 7/1/2024]
8.252.400.2 SCOPE: The rule applies to the general public .
[8.252.400.2 NMAC - Rp 8.252.400.2 NMAC, 7/1/2024
8.252.400.3 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 27-2-12 et. seq. 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.
[8.252.400.3 NMAC - Rp 8.252.400.3 NMAC, 7/1/2024
8.252.400.4 DURATION: Permanent.
[8.252.400.4 NMAC - Rp 8.252.400.4 NMAC, 7/1/2024
8.252.400.5 EFFECTIVE DATE: July 1, 2024, unless a later date is cited at the end of a section.
[8.252.400.5 NMAC - Rp 8.252.400.5 NMAC, 7/1/2024
8.252.400.6 OBJECTIVE: The objective of these regulations is to provide eligibility policy and procedures for the medicaid program.
[8.252.400.6 NMAC - Rp 8.252.400.6 NMAC, 7/1/2024
8.252.400.7 DEFINITIONS: [ RESERVED ]
8.252.400.8 MISSION: To transform lives. Working with our partners, we design and deliver innovative, high quality health and human services that improve the security and promote independence for New Mexicans in their communities.
[8.252.400.8 NMAC - Rp 8.252.400.8 NMAC, 7/1/2024
8.252.400.9 BREAST AND CERVICAL CANCER (BCC) - Category 052: The HCA is the single state agency designated to administer the medicaid program in New Mexico. The department of health (DOH) and the HCA are charged with developing and implementing a program for uninsured women under the age of 65 years, who have met screening criteria as set forth in the centers for disease control and prevention’s (CDC) national breast and cervical cancer early detection program (NBCCEDP). The DOH is responsible for verifying that women referred for treatment have met screening requirements that include an income test of two hundred and fifty percent of the federal poverty guidelines, and diagnostic testing by a contracted CDC provider resulting in a diagnosis of breast or cervical cancer including pre-cancerous conditions. Women who have met CDC screening criteria and identified as needing treatment for a diagnosis of breast or cervical cancer, including pre-cancerous conditions will be referred for treatment that includes the completion of a medicaid application for the BCC program. The Breast and Cervical Cancer Prevention and Treatment Act allows states to extend presumptive eligibility to applicants in order to ensure that needed treatment begins as early as possible.
[8.252.400.9 NMAC - Rp 8.252.400.9 NMAC, 7/1/2024
8.252.400.10 BASIS FOR DEFINING THE GROUP : Women who have been determined as having met CDC program screening requirements will be identified and referred for treatment. Public Law 106-354 does not provide eligibility for men diagnosed with cancer.
[8.252.400.10 NMAC - Rp 8.252.400.10 NMAC, 7/1/2024
8.252.400.11 GENERAL RECIPIENT REQUIREMENTS: Eligibility for the breast and cervical cancer program is always prospective. Women must meet, or expect to meet, all medicaid and CDC financial and non-financial eligibility criteria in the month for which determination of eligibility is made.
[8.252.400.11 NMAC - Rp 8.252.400.11 NMAC, 7/1/2024
8.252.400.12 ENUMERATION: A woman must furnish her social security account number. Medicaid eligibility is denied or terminated for a woman who fails to furnish her social security number. If a woman does not have a valid social security number, she must apply for one as a condition of medicaid eligibility. Presentation of the application for a social security number, or proof that an application has been made at a social security administration office, meets this requirement. A woman must provide her social security account number upon receipt of the number from SSA but no later than her next recertification.
[8.252.400.12 NMAC - Rp 8.252.400.12 NMAC, 7/1/2024
8.252.400.13 CITIZENSHIP: Refer to 8.200.410.11 NMAC. Women who do not meet citizenship eligibility criteria may be eligible to receive coverage for emergency services under the emergency medical services for undocumented non-citizens (EMSNC) program.
[8.252.400.13 NMAC - Rp 8.252.400.13 NMAC, 7/1/2024
8.252.400.14 RESIDENCE: To be eligible for medicaid , a woman must be physically present in New Mexico on the date of application or final determination of eligibility and must have intent to remain in the state.
A. Establishing residence: Residence in New Mexico is established by living in the state and carrying out the types of activities normally indicating residency, such as occupying a home, enrolling child (ren) in school, getting a state driver’s license, or renting a post office box. A woman who is homeless is considered to have met the residence requirements if she intends to remain in the state.
B. Recipients receiving benefits out-of-state: A women who receives medical assistance in another state is considered a resident of that state until the income support division (ISD) staff receives verification from the other state agency indicating that it has been notified by the woman of the abandonment of residence in that state.
C. Abandonment: Residence is not abandoned by temporary absences. Temporary absences occur when a woman leaves New Mexico for specific purposes with time-limited goals. Residence is considered abandoned when any of the following occurs:
(1) a woman leaves New Mexico and indicates that she intends to establish residence in another state;
(2) a woman leaves New Mexico for no specific purpose with no clear intention of returning;
(3) a woman leaves New Mexico and applies for financial, food or medical assistance in another state.
[8.252.400.14 NMAC - Rp 8.252.400.14 NMAC, 7/1/2024
8.252.400.15 NON-CONCURRENT RECEIPT OF ASSISTANCE: A woman may not be receiving assistance in another medicaid category.
[8.252.400.15 NMAC - Rp 8.252.400.15 NMAC, 7/1/2024
8.252.400.16 SPECIAL RECIPIENT REQUIREMENTS: A woman must have been screened and diagnosed with breast or cervical cancer or a pre-cancerous condition by a provider of the centers for disease control and prevention’s (CDC) national breast and cervical cancer early detection program and be in need of treatment. Women identified as in need of treatment, will be given an application that includes the DOH’s CDC contracted provider referral for treatment form. The DOH is responsible for verifying the referring physician is a contracted CDC provider.
[8.252.400.16 NMAC - Rp 8.252.400.16 NMAC, 7/1/2024
8.252.400.17 AGE: To be eligible for this category, a woman must be under 65 years of age. Medicaid eligibility ends the last day of the month a woman turns 65 years of age.
[8.252.400.17 NMAC - Rp 8.252.400.17 NMAC, 7/1/2024
8.252.400.18 THIRD PARTY LIABILITY: A woman must be uninsured.
A. A woman is considered uninsured when her health insurance policy has lifetime limits and she has exhausted those limits or she is denied coverage due to a pre-existing condition.
B. Women with high deductibles or limits on coverage, such as the limit of doctor visits or drug coverage that have not been exhausted, are considered insured.
C. There is no penalty for dropping insurance.
[8.252.400.18 NMAC - Rp 8.252.400.18 NMAC, 7/1/2024
8.252.400.19 PRESUMPTIVE ELIGIBILITY: A woman may be eligible to receive medicaid services from the date the presumptive eligibility determination is made until the end of the month following the month in which the determination was made, for a period of up to 60 days. The purpose of the presumptive eligibility is to allow medicaid payment for health care services furnished to a woman while her application for medicaid is being processed. Only one presumptive eligibility period is allowed per 12-month period. The period of presumptive eligibility begins when an approved presumptive eligibility provider establishes eligibility. Presumptive eligibility criteria are a simplified version of Category 052 eligibility requirements.
A. Processing presumptive eligibility information: The medical assistance division (MAD) authorizes certain providers to make presumptive eligibility determinations. The provider must notify MAD through its claims processing contractor of the determination within 24 hours of the determination of presumptive eligibility.
B. Provider responsibility: The presumptive eligibility provider must process both presumptive eligibility as well as an application for medical assistance for the woman.
C. Provider eligibility: Entities who may participate must be a CDC Title XV grantees are those entities receiving funds under a cooperative agreement with CDC to support activities related to the national breast and cervical cancer detection program.
[8.252.400.19 NMAC - Rp 8.252.400.19 NMAC, 7/1/2024
8.252.400.20 RECIPIENT RIGHTS AND RESPONSIBILITIES: A woman or her representative is responsible for establishing her eligibility for medicaid . As part of this responsibility, the woman must provide required information and documents, or take the actions necessary to establish eligibility. Failure to do so must result in a decision that eligibility does not exist. A woman must also grant the HCA permission to contact other persons, agencies or sources of information necessary to establish eligibility. See 8.200.430 NMAC, Recipient Rights and Responsibilities for specific information.
[8.252.400.20 NMAC - Rp 8.252.400.20 NMAC, 7/1/2024
8.252.400.21 REPORTING REQUIREMENTS: A woman or any other responsible party must:
A. report any changes in circumstances, which may affect the woman’s eligibility within 10 days of the date of the change to the county ISD office;
B. the ISD worker must evaluate the effect of the change and take any required action as soon as possible; however, the action must take effect no later than the end of the month following the month in which the change took place.
[8.252.400.21 NMAC - Rp 8.252.400.21 NMAC, 7/1/2024
HISTORY OF 8.252.400 NMAC: [ RESERVED ]
History of Repealed Material: 8.252.400 NMAC - Recipient Policies (filed 6/14/2002) Repealed 7/1/2024.
Other: 8.252.400 NMAC - Recipient Policies (filed 6/14/2002) Replaced by 8.252.400 NMAC - Recipient Policies effective 7/1/2024.
TITLE 8 SOCIAL SERVICES
CHAPTER 252 MEDICAL ASSISTANCE PROGRAM ELIGIBILITY - BREAST AND CERVICAL CANCER PROGRAM
PART 500 INCOME AND RESOURCE STANDARDS
8.252.500.1 ISSUING AGENCY: New Mexico Health Care Authority .
[8.252.500.1 NMAC - Rp, 8.252.500.1 NMAC, 1/1/2014 ; A, 7/1/2024]
8.252.500.2 SCOPE: This rule applies to the general public.
[8.252.500.2 NMAC - Rp, 8.252.500.2 NMAC, 1/1/2014]
8.252.500.3 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.
[8.252.500.3 NMAC - Rp, 8.252.500.3 NMAC, 1/1/2014 ; A, 7/1/2024 ]
8.252.500.4 DURATION: Permanent.
[8.252.500.4 NMAC - Rp, 8.252.500.4 NMAC, 1/1/2014]
8.252.500.5 EFFECTIVE DATE: January 1, 2014, unless a later date is cited at the end of a section.
[8.252.500.5 NMAC - Rp, 8.252.500.5 NMAC, 1/1/2014]
8.252.500.6 OBJECTIVE: The objective of this rule is to provide specific instructions when determining eligibility for the medicaid program and other health care programs. Generally, applicable eligibility rules are detailed in the medical assistance division (MAD) eligibility policy manual, specifically 8.200.400 NMAC, General Medicaid Eligibility . Processes for establishing and maintaining MAD eligibility are detailed in the income support division (ISD) general provisions 8.100 NMAC, General Provisions for Public Assistance Programs .
[8.252.500.6 NMAC - Rp, 8.252.500.6 NMAC, 1/1/2014]
8.252.500.7 DEFINITIONS: [ RESERVED ]
8.252.500.8 MISSION: 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.
[8.252.500.8 NMAC - N, 1/1/2014]
8.252.500.9 RESOURCES: Resources are not an eligibility factor.
[8.252.500.9 NMAC - Rp, 8.252.500.9 NMAC, 1/1/2014]
8.252.500.10 INCOME: Income is not an eligibility factor.
[8.252.500.10 NMAC - Rp, 8.252.500.10 NMAC, 1/1/2014]
HISTORY OF 8.252.500 NMAC:
History of Repealed Material:
8.252.500 NMAC, Income and Resource Standards, filed 6-14-02 - Repealed effective 1/1/2014.
TITLE 8 SOCIAL SERVICES
CHAPTER 252 MEDICAL ASSISTANCE PROGRAM ELIGIBILITY - BREAST AND CERVICAL CANCER PROGRAM
PART 600 BENEFIT DESCRIPTION
8.252.600.1 ISSUING AGENCY: New Mexico Health Care Authority.
[8.252.600.1 NMAC - Rp, 8.252.600.1 NMAC, 1/1/2019 ; A, 7/1/20
8.252.600.2 SCOPE: This rule applies to the general public .
[8.252.600.2 NMAC - Rp, 8.252.600.2 NMAC, 1/1/2019]
8.252.600.3 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 Section 27-1-12 et seq ., NMSA 1978. 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.
[8.252.600.3 NMAC - Rp, 8.252.600.3 NMAC, 1/1/2019 ; A, 7/1/2024 ]
8.252.600.4 DURATION: Permanent.
[8.252.600.4 NMAC - Rp, 8.252.600.4 NMAC, 1/1/2019]
8.252.600.5 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.
[8.252.600.5 NMAC - Rp, 8.252.600.5 NMAC, 1/1/2019]
8.252.600.6 OBJECTIVE: The objective of this rule is to provide specific instructions when determining eligibility for the medicaid program and other health care programs. Generally, applicable eligibility rules are detailed in the medical assistance division (MAD) eligibility policy manual, specifically 8.200.400 NMAC, General Medicaid Eligibility . Processes for establishing and maintaining MAD eligibility are detailed in the income support division (ISD) general provisions 8.100 NMAC, General Provisions for Public Assistance Programs .
[8.252.600.6 NMAC - Rp, 8.252.600.6 NMAC, 1/1/2019]
8.252.600.7 DEFINITIONS: [ RESERVED ]
8.252.600.8 [RESERVED]
[8.252.600.8 NMAC – Rp, 8.252.600.8 NMAC, 1/1/2019]
8.252.600.9 GENERAL BENEFIT DESCRIPTION: A woman who is determined eligible for medicaid coverage under the breast and cervical cancer program (Category 052) can receive the full range of medicaid covered.
[8.252.600.9 NMAC - Rp, 8.252.600.9 NMAC, 1/1/2019]
8.252.600.10 BENEFIT DETERMINATION: Completed applications must be acted upon and notice of approval, denial, or delay sent out within 45 days of the date of application. The applicant will have time limits explained, and be informed of the date by which the application should be processed.
[8.252.600.10 NMAC - Rp, 8.252.600.10 NMAC, 1/1/2019]
8.252.600.11 INITIAL BENEFITS: Eligibility is always prospective and begins the month of application. When an eligibility determination is made, notice of the approval or denial is sent to the applicant. If the application is denied, the notice shall include reason(s) for denial and the applicant’s right to request a fair hearing.
[8.252.600.11 NMAC - Rp, 8.252.600.11 NMAC, 1/1/2019]
8.252.600.12 ONGOING BENEFITS: An eligible recipient is responsible to report changes affecting eligibility within 10 calendar days from the date on which the change took place. Changes in eligibility status will be effective the first day of the following month. A redetermination of eligibility is made every 12 months.
[8.252.600.12 NMAC - Rp, 8.252.600.12 NMAC, 1/1/2019]
8.252.600.13 RETROACTIVE BENEFIT COVERAGE: Retroactive medicaid coverage is provided in accordance with 8.200.400.14 NMAC.
[8.252.600.13 NMAC - Rp, 8.252.600.13 NMAC, 1/1/2019]
8.252.600.14 CHANGES IN ELIGIBILITY: A recipient’s eligibility ends when medical assistance division (MAD) receives information from the treating physician or from the recipient that her course of treatment is completed. A case is closed, with provision of advance notice, when the recipient becomes ineligible. The case is closed the month following the death of an eligible recipient.
[8.252.600.14 NMAC - Rp, 8.252.600.14 NMAC, 1/1/2019]
HISTORY OF 8.252.600 NMAC:
History of Repealed Material:
8.252.600 NMAC, Benefit Description, filed 6-14-02 - Repealed effective 1/1/2014.
8.252.600 NMAC, Benefit Description, filed 12/2/2013 - Repealed effective 1/1/2019.
TITLE 8 SOCIAL SERVICES
CHAPTER 259 MEDICAL ASSISTANCE PROGRAM ELIGIBILITY - REFUGEES WITH SPEND DOWN PROVISION
PART 400 RECIPIENT REQUIREMENTS
8.259.400.1 ISSUING AGENCY: New Mexico Health Care Authority.
[8.259.400.1 NMAC - Rp, 8.259.400.1 NMAC, 1/1/2014; A, 7/1/2024]
8.259.400.2 SCOPE: The rule applies to the general public .
[8.259.400.2 NMAC - Rp, 8.259.400.2 NMAC, 1/1/2014]
8.259.400.3 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 , Section 27-1-12 et seq . NMSA 1978. 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.
[8.259.400.3 NMAC - Rp , 8.259.400.3 NMAC, 1/1/2014 ; A, 7/1/2024 ]
8.259.400.4 DURATION: Permanent.
[8.259.400.4 NMAC - Rp, 8.259.400.4 NMAC, 1/1/2014]
8.259.400.5 EFFECTIVE DATE: January 1, 2014, unless a later date is cited at the end of a section.
[8.259.400.5 NMAC - Rp, 8.259.400.5 NMAC, 1/1/2014]
8.259.400.6 OBJECTIVE: The objective of this rule is to provide specific instructions when determining eligibility for the medicaid program and other health care programs. Generally, applicable eligibility rules are detailed in the medical assistance division (MAD) eligibility policy manual, specifically 8.200.400 NMAC, General Medicaid Eligibility . Processes for establishing and maintaining MAD eligibility are detailed in the income support division (ISD) general provisions 8.100 NMAC, General Provisions for Public Assistance Programs .
[8.259.400.6 NMAC - Rp, 8.259.400.6 NMAC, 1/1/2014]
8.259.400.7 DEFINITIONS: [RESERVED]
8.259.400.8 MISSION: 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.
[8.259.400.8 NMAC - N, 1/1/2014 ]
8.259.400.9 REFUGEE MEDICAL ASSISTANCE SPEND DOWN ONLY - CATEGORY 059: Refer to 8.249.400 NMAC.
[8.259.400.9 NMAC - Rp, 8.259.400.9 NMAC, 1/1/2014]
8.259.400.10 BASIS FOR DEFINING THE GROUP: Refer to 8.249.400 NMAC.
[8.259.400.10 NMAC - Rp, 8.259.400.10 NMAC, 1/1/2014]
8.259.400.11 GENERAL RECIPIENT REQUIREMENTS: Refer to 8.249.400 NMAC.
[8.259.400.11 NMAC - Rp, 8.259.400.11 NMAC, 1/1/2014]
8.259.400.12 ENUMERATION: Refer to 8.249.400 NMAC.
[8.259.400.12 NMAC - Rp, 8.259.400.12 NMAC, 1/1/2014]
8.259.400.13 CITIZENSHIP: Refer to 8.249.400 NMAC.
[8.259.400.13 NMAC - Rp, 8.259.400.13 NMAC, 1/1/2014]
8.259.400.14 RESIDENCE: Refer to 8.249.400 NMAC.
[8.259.400.14 NMAC - Rp, 8.259.400.14 NMAC, 1/1/2014]
8.259.400.15 SPECIAL RECIPIENT REQUIREMENTS: Refer to 8.249.400 NMAC.
[8.259.400.15 NMAC - Rp, 8.259.400.15 NMAC, 1/1/2014]
8.259.400.16 AGE: Refer to 8.249.400 NMAC.
[8.259.400.16 NMAC - Rp, 8.259.400.16 NMAC, 1/1/2014]
8.259.400.17 RECIPIENT RIGHTS AND RESPONSIBILITIES: Refer to 8.249.400 NMAC.
[8.259.400.17 NMAC - Rp, 8.259.400.17 NMAC, 1/1/2014]
8.259.400.18 ASSIGNMENTS OF MEDICAL SUPPORT: Refer to 8.249.400 NMAC.
[8.259.400.18 NMAC - Rp, 8.259.400.18 NMAC, 1/1/2014]
HISTORY OF 8.259.400 NMAC:
Pre-NMAC History: The material in this part was derived from that previously filed with the State Records Center:
MAD Rule 822, Refugee Medical Assistance, filed 5/22/1992.
History of Repealed Material:
MAD Rule 822, Refugee Medical Assistance, filed 5/22/1992 - Repealed effective 2/1/1995.
8.259.400 NMAC, Recipient Requirements, filed 6/13/2003 - Repealed effective 1/1/2014.
TITLE 8 SOCIAL SERVICES
CHAPTER 259 MEDICAL ASSISTANCE PROGRAM ELIGIBILITY - REFUGEES WITH SPEND DOWN PROVISION
PART 500 INCOME AND RESOURCE STANDARDS
8.259.500.1 ISSUING AGENCY: New Mexico Health Care Authority.
[8.259.500.1 NMAC - Rp, 8.259.500.1 NMAC, 1/1/2014; A,7/1/2024; A, 7/1/2024]
8.259.500.2 SCOPE: The rule applies to the general public .
[8.259.500.2 NMAC - Rp, 8.259.500.2 NMAC, 1/1/2014]
8.259.500.3 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 Section 27-1-12 et seq . NMSA 1978. 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.
[8.259.500.3 NMAC - Rp , 8.259.500.3 NMAC, 1/1/ 2014 ; A, 7/1/2024 ]
8.259.500.4 DURATION: Permanent.
[8.259.500.4 NMAC - Rp, 8.259.500.4 NMAC, 1/1/2014]
8.259.500.5 EFFECTIVE DATE: January 1, 2014, unless a later date is cited at the end of a section.
[8.259.500.5 NMAC - Rp, 8.259.500.5 NMAC, 1/1/2014]
8.259.500.6 OBJECTIVE: The objective of this rule is to provide specific instructions when determining eligibility for the medicaid program and other health care programs. Generally, applicable eligibility rules are detailed in the medical assistance division (MAD) eligibility policy manual, specifically 8.200.400 NMAC, General Medicaid Eligibility . Processes for establishing and maintaining MAD eligibility are detailed in the income support division (ISD) general provisions 8.100 NMAC, General Provisions for Public Assistance Programs .
[8.259.500.6 NMAC - Rp, 8.259.500.6 NMAC, 1/1/2014]
8.259.500.7 DEFINITIONS: [RESERVED]
8.259.500.8 MISSION: 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.
[8.259.500.8 NMAC - N, 1/1/2014 ]
8.259.500.9 NEED DETERMINATION: Refer to 8.249.500 NMAC.
[8.259.500.9 NMAC - Rp, 8.259.500.9 NMAC, 1/1/2014]
8.259.500.10 RESOURCE STANDARDS: Refer to 8.249.500 NMAC.
[8.259.500.10 NMAC - Rp, 8.259.500.10 NMAC, 1/1/2014]
8.259.500.11 INCOME STANDARDS: Refer to 8.249.500 NMAC.
[8.259.500.11 NMAC - Rp, 8.259.500.11 NMAC, 1/1/2014]
HISTORY OF 8.259.500 NMAC:
Pre-NMAC History: The material in this part was derived from that previously filed with the State Records:
MAD Rule 822, Refugee Medical Assistance, filed 5/22/1992.
History of Repealed Material:
MAD Rule 822, Refugee Medical Assistance filed 5/22/1992 - Repealed effective 2/1/1995.
8.259.500 NMAC, Income and Resource Standards, filed 3/25/2010 - Repealed effective 1/1/2014.
TITLE 8 SOCIAL SERVICES
CHAPTER 259 MEDICAL ASSISTANCE PROGRAM ELIGIBILITY - REFUGEES WITH SPEND DOWN PROVISION
PART 600 BENEFIT DESCRIPTION
8.259.600.1 ISSUING AGENCY: New Mexico Health Care Authority.
[8.259.600.1 NMAC - Rp, 8.259.600.1 NMAC, 1/1/2014; A, 7/1/2024]
8.259.600.2 SCOPE: The rule applies to the general public .
[8.259.600.2 NMAC - Rp, 8.259.600.2 NMAC, 1/1/2014]
8.259.600.3 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 Section 27-1-12 et seq . NMSA 1978. 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.
[8.259.600.3 NMAC - Rp , 8.259.600.3 NMAC, 1/1/2014 ; A, 7/1/2024 ]
8.259.600.4 DURATION: Permanent.
[8.259.600.4 NMAC - Rp, 8.259.600.4 NMAC, 1/1/2014]
8.259.600.5 EFFECTIVE DATE: January 1, 2014, unless a later date is cited at the end of a section.
[8.259.600.5 NMAC - Rp, 8.259.600.5 NMAC, 1/1/2014]
8.259.600.6 OBJECTIVE: The objective of this rule is to provide specific instructions when determining eligibility for the medicaid program and other health care programs. Generally, applicable eligibility rules are detailed in the medical assistance division (MAD) eligibility policy manual, specifically 8.200.400 NMAC, General Medicaid Eligibility . Processes for establishing and maintaining MAD eligibility are detailed in the income support division (ISD) general provisions 8.100 NMAC, General Provisions for Public Assistance Programs .
[8.259.600.6 NMAC - Rp, 8.259.600.6 NMAC, 1/1/2014]
8.259.600.7 DEFINITIONS: [RESERVED]
8.259.600.8 MISSION: 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.
[8.259.600.8 NMAC - N, 1/1/2014 ]
8.259.600.9 BENEFIT DESCRIPTION: Refer to 8.249.600 NMAC.
[8.259.600.9 NMAC - Rp, 8.259.600.9 NMAC, 1/1/2014]
8.259.600.10 BENEFIT DETERMINATION: Refer to 8.249.600 NMAC.
[8.259.600.10 NMAC - Rp, 8.259.600.10 NMAC, 1/1/2014]
HISTORY OF 8.259.600 NMAC:
Pre-NMAC History: The material in this part was derived from that previously filed with the State Records Center:
MAD Rule 822, Refugee Medical Assistance, filed 5/22/1992.
History of Repealed Material:
MAD Rule 822, Refugee Medical Assistance filed 5/22/1992 - Repealed effective 2/1/1995.
8.259.600 NMAC, Benefit Description, filed 9/3/2013 - Repealed effective 1/1/2014.
TITLE 8 SOCIAL SERVICES
CHAPTER 280 MEDICAID ELIGIBILITY - PROGRAM OF ALL INCLUSIVE CARE FOR THE ELDERLY (PACE)
PART 400 RECIPIENT POLICIES
8.280.400.1 ISSUING AGENCY: New Mexico Health Care Authority.
[8.280.400.1 NMAC - Rp, 8.280.400.1 NMAC, 1/1/2019 ; A,7/1/2024; A, 7/1/2024
8.280.400.2 SCOPE: The rule applies to the general public .
[8.280.400.2 NMAC - Rp, 8.280.400.2 NMAC, 1/1/2019]
8.280.400.3 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.
[8.280.400.3 NMAC - Rp, 8.280.400.3 NMAC, 1/1/2019; A,7/1/2024; A, 7/1/2024]
8.280.400.4 DURATION: Permanent.
[8.280.400.4 NMAC - Rp, 8.280.400.4 NMAC, 1/1/2019]
8.280.400.5 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.
[8.280.400.5 NMAC - Rp, 8.280.400.5 NMAC, 1/1/2019]
8.280.400.6 OBJECTIVE: The objective of these regulations is to provide eligibility policy and procedures for the medicaid program.
[8.280.400.6 NMAC - Rp, 8.280.400.6 NMAC, 1/1/2019]
8.280.400.7 DEFINITIONS: [ RESERVED ]
8.280.400.8 MISSION STATEMENT: To transform lives. Working with our partners, we design and deliver innovative, high quality health and human services that improve the security and promote independence for New Mexicans in their communities.
[8.280.400.8 NMAC - N, 2/1/2021]
8.280.400.9 PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) - CATEGORIES 081, 083, AND 084: Certain populations meeting financial, non-financial, and medical criteria can receive acute and long-term care services in the community. These services are funded by medicaid on a capitated basis.
[8.280.400.9 NMAC - Rp, 8.280.400.9 NMAC, 1/1/2019]
8.280.400.10 BASIS FOR DEFINING THE GROUP: Recipients and eligible applicants must live in certain designated zip codes within New Mexico. A PACE recipient cannot concurrently receive other medicaid home and community-based services. A PACE recipient may be placed in a qualifying nursing facility upon a medical doctor's orders and continue to participate in PACE. Upon disenrollment from PACE, a former PACE recipient may receive institutional care (IC) medicaid services as long as the individual meets all IC medicaid eligibility requirements. PACE recipients can concurrently receive the qualified medicare beneficiaries program (QMB), the specified low income medicare beneficiaries program (SLIMB), or supplemental security income (SSI). For PACE applicants/recipients who receive SSI benefits no further verification of income, resources, citizenship, age, disability, or blindness is required.
[8.280.400.10 NMAC - Rp, 8.280.400.10 NMAC, 1/1/2019; A, 2/1/2021]
8.280.400.11 APPLICANT AND RECIPIENT REQUIREMENTS: Applicants must live within the designated PACE service area and meet all of the criteria listed below at the time of application and enrollment.
A . Applicants must be 55 years of age or older. Applicants/recipients must be determined blind or disabled if under the age of 65 years.
(1) To be considered blind, an applicant/recipient must have central visual acuity of 20/200 or less with corrective lenses or must be considered blind for practical purposes.
(2) To be considered disabled, an applicant/recipient must be unable to engage in any substantial gainful activity, because of any medically determinable physical, developmental, or mental impairment which has lasted, or is expected to last, for a continuous period of at least 12 months.
(3) If a determination of blindness or disability has not been made, the income support division worker will submit medical reports to the disability determination unit.
B. Level of care requirements must be met in addition to all other requirements. An applicant or recipient must be eligible for institutional nursing facility level of care as determined by the medical assistance division (MAD) utilization review contractor. An institutional level of care must be recommended for the applicant or recipient by a PACE physician licensed to practice medicine or osteopathy in the state of New Mexico. Institutions are defined as acute care hospitals, nursing facilities (either high NF or low NF as defined by medicaid regulations) and intermediate care facilities for individuals with intellectual disabilities (ICF/IID). Level of care determinations are performed by the MAD utilization review contractor. Level of care for approved recipients will be determined on an annual basis.
C. An interview is not required in accordance with 8.281.400.11 NMAC.
D. Upon enrollment, applicants must be able to live in a community setting without jeopardizing their individual health and safety. The ability to live safely in the home and community is determined by the PACE organization’s interdisciplinary team.
[8.280.400.11 NMAC - Rp, 8.280.400.11 NMAC, 1/1/2019; A, 2/1/2021, A, 1/1/2022]
8.280.400.12 RECIPIENT RIGHTS AND RESPONSIBILITIES: Applicants and recipients are responsible for establishing eligibility for medicaid . As part of this responsibility, the applicant or recipient must provide required information and documents or take the actions necessary to establish eligibility. Failure to do so must result in a decision that eligibility does not exist.
[8.280.400.12 NMAC - Rp, 8.280.400.12 NMAC, 1/1/2019; A, 2/1/2021]
8.280.400.13 REPORTING REQUIREMENTS: All changes that may affect eligibility must be reported within 10 calendar days of the date of the change in accordance with 8.200.430.18 NMAC.
[8.280.400.13 NMAC - Rp, 8.280.400.13 NMAC, 1/1/2019]
HISTORY OF 8.280.400 NMAC:
History of Repealed Material:
8 NMAC 4.PAC.400, Recipient Policies, filed 1/20/1998 - Repealed effective 12/1/2006.
8.280.400 NMAC - Recipient Policies, filed 11/15/2006 - Repealed effective 1/1/2019.
TITLE 8 SOCIAL SERVICES
CHAPTER 280 MEDICAID ELIGIBILITY - PROGRAM OF ALL INCLUSIVE CARE FOR THE ELDERLY (PACE)
PART 500 INCOME AND RESOURCE STANDARDS
8.280.500.1 ISSUING AGENCY: New Mexico Health Care Authority.
[8.280.500.1 NMAC - Rp, 8.280.500.1 NMAC, 7/1/2024]
8.280.500.2 SCOPE: The rule applies to the general public .
[8.280.500.2 NMAC - Rp, 8.280.500.2 NMAC, 7/1/2024]
8.280.500.3 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.
[8.280.500.3 NMAC - Rp, 8.280.500.3 NMAC, 7/1/2024]
8.280.500.4 DURATION: Permanent.
[8.280.500.4 NMAC - Rp, 8.280.500.4 NMAC, 7/1/2024]
8.280.500.5 EFFECTIVE DATE: July 1, 2024, unless a later date is cited at the end of a section.
[8.280.500.5 NMAC - Rp, 8.280.500.5 NMAC, 7/1/2024]
8.280.500.6 OBJECTIVE: The objective of these regulations is to provide eligibility policy and procedures for the medicaid program.
[8.280.500.6 NMAC - Rp, 8.280.500.6 NMAC, 7/1/2024]
8.280.500.7 DEFINITIONS: [ RESERVED ]
8.280.500.8 MISSION STATEMENT: To transform lives. Working with our partners, we design and deliver innovative, high quality health and human services that improve the security and promote independence for New Mexicans in their communities.
[8.280.500.8 NMAC - Rp, 8.280.500.8 NMAC, 7/1/2024]
8.280.500.9 NEED DETERMINATION: Eligibility for PACE is determined prospectively. Applicants/recipients must meet, or expect to meet, all financial eligibility criteria in the month for which a determination of eligibility is made. Applicants for and recipients of medicaid through PACE must apply for, and take all necessary steps to obtain, any income or resources to which they may be entitled. Such steps must be taken within 30 days of the date the HCA (HCA) furnishes notice of the potential entitlement. Failure or refusal to apply for and take all necessary steps to determine eligibility for other benefits after notice is received results in an applicant/recipient becoming ineligible for medicaid .
A. Applicants/recipients who have elected a lower veterans affairs (VA) payment do not need to reapply for veteran’s administration improved pension (VAIP) benefits.
B . Crime victims are not required to accept victim’s compensation payments from a state-administered fund as a condition of medicaid eligibility.
[8.280.500.9 NMAC - Rp, 8.280.500.9 NMAC, 7/1/2024]
8.280.500.10 RESOURCE STANDARDS: See 8.281.500.10 NMAC and all following subsections.
[8.280.500.10 NMAC - Rp, 8.280.500.10 NMAC, 7/1/2024]
8.280.500.11 APPLICABLE RESOURCE STANDARDS: An applicant/recipient is eligible for medicaid on the factor of resources if countable resources do not exceed $2,000. See 8.281.500.11 NMAC.
[8.280.500.11 NMAC - Rp, 8.280.500.11 NMAC, 7/1/2024]
8.280.500.12 COUNTABLE RESOURCES: See 8.281.500.12 NMAC.
[8.280.500.12 NMAC - Rp, 8.280.500.12 NMAC, 7/1/2024]
8.280.500.13 RESOURCE EXCLUSIONS: See 8.281.500.13 NMAC.
[8.280.500.13 NMAC - Rp, 8.280.500.13 NMAC, 7/1/2024]
8.280.500.14 ASSET TRANSFERS: See 8.281.500.14 NMAC for regulations governing transfers of assets. All provisions pertaining to transfers under institutional care medicaid apply to transfers under PACE with the exception of the penalty for transfers without fair return. The penalty for transfers of assets without fair return for PACE applicants/recipients is ineligibility for medicaid under PACE.
[8.280.500.14 NMAC - Rp, 8.280.500.14 NMAC, 7/1/2024]
8.280.500.15 TRUSTS: See 8.281.500.15 NMAC.
[8.280.500.15 NMAC - Rp, 8.280.500.15 NMAC, 7/1/2024]
8.280.500.16 RESOURCE STANDARDS FOR MARRIED COUPLES: See 8.281.500.16 NMAC for spousal impoverishment methodology used in the determination of eligibility for married applicants/recipients with a spouse in the home who began receiving PACE services on or after September 30, 1989. A resource assessment is completed as of the first moment of the first day of the month in which the level of care is approved.
[8.280.500.16 NMAC - Rp, 8.280.500.16 NMAC, 7/1/2024]
8.280.500.17 DEEMING RESOURCES: Not applicable to PACE.
[8.280.500.17 NMAC - Rp, 8.280.500.17 NMAC, 7/1/2024]
8.280.500.18 INCOME: An applicant/recipient’s gross countable monthly income must be less than the maximum allowable monthly income standard. See 8.281.500.18 NMAC.
[8.280.500.18 NMAC - Rp, 8.280.500.18 NMAC, 7/1/2024]
8.280.500.19 INCOME STANDARDS: See 8.281.500.19 NMAC.
[8.280.500.19 NMAC - Rp, 8.280.500.19 NMAC, 7/1/2024]
8.280.500.20 UNEARNED INCOME: See 8.281.500.20 NMAC.
[8.280.500.20 NMAC - Rp, 8.280.500.20 NMAC, 7/1/2024]
8.280.500.21 DEEMED INCOME: See 8.281.500.21 NMAC.
[8.280.500.21 NMAC - Rp, 8.280.500.21 NMAC, 7/1/2024]
8.280.500.22 DISREGARDS: See 8.281.500.22 NMAC.
[8.280.500.22 NMAC - Rp, 8.280.500.22 NMAC, 7/1/2024]
8.280.500.23 MEDICAL CARE CREDIT: There are medical care credits in PACE only when a PACE recipient enters a nursing facility. See 8.281.500.22 NMAC.
[8.280.500.23 NMAC - Rp, 8.280.500.23 NMAC, 7/1/2024]
HISTORY OF 8.280.500 NMAC:
History of Repealed Material:
8 NMAC 4.PAC.500, Income and Resource Standards, filed 1/20/1998 - Repealed effective 12/1/2006.
280.500 NMAC - Income And Resource Standards (filed 11/15/2006) Repealed effective 7/1/2024.
Other : 280.500 NMAC - Income And Resource Standards (filed 11/15/2006) Replaced by 280.500 NMAC - Income And Resource Standards effective 7/1/2024.
TITLE 8 SOCIAL SERVICES
CHAPTER 280 MEDICAID ELIGIBILITY - PROGRAM OF ALL INCLUSIVE CARE FOR THE ELDERLY (PACE)
PART 600 BENEFIT DESCRIPTION
8.280.600.1 ISSUING AGENCY: New Mexico Health Care Authority.
[8.280.600.1 NMAC - Rp, 8.280.600.1 NMAC, 1/1/2019; A, 7/1/2024]
8.280.600.2 SCOPE: The rule applies to the general public .
[8.280.600.2 NMAC - Rp, 8.280.600.2 NMAC, 1/1/2019]
8.280.600.3 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.
[8.280.600.3 NMAC - Rp, 8.280.600.3 NMAC, 1/1/2019; A, 7/1/2024]
8.280.600.4 DURATION: Permanent.
[8.280.600.4 NMAC - Rp, 8.280.600.4 NMAC, 1/1/2019]
8.280.600.5 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.
[8.280.600.5 NMAC - Rp, 8.280.600.5 NMAC, 1/1/2019]
8.280.600.6 OBJECTIVE: The objective of these regulations is to provide eligibility policy and procedures for the medicaid program.
[8.280.600.6 NMAC - Rp, 8.280.600.6 NMAC, 1/1/2019]
8.280.600.7 DEFINITIONS: [ RESERVED ]
8.280.600.8 [ RESERVED ]
8.280.600.9 BENEFIT DESCRIPTION: An applicant/recipient who is eligible for PACE is eligible for specified services available under the program. See specific program policy sections for covered services.
[8.280.600.9 NMAC - Rp, 8.280.600.9 NMAC, 1/1/2019]
8.280.600.10 BENEFIT DETERMINATION: Application for PACE is made using the HSD 100 application. Applications must be acted upon and notice of approval, denial, or delay sent out within 45 days of the date of application. The applicant/recipient may complete the form himself, or receive help from a relative, friend, guardian, or other designated representative. To avoid a conflict of interest, a PACE provider must not complete the application nor be a designated representative.
[8.280.600.10 NMAC - Rp, 8.280.600.10 NMAC, 1/1/2019]
8.280.600.11 INITIAL BENEFITS: An application for PACE can be approved when all factors of eligibility have been met and the individual is enrolled in the program. The effective date for PACE enrollment is the first day of the calendar month following the signing of the enrollment agreement (if all financial, non-financial, and medical eligibility criteria are met and an approved level of care (LOC) is in place). Applicants determined to be ineligible for PACE are notified of the reason for the denial and provided with an explanation of appeal rights. Applicants determined to be eligible for PACE are notified of the approval.
[8.280.600.11 NMAC - Rp, 8.280.600.11 NMAC, 1/1/2019]
8.280.600.12 ONGOING BENEFITS:
A. A complete redetermination of eligibility must be performed annually by the income support division worker for each open case.
B. Level of care reviews are required to be completed at least annually. Level of care determinations for PACE are made by the utilization review contractor.
[8.280.600.12 NMAC - Rp, 8.280.600.12 NMAC, 1/1/2019]
8.280.600.13 RETROACTIVE BENEFITS: Retroactive coverage is not available in the PACE program.
[8.280.600.13 NMAC - Rp, 8.280.600.13 NMAC, 1/1/2019]
8.280.600.14 CHANGES IN ELIGIBILITY: If the recipient ceases to meet any of the eligibility criteria, the case is closed following provision of advance notice as appropriate. See 8.200.430 NMAC for information about notices and hearing rights.
A. Non-provision of PACE services: To be eligible for PACE, an applicant/recipient must receive PACE services. If PACE services are no longer being provided and are not expected to be provided for at least a full calendar month, the recipient is ineligible for the program and the case must be closed after appropriate notice is provided, unless an exception has been prior authorized by MAD.
B. Admission to an acute care or nursing facility: If a PACE recipient enters an acute care or nursing facility, he still remains eligible. A PACE recipient may be disenrolled from the program either voluntarily or involuntarily. If disenrollment occurs, a new application for institutional care medicaid is not required in the following circumstances: the former PACE recipient is in an acute care or nursing facility; he continues to meet all eligibility criteria for institutional care medicaid ; or the periodic review on the PACE case is not due in either the month of disenrollment or the following month.
C. Reporting changes in circumstances: The primary responsibility for reporting changes in the recipient's circumstances rests with the recipient or representative. At the initial eligibility determination and all on-going eligibility redeterminations, the income support division (ISD) must explain the reporting responsibilities requirement to the applicant/recipient or representative and document that such explanation was given. In the event that PACE services should cease, the PACE provider must immediately notify the income support division office by telephone of that fact. The telephone call is to be followed by a written notice to the ISD.
D. Disenrollment: A PACE recipient loses medicaid eligibility under this program when he is either voluntarily or involuntarily disenrolled. The PACE provider must inform the ISD office when disenrollment occurs. A one time only reinstatement will be allowed if the individual continues to meet all financial, non-financial and medical eligibility criteria. Reinstatement is subject to availability of positions and redetermination of medicaid eligibility. A PACE recipient may voluntarily disenroll at any time. Involuntary disenrollment occurs when any of the following situations exist:
(1) recipient moves out of PACE service area;
(2) recipient is a person with decision-making capacity who consistently does not comply with the individual plan of care and poses a significant risk to self or others;
(3) recipient experiences a breakdown in the physician or team relationship such that the PACE provider ability to furnish services to either the recipients or other recipients is seriously impaired;
(4) recipient refuses services or is unwilling to meet conditions of participation as they appear in the enrollment agreement;
(5) recipient refuses to provide accurate financial information, provides false information or illegally transfers assets;
(6) recipient is out of the PACE service area for more than one calendar month (unless other arrangements have been made);
(7) recipient is enrolled in PACE that loses its contract or licenses which enables it to cover health care services;
(8) recipient fails to meet the financial or non-financial criteria; or
(9) recipient ceases to meet the level of care at any time.
[8.280.600.14 NMAC - Rp, 8.280.600.14 NMAC, 1/1/2019]
HISTORY OF 8.280.600 NMAC:
History of Repealed Material:
8 NMAC 4.PAC.600, Benefit Description, filed 1-20-98 - Repealed effective 12/1/2006.
8.280.600 NMAC - Benefit Description, filed 11/15/2006 - Repealed effective 1/1/2019.
TITLE 8 SOCIAL SERVICES
CHAPTER 281 MEDICAID ELIGIBILITY - INSTITUTIONAL CARE (CATEGORIES 081, 083 and 084)
PART 400 RECIPIENT POLICIES
8.281.400.1 ISSUING AGENCY: New Mexico Health Care Authority.
[8.281.400.1 NMAC - Rp, 8.281.400.1 NMAC, 1/1/2019; A, 5/1/2021; A, 7/1/2024]
8.281.400.2 SCOPE: The rule applies to the general public .
[8.281.400.2 NMAC - Rp, 8.281.400.2 NMAC, 1/1/2019]
8.281.400.3 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.
[8.281.400.3 NMAC - Rp , 8.281.400.3 NMAC, 1/1/2019 ; A, 7/1/2024 ]
8.281.400.4 DURATION: Permanent.
[8.281.400.4 NMAC - Rp, 8.281.400.4 NMAC, 1/1/2019]
8.281.400.5 EFFECTIVE DATE: January 1, 2019 , unless a later date is cited at the end of a section.
[8.281.400.5 NMAC - Rp, 8.281.400.5 NMAC, 1/1/2019]
8.281.400.6 OBJECTIVE: The objective of these regulations is to provide eligibility policy and procedures for the medicaid program.
[8.281.400.6 NMAC - Rp, 8.281.400.6 NMAC, 1/1/2019]
8.281.400.7 DEFINITIONS: [ RESERVED ]
8.281.400.8 MISSION STATEMENT: To transform lives. Working with our partners, we design and deliver innovative, high quality health and human services that improve the security and promote independence for New Mexicans in their communities.
[8.281.400.8 NMAC - N, 5/1/2021]
8.281.400.9 INSTITUTIONAL CARE MEDICAID CATEGORIES 081, 083 AND 084: The New Mexico medicaid program ( medicaid ) pays for services furnished to individuals who require institutional care and who meet all supplemental security income (SSI) eligibility criteria and whose monthly gross countable income is less than the maximum allowed amount for institutional care.
[8.281.400.9 NMAC - Rp, 8.281.400.9 NMAC, 1/1/2019]
8.281.400.10 BASIS FOR DEFINING THE GROUP: An applicant or recipient must require institutional care as certified by a physician licensed to practice medicine or osteopathy. The applicant or recipient must be institutionalized in a medicaid qualifying bed in a New Mexico medicaid approved institution or in a hospital administered under the authority of the US department of veterans affairs (VA). Medicaid approved “Institutions” are defined as acute care hospitals (ACHs), nursing facilities (NFs) and intermediate care facilities for individuals with intellectual disabilities (ICF/IID), swing beds and certified instate inpatient rehabilitation centers. Level of care (LOC) determinations for institutional care medicaid eligibility are made by the MAD utilization review (UR) contractor or a member's selected or assigned Managed Care Organization (MCO). Documentation of these determinations is provided to the institution by the UR contractor or MCO. For applicants or recipients in a hospital awaiting placement in NFs, confirmation letters are furnished by the MAD UR contractor for use by hospital staff. A level of care (LOC) is not required for acute care hospitals. Documentation of acute care hospitalization must be provided by the hospital to determine the eligibility period.
[8.281.400.10 NMAC - Rp, 8.281.400.10 NMAC, 1/1/2019; A, 5/1/2021]
8.281.400.11 INTERVIEW REQUIREMENTS:
An interview is not required for institutional care medicaid . An applicant or recipient can request an interview from the income support division (ISD).
[8.281.400.11 NMAC - Rp, 8.281.400.11 NMAC, 1/1/2019; A, 5/1/2021]
8.281.400.12 ENUMERATION: An applicant or recipient must furnish their social security number in accordance with 8.200.410.10 NMAC.
[8.281.400.12 NMAC - Rp, 8.281.400.12 NMAC, 1/1/2019; A, 5/1/2021; A, 12/1/2022]
8.281.400.13 CITIZENSHIP: Refer to medical assistance program manual Section 8.200.410.11 NMAC.
[8.281.400.13 NMAC - Rp, 8.281.400.13 NMAC, 1/1/2019]
8.281.400.14 RESIDENCE:
A. Residence in the United States: An applicant or recipient must be residing in the United States at the time of approval. An applicant or recipient who leaves the United States for an entire calendar month loses eligibility. The applicant or recipient must re-establish their residence in the United States for at least 30 consecutive days before becoming eligible for any SSI-related medicaid program.
B. Residence in New Mexico: To be eligible for institutional care medicaid , an applicant or recipient must be physically present in New Mexico on the date of application or final determination of eligibility and must have demonstrated intent to remain in the state. If the individual does not have the present mental capacity to declare intent, the parent, guardian or adult child may assume responsibility for a declaration of intent. If the individual does not have the present mental capacity to declare intent and there is no guardian or relative to assume responsibility for a declaration of intent, the state where the person is living is recognized as the state of residence. A temporary absence from the state does not preclude eligibility. A temporary absence exists if the applicant or recipient leaves the state for a specific purpose with a time-limited goal and intends to return to New Mexico when the goal is accomplished.
[8.281.400.14 NMAC - Rp, 8.281.400.14 NMAC, 1/1/2019; A, 5/1/2021]
8.281.400.15 SPECIAL RECIPIENT REQUIREMENTS:
A. Institutional care medicaid : To be eligible for institutional care medicaid an applicant or recipient must be aged, blind, or disabled as defined by the social security administration (SSA). Recipients of institutional care medicaid in New Mexico are terminated from assistance if they are transferred to, or choose to move to, a long term care facility out-of-state. New Mexico medicaid does not cover NF services furnished to applicants or recipients in out-of-state facilities with the exception of out-of-state long-term care facilities that are not available in the state of New Mexico in accordance with Subsection F of 8.302.4.12 NMAC.
B. Intermediate care facilities for individuals with intellectual disabilities (ICF/IID): To be eligible for an ICF/IID, applicants or recipients must obtain a match letter from the department of health to confirm that they meet the definition of an individual with a developmental disability as determined by the department of health/developmental disabilities supports division, in accordance with 8.290.400.10 NMAC.
[8.281.400.15 NMAC - Rp, 8.281.400.15 NMAC, 1/1/2019; A, 5/1/2021; A, 12/1/2022]
8.281.400.16 AGED: To be considered aged, an applicant or recipient must be 65 years of age or older. Age is verified by the following:
A. decision from SSA regarding age;
B. acceptable documentary evidence including:
(1) birth certificate or delayed birth certificate;
(2) World War II ration books;
(3) baptismal records;
(4) marriage license or certificate;
(5) military discharge papers;
(6) insurance policies;
(7) Indian census records;
(8) dated newspaper clippings;
(9) voting registration;
(10) World War I registration;
(11) veterans administration records; or
(12) school census.
[8.281.400.16 NMAC - Rp, 8.281.400.16 NMAC, 1/1/2019; A, 5/1/2021]
8.281.400.17 BLIND: To be considered blind, an applicant or recipient must have central visual acuity of 20/200 or less with corrective lenses.
A. Documentation of blindness: An applicant or recipient must meet the SSA’s definition of blindness. If the applicant or recipient is receiving social security or supplemental security income (SSI) benefits based on the condition of blindness, verification of this factor can be accomplished through documents, such as award letters or benefit checks.
B. Status of SSA determination: If it has not been determined whether an applicant or recipient meets SSA’s definition of blindness or if only a temporary determination was made, the ISD worker must request a determination from the disability determination unit (DDU). Eligibility based on blindness cannot be considered to exist without a DDS determination.
C. Redetermination of blindness: A redetermination of blindness by the DDU is not required on a re-application following an applicant or recipient’s termination from SSI/SSA or medicaid , if a permanent condition of blindness was previously established or the termination was based on a condition unrelated to blindness and there was no indication of possible improvement in an applicant or recipient’s vision.
D. Remedial treatment: If the DDU recommends remedial medical treatment that carries no more than the usual risk or a reasonable plan for vocational training, an applicant or recipient must comply with the recommendation unless good cause for not doing so exists.
[8.281.400.17 NMAC - Rp, 8.281.400.17 NMAC, 1/1/2019; A, 5/1/2021]
8.281.400.18 DISABILITY: To be considered disabled, an applicant or recipient under 65 years of age is considered to have a qualifying disability if they are unable to engage in any substantial gainful activity because of any medically determinable physical, developmental, or mental impairment which has lasted, or is expected to last, for a continuous period of at least 12 months.
A. Documentation of disability: An applicant or recipient must meet the social security administration (SSA)’s definition of disability. If the applicant or recipient is receiving social security or supplemental security income (SSI) benefits based on the condition of disability, verification of this factor can be accomplished through documents, such as award letters or benefit checks.
B. Status of SSA determination: If it has not been determined whether an applicant or recipient meets the SSA’s definition of disability or if only a temporary determination was made, the ISS must request a determination from the DDU. Eligibility based on disability cannot be considered to exist without a DDS determination.
C. Redetermination of disability: A redetermination of disability by the DDU is not required on a re-application following an applicant or recipient’s termination from SSI/SSA or medicaid , if a permanent condition of disability was previously established or the termination was based on a condition unrelated to disability and there was no indication of possible improvement in an applicant/recipient’s physical condition.
D. Remedial treatment: If the DDU recommends remedial medical treatment that carries no more than the usual risk or a reasonable plan for vocational training, an applicant or recipient must comply with the recommendation unless good cause for not doing so exists.
[8.281.400.18 NMAC - Rp, 8.281.400.18 NMAC, 1/1/2019; A, 5/1/2021]
8.281.400.19 SSI STATUS: The ISD worker determines whether an applicant or recipient’s SSI eligibility will continue while they are institutionalized.
A. Applicant/recipient currently eligible for SSI: If an applicant or recipient will not continue to be eligible for SSI while institutionalized, the ISD worker processes the application regardless of the fact that SSA will not terminate SSI benefits until the month following the month the applicant or recipient enters an institution.
B. Applicant not currently receiving SSI: If an applicant or recipient is not receiving SSI or has not applied for SSI before applying for medicaid and their gross income is less than $50, the ISD worker processes the application and refers the applicant to the SSA for determination of eligibility for SSI benefits. If an applicant’s gross monthly income is $50 or more but not in excess of the maximum allowable income standard, the ISD worker determines eligibility for institutional care medicaid based on remaining financial and nonfinancial criteria.
[8.281.400.19 NMAC - Rp, 8.281.400.19 NMAC, 1/1/2019; A, 5/1/2021]
8.281.400.20 RECIPIENT RIGHTS AND RESPONSIBILITIES: An applicant or recipient is responsible for establishing their eligibility for medicaid . As part of this responsibility, the applicant or recipient must provide required information and documents or take the actions necessary to establish eligibility. Failure to do so must result in a decision that eligibility does not exist. An applicant or recipient must also grant the HSD permission to contact other persons, agencies or sources of information, which are necessary to establish eligibility.
[8.281.400.20 NMAC - Rp, 8.281.400.20 NMAC, 1/1/2019; A, 5/1/2021]
8.281.400.21 RIGHT TO HEARING: An applicant or recipient residing in an institution can request an administrative hearing to dispute issues relating to the eligibility determination process at the time of the eligibility determination (see Section 8.200.430.12 NMAC, Right to Hearing).
[8.281.400.21 NMAC - Rp, 8.281.400.21 NMAC, 1/1/2019; A, 5/1/2021]
8.281.400.22 ASSIGNMENTS OF MEDICAL SUPPORT: Refer to medical assistance program manual Subsection F of Section 8.200.420.12 NMAC.
[8.281.400.22 NMAC - Rp, 8.281.400.22 NMAC, 1/1/2019]
8.281.400.23 REPORTING REQUIREMENTS: Medicaid recipients must report any change in circumstances, which may affect their eligibility to their local ISD office within 10 days of the change in accordance with 8.200.430.18 NMAC.
[8.281.400.23 NMAC - Rp, 8.281.400.23 NMAC, 1/1/2019; A, 5/1/2021]
HISTORY OF 8.281.400 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 11/16/191994.
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 11/16/191994.
MAD Rule 882, Resources, filed 12/29/191994.
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 11/16/191994.
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 2/1/191995.
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.
8.281.400 NMAC - Recipient Policies, filed 6/13/2003 - Repealed effective 1/1/2019.
TITLE 8 SOCIAL SERVICES
CHAPTER 281 MEDICAID ELIGIBILITY - INSTITUTIONAL CARE (CATEGORIES 081, 083, 084)
PART 500 INCOME AND RESOURCE STANDARDS
8.281.500.1 ISSUING AGENCY: New Mexico Health Care Authority.
8.281.500.2 SCOPE: The rule applies to the general public.
[8. 281.500 .2 NMAC - Rp, 8.281.500.2 NMAC, 8/15/2015]
8.281.500.3 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, Section 27-1-12 et seq. NMSA 1978. 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. 281.500 .3 NMAC - Rp, 8.281.500.3 NMAC, 8/15/2015 ; A, 7/1/2024]
8.281.500.4 DURATION: Permanent.
[8. 281.500 .4 NMAC - Rp, 8.281.500.4 NMAC, 8/15/2015]
8.281.500.5 EFFECTIVE DATE: August 15, 2015, unless a later date is cited at the end of a section.
[8. 281.500 .5 NMAC - Rp, 8.281.500.5 NMAC, 8/15/2015]
8.281.500.6 OBJECTIVE: The objective of this rule is to provide specific instructions when determining eligibility for the medicaid program and other health care programs it administers. Generally, applicable eligibility rules are detailed in the medical assistance division (MAD) medical assistance programs (MAP) eligibility rules manual, specifically Section 8.200.400 NMAC. Processes for establishing and maintaining MAP eligibility are detailed in the income support division (ISD) general provisions 8.100 NMAC.
[8. 281.500 .6 NMAC - Rp, 8.281.500.6 NMAC, 8/15/2015]
8.281.500.7 DEFINITIONS:
A. Definitions beginning with “A”:
(1) Actuarially sound: With respect to an annuity or promissory note, the payments made to the beneficiary must not exceed their life expectancy and returns to the beneficiary an amount at least equal to the amount used to establish the contract.
(2) Annuity: A financial instrument, usually sold by a life insurance company, that pays out a regular income at fixed intervals for a certain period of time, often beginning at a certain age and continuing for the life of the owner.
(3) Asset limit: An applicant or recipient may be eligible for a MAP category of institutional care on the factor of resources if countable resources do not exceed $2,000.
(4) Assets: All income and resources of an applicant or recipient and their spouse, if applicable.
(5) Authorized representative: The individual designated to represent and act on the applicant’s or recipient’s behalf during the eligibility process. The applicant or recipient or their authorized representative must provide formal documentation authorizing the named individual or individuals to access the identified case information for a specified purpose and time frame. An authorized representative may be an attorney representing a person or household, a person acting under the authority of a valid power of attorney, a guardian, or any other individual or individuals designated in writing by the claimant.
B. Definitions beginning with “B”: Bona fide: A bona fide agreement is made in good faith and is legally valid.
C. Definitions beginning with “C”:
(1) Community spouse: The spouse of an institutionalized applicant or eligible recipient who is residing in the community and is not in an institution.
(2) Community spouse resource allowance (CSRA): An amount of a married couple’s resources that is set aside for the community spouse when the eligible recipient is institutionalized. There is a MAD minimum and a federal maximum amount of resources that can be set aside for the community spouse.
D. Definitions beginning with “D”: [RESERVED]
E. Definitions beginning with “E”: Encumbrance: A general term for any claim or lien on a parcel of real property, including mortgages, deeds of trust and abstracts of judgments.
F. Definitions beginning with “F”: Fair market value: An estimate of the value of an asset, if sold at the prevailing price at the time it was actually transferred. Value is based on criteria used in appraising the value of assets for the purpose of determining a MAP category of eligibility.
G. Definitions beginning with “G”: [RESERVED]
H. Definitions beginning with “H”: Home equity: (Also known as equity value.) The value of a home minus the total amount owed on it in mortgages, liens and other encumbrances.
I. Definitions beginning with “I”:
(1) Income: Anything that an applicant or recipient receives in cash or in kind that [he or she] they can use to meet their needs for food and shelter. In-kind income is not cash, but is actual food or shelter, or something that the applicant or recipient can use to get one of these.
(2) Institutionalized spouse: An applicant or recipient who is in an acute care hospital, nursing facility, intermediate care facility for individuals with intellectual disabilities (ICF-IID), swing bed or certified in-state inpatient rehabilitation center.
J. Definitions beginning with “J”: [RESERVED]
K. Definitions beginning with “K”: [RESERVED]
L. Definitions beginning with “L”:
(1) Life estate: An interest in property that exists for the life of a person. For example, an individual gives a life estate in a house to person A and the remainder to person B. Person A has a life estate and person B has a remainder interest until person A dies.
(2) Liquid resource: Cash or something that can easily be converted to cash within 20 business days.
(3) Loan: A transaction in which one party advances money to, or on behalf of another party, who promises to repay the lender in full, with or without interest.
(4) Long-term Care Insurance Policy: A type of insurance developed specifically to cover the costs of nursing homes , assisted living , home health care and other long-term care services as specified in the individual’s policy.
(5) Lookback period: A period of time in the past through which the ISD caseworker may examine all financial transactions for asset transfers.
M. Definitions beginning with “M”: Minimum monthly maintenance needs allowance: A minimum level of income that the federal government allows to be set aside for the support of the community spouse when the other spouse is in an institution.
N. Definitions beginning with “N”:
(1) Negotiable agreement: An agreement (i.e., a loan) in which the ownership of the agreement and the whole amount of money can be transferred from one person to another.
(2) Non-liquid resource: An asset such as real property, which cannot be easily converted to cash within 20 days.
O. Definitions beginning with “O”: [RESERVED]
P. Definitions beginning with “P”:
(1) Promissory note: A promissory note is a written, unconditional agreement in which one person promises to pay a specified sum of money at a specified time to another person.
(2) Protected Asset Limit: Protected assets up to the amount of qualified long-term care insurance partnership (QLTCPI) benefit payments made to or on the behalf of individual. This is the applicant’s or recipient’s protected asset limit (PAL).
Q. Definitions beginning with “Q”: Qualified state long-term care insurance partnership (QSLTCIP) program: A partnership program that joins MAD with private insurance companies that offer long-term care insurance policies. The MAP eligibility requirements are adjusted to provide financial incentives for eligible recipients to purchase private QSLTCIP coverage.
R. Definitions beginning with “R”:
(1) Relative: Relative is defined as a spouse, son or daughter; grandson or granddaughter; step-son or step-daughter; in-laws; mother or father; step-mother or step-father; half-sister or half-brother; grandmother or grandfather; aunt or uncle; sister or brother; step-brother or step-sister; and niece or nephew.
(2) Remainder/remainder man: An interest in property that occurs after a life estate. For example, an individual gives a life estate in a house to person A and the remainder to person B. Person A has a life estate and Person B has a remainder interest until person A dies. Person B is also called the remainderman.
(3) Resources: Cash or other liquid assets and any real or personal property that applicant or recipient (or spouse if any) owns and could convert to be used for their support and maintenance.
(4) Restricted coverage: An eligible recipient who has restricted coverage may access medically necessary MAD benefits except for long-term care services in a nursing facility.
(5) Reverse mortgage: A loan against home equity providing cash advances to a borrower and requiring no repayment until a future date.
S. Definitions beginning with “S”:
(1) Sole benefit of: A transfer is considered for the sole benefit of a spouse, blind or disabled child, or a disabled individual if the transfer is arranged in such a way that no individual or entity except the spouse, blind, or disabled child, or disabled individual can benefit from the assets transferred in any way, whether at the time of the transfer or at any time in the future.
(2) Spouse : For purposes of this rule, a spouse is an individual who is legally married under the laws of a state, a territory, or a foreign jurisdiction in which the marriage was celebrated.
T. Definitions beginning with “T”: Transfer: To change over the possession, control or ownership of something.
U. Definitions beginning with “U”: [RESERVED]
V. Definitions beginning with “V”: [RESERVED]
W. Definitions beginning with “W”: [RESERVED]
X. Definitions beginning with “X”: [RESERVED]
Y. Definitions beginning with “Y”: [RESERVED]
Z. Definitions beginning with “Z”: [RESERVED]
[8. 281.500 .7 NMAC - Rp, 8.281.500.7 NMAC, 8/15/2015; A, 3/1/2018; A, 12/1/2022]
8.281.500.8 MISSION: To transform lives. Working with our partners, we design and deliver innovative, high quality health and human services that improve the security and promote independence for New Mexicans in their communities.
[8.281.500.10 NMAC - N, 12/1/2022]
8.281.500.9 NEED DETERMINATION: Applicants for and recipients of institutional care must apply for and take all necessary steps to obtain any income or resources to which they may be entitled. When an applicant or recipient is given notification by HSD to apply for and obtain specific income and resources they must take steps to do so within 30 calendar days.
A. Failure to apply for and take steps to determine eligibility for other benefits: Failure or refusal to apply for and take all necessary steps to determine eligibility for other benefits after notice is received results in an applicant or recipient becoming ineligible for a MAP category of eligibility for institutional care.
B. Exceptions to general requirement: Applicants or recipients who have elected a lower veterans administration (VA) payment do not need to reapply for veterans administration improved pension (VAIP) benefits. Crime victims are not required to accept victims compensation payments from a state-administered fund as a condition of MAP eligibility.
[8. 281.500 .9 NMAC - Rp, 8.281.500.9 NMAC, 8/15/2015; A, 12/1/2022]
8.281.500.10 RESOURCE STANDARDS: A “resource” is defined as cash or liquid assets and real or personal property which is owned and can be used either directly, or by sale or conversion, for the applicant’s or recipient’s support and maintenance. Resources may be liquid or non-liquid and may be excluded from the eligibility determination process under certain conditions. A liquid resource is an asset which can readily be converted to cash. A non-liquid resource is an asset or property which cannot readily be converted to cash.
A. Resource determination: The resource determination for a MAP category of eligibility for institutional care is made as of the first moment of the first day of the month. An applicant or recipient is ineligible for any month in which their countable resources exceed the allowable resource standard as of the first moment of the first day of the month. Changes in the amount of countable resources during a month do not affect eligibility or ineligibility for that month.
B. Distinguishing between resources and income: Resources must be distinguished from income to avoid counting a single asset twice. As a general rule, ownership of a resource precedes the current month while income is received in the current month. Income held by an applicant or recipient until the following month becomes a resource.
[8. 281.500 .10 NMAC - Rp, 8.281.500.10 NMAC, 8/15/2015; A, 12/1/2022]
8.281.500.11 APPLICABLE RESOURCE STANDARDS: The resource criteria and eligibility standards of this section apply to all applicants for and recipients of a MAP category of eligibility for institutional care. An applicant or recipient is eligible for a MAP category of eligibility for institutional care on the factor of resources if countable resources do not exceed $2,000. Some of an applicant’s or recipient’s resources are counted in the eligibility determination and some resources are excluded. Any resource which is not specifically excluded in Section 8.281.500.13 NMAC is considered a countable resource for the purpose of determining a MAP category of eligibility for institutional care.
A. Liquid resources: A liquid resource is cash or something that can easily be converted to cash within 20 business days. The face or surrender value of liquid resources such as cash, savings or checking accounts, and other financial instruments are considered in determining a MAP category of eligibility. The countable value of liquid resources is based on their current fair market value.
(1) An applicant or recipient must provide verification of the value of all liquid resources. The resource value of a bank account is customarily verified by a statement from the bank showing the account balance as of the first moment of the first day of the month in question. If an applicant or recipient cannot provide this verification, the ISD worker provides the applicant or recipient with a detailed request of all documents needed to determine a MAP category of eligibility.
(2) If the applicant or recipient can demonstrate that a check was written and delivered to a payee but not cashed by the payee prior to the first moment of the first day of the month, the amount of that check is subtracted from the applicant or recipient checking account balance to arrive at the amount to be considered a countable resource.
B. Non-liquid resources: A non-liquid resource is something such as real property that cannot easily be converted to cash within 20 business days. The value of non-liquid resources is computed at current market value minus encumbrances or financial penalties for early withdrawal.
[8. 281.500 .11 NMAC - Rp, 8.281.500.11 NMAC, 8/15/2015]
8.281.500.12 COUNTABLE RESOURCES: Before a resource can be considered countable, the three criteria listed below must be met.
A. Ownership interest: An applicant or recipient must have an ownership interest in a resource for it to be countable. The fact that an applicant or recipient has access to a resource, or has a legal right to use it, does not make it countable unless the applicant or recipient also has an ownership interest in it.
B. Legal right to convert resource to cash: An applicant or recipient must have the legal ability to spend the funds or to convert non-cash resources into cash.
(1) Physical possession of resource: The fact that an applicant or recipient does not have physical possession of a resource does not mean it is not their resource. If they have the legal ability to spend the funds or convert the resource to cash, the resource is considered countable. Physical possession of savings bonds is a legal requirement for cashing them.
(2) Unrestricted use of resource: An applicant or recipient is considered to have free access to the unrestricted use of a resource even if they can take those actions only through an agent, such as a representative payee, guardian, conservator, trustee, or another authorized representative. If there is a legal bar to the sale of a resource, the resource is not countable. However, if a co-owner of real property can bring an action to partition and sell the property, their interest in the property is a countable resource.
C. Legal ability to use a resource: If a legal restriction exists which prevents the use of a resource for the applicant’s or recipient’s own support and maintenance, the resource is not countable.
D. Joint ownership of resources: If an applicant or recipient owns either liquid or non-liquid resources jointly with others, they have 30 calendar days from the date requested by the ISD worker to submit all documentation required to verify their claims regarding ownership of, access to, and legal ability to use the resource for personal support and maintenance. Failure to do so results in the presumption that the resource is countable and belongs to the applicant or recipient.
(1) Jointly held property: If jointly held property is identified during review of an active case, the ISD worker must:
(a) determine whether the property is a countable resource;
(b) determine whether the value of the jointly held property plus the value of other countable resources exceeds the allowable resource maximum; and
(c) if the value of countable resources exceeds the allowable maximum, advance notice is furnished to the applicant or recipient of the intent to close their case and their right to verify claims regarding ownership of, access to, and legal ability to use the property for personal support and maintenance.
(i) If the applicant or recipient fails to provide required information or respond within the advance notice period, their case is closed.
(ii) If, after expiration of the advance notice period but prior to the end of the month in which the advance notice expires, the applicant or recipient provides the required evidence to show the property is not a countable resource, or is countable in an amount which, when added to the value of other countable resources, does not exceed the maximum allowable limit, and eligibility continues to exist on all other factors, the case is reinstated for the next month.
(2) Joint bank accounts: If liquid resources are in a joint bank account of any type, the applicant’s or recipient’s ownership interest, while the parties to the account are alive, is presumed to be proportionate to the applicant’s or recipient’s contributions to the total resources on deposit.
(a) The applicant or recipient is presumed to own a proportionate share of the funds on deposit unless they present clear and convincing evidence that the parties to the account intended the applicant or recipient to have a different ownership interest.
(b) To establish the applicant’s or recipient’s ownership interest in a joint account, the following are required:
(i) statement by the applicant or recipient regarding contributions to the account; reasons for establishing the account; who owns the funds in the account; and any supporting documentation; plus
(ii) corroborating statements from the other account holder(s);
(iii) if either the applicant or recipient or the other account holder is not capable of making a statement, the applicant or recipient or an authorized representative must obtain a statement from a third party who has knowledge of the circumstances surrounding the establishment of the joint account.
(c) Failure to provide required documentation within 30 calendar days of the date requested by the ISD worker results in a determination that the entire account amount belongs to the applicant or recipient.
(d) If the existence of a jointly held bank account is identified during the review of an active case, the ISD worker requests evidence of ownership and accessibility. If the evidence is not furnished within 30 calendar days of the request, their case is closed.
(3) Life estate: A life estate interest in the applicant’s or recipient’s own home will count as a resource if the applicant or recipient has not resided on the property continuously for at least 12 months from the date of the life estate purchase. For a purchase of a life estate in the home of another, see Subsection D of 8.281.500.14 NMAC.
(a) The “unisex life estate and remainder interest tables” are used to determine the value of a life estate. See 8.200.520 NMAC. The value is computed by multiplying the current fair market value by the percentage reduction on the unisex table under the column for the applicant’s or recipient’s age.
(b) If an applicant or recipient feels the value calculated based on this method is overstated, they can obtain a valuation of the life estate in the area for use as documentation of lesser value.
E. The home as a countable resource: If the applicant or recipient or their authorized representative states the applicant or recipient does not intend to return to the home and it is not the residence of applicant’s or recipient’s spouse or dependent relative, the home is considered a countable resource. If the applicant or recipient or their authorized representative puts the home up for sale and it is not the primary residence of the applicant’s or recipient’s spouse or a dependent relative, the home is considered a countable resource. A dependent relative is a minor child or adult disabled child of the applicant, recipient, or community spouse.
F. Value of property: The applicant or recipient must supply HSD with written documentation regarding the fair market value of the property from a real estate agent, title company or mortgage insurance company familiar with the area in which the property is located in addition to any encumbrances against the property. The ISD worker determines the equity value of the property by subtracting the amount of the encumbrances from the fair market value of the property.
G. Hardship: Applicants or recipients who are on restricted coverage due to excess equity in their homes may request an undue hardship waiver based on the criteria specified in 8.281.500.24 NMAC.
H. Real property:
(1) If an applicant or recipient is the sole owner of real property, other than the applicant’s or recipient’s or their primary residence and has the right to dispose of it, the entire equity value is included as a countable resource.
(2) If an applicant or recipient owns property with one or more individuals and the applicant or recipient has the right, authority or power to liquidate the property or their pro-rata share of the property, it is considered a resource. If a property right cannot be liquidated, the property will not be considered a resource to applicant or recipient. The applicant or recipient must provide a copy of the legal document which indicates [his or her] their interest in the property.
I. Vehicles: One automobile is totally excluded regardless of value if it is used for transportation for the applicant or recipient or a member of applicant’s or recipient’s household. Any other automobiles are considered to be non-liquid resources. Recreational vehicles and boats are considered household goods and personal effects rather than vehicles.
J. Household goods and personal effects: Household goods and personal effects are considered countable resources if the items were acquired or are held for their value or are held as an investment. Such items can include but are not limited to gems and jewelry that is not worn or held for family significance, or collectibles.
K. Promissory notes: If an applicant or recipient holds or owns a promissory note and the note is negotiable, it is a countable resource. The value is the outstanding principal balance due at the time of the applicant’s or recipient’s MAP application, unless the applicant or recipient proves that it has a lower value.
(1) A promissory note held by the applicant or recipient must be a bona fide loan. This means that it must be legally valid and made in good faith. The ISD worker must evaluate the note and determine whether or not it is a bona fide loan. In order to determine if the note is a bona fide loan, the ISD worker should obtain documentation of the applicant’s or recipient’s receipt of payments on the note at the time of application and at re-certification. If the applicant or recipient sells or transfers the promissory note, then [he or she] they may be subject to a penalty for a transfer of assets for less than fair market value.
(2) If the promissory note is non-negotiable, and the applicant or recipient receives payments on the note that could be used for food or shelter, then the amount of the payment retained in the month following receipt is a resource to the applicant or recipient.
(3) If an applicant or recipient purchases a promissory note, loan or mortgage, the repayment terms must be actuarially sound, provide for equal payment amounts with no deferral or balloon payments, and it must contain a provision that prohibits cancellation of the balance upon the death of the lender. A promissory note not meeting these requirements shall be treated as a transfer of assets for less than fair market value. If a promissory note does not meet these requirements, the value of the note, loan or mortgage is the outstanding balance due on the date of the applicant’s or recipient’s MAP application.
L. Pension funds: A pension fund, if accessible to the applicant or recipient, is a countable resource. Any fees for withdrawal of the funds are subtracted from the balance and the remainder is a countable resource.
M. Individual retirement accounts (IRA): An IRA is a tax-deductible savings account that sets aside money for retirement. Funds in an IRA are counted as an asset in their entirety less the amount of penalty for early withdrawal.
N. Keogh plan: A Keogh plan is a retirement plan established by a self-employed applicant or recipient alone or for the self-employed applicant or recipient and their employees. If the Keogh plan was established for the self-employed applicant or recipient alone, the funds in the plan are counted as an asset in their entirety less the amount of penalty for early withdrawal. If the Keogh plan was established for employees other than the spouse of the applicant or recipient, the funds do not count as an asset.
O. Loans: In some circumstances a loan may be a countable resource.
(1) Negotiable loan. If an applicant or recipient owns a loan agreement or is a lender and the agreement is a negotiable, bona fide loan:
(a) the outstanding principal balance is a resource of the applicant or recipient;
(b) the cash provided to the borrower is no longer the applicant or recipient lender’s resource because they cannot access it for their own use; the loan agreement replaces the cash as the applicant or recipient lender’s resource;
(c) payments that the applicant or recipient lender receives from the borrower against the loan principal are conversions of a resource, not income; if retained, the payments are counted as the applicant or recipient lender’s resource starting in the month following the month of receipt; and
(d) interest income received by the applicant or recipient lender is unearned income.
(2) Non-negotiable loan. If the applicant or recipient owns a loan agreement or is a lender and the loan agreement is not a bona fide loan or is not negotiable:
(a) the agreement is not a resource of the applicant or recipient lender;
(b) payments against the principal are income to the applicant or recipient lender, not conversion of a resource;
(c) the cash specified in the agreement may be a resource if the applicant or recipient lender can access it for their own use; and
(d) interest income received by the applicant or recipient lender is unearned income.
(3) Bona fide loan. If the applicant or recipient is the borrower and the agreement is a bona fide loan:
(a) the loan agreement itself is not a resource for the applicant or recipient; and
(b) the cash provided by the applicant or recipient lender is not income, but is the borrower’s resource if retained in the month following the month of receipt.
(4) Not a bona fide loan. If the applicant or recipient is the borrower and the agreement is not a bona fide loan:
(a) the loan agreement itself is not a resource of the applicant or recipient; and
(b) the cash provided by the applicant or recipient lender is income in the month received and is a resource if retained in the month following the month it was received.
(5) Informal loan. If the agreement is an agreement between applicants or recipients who are not in the business of lending money or providing credit, it is an informal loan. An informal loan is bona fide if it meets all of the following criteria:
(a) the agreement is enforceable under state law;
(b) the agreement is in effect at the time that the cash is provided to the borrower; money given to an applicant or recipient with no obligation to repay cannot become a loan at a later date;
(c) the obligation to repay the loan must be acknowledged by both the applicant or recipient lender and the borrower; when money or property is given and accepted based on any understanding other than it is to be repaid by the receiver, there is no loan;
(d) the agreement must include a plan or schedule for repayment, and the borrower’s express intent to repay by pledging real or personal property or anticipated future income (such as social security insurance (SSI) benefits);
(e) the repayment plan or schedule must be feasible; in determining the plan’s feasibility, consider the amount of the loan, the applicant’s or recipient’s resources and income and the applicant’s or recipient’s living expenses;
(f) if the applicant or recipient is the borrower, the loan proceeds are a resource if they are retained in the month following the month of receipt; the resource value is the amount of the proceeds that the applicant or recipient still holds in the month following the month of receipt;
(g) if the applicant or recipient is the lender, the agreement is a countable resource starting in the month after the month that the applicant or recipient lender provides the proceeds to the borrower; and
(h) the agreement’s resource value is the outstanding principal balance unless the applicant or recipient lender provides evidence that the loan has a lower value.
P. Other financial instruments: Other financial instruments will be evaluated by HSD to determine if they are a countable resource.
Q. Continuing care retirement community, assisted living, life care community or like living arrangement: The portion of initial fees paid upon signing a contract for housing and care that has a potential to be refunded to the applicant or recipient is countable.
R. Other countable resources: Other liquid or non-liquid resources must be considered in the calculation of total countable resources. The following non-liquid resources may be included in the calculation of countable resources if they cannot be excluded pursuant to 8.281.500.13 NMAC:
(1) burial funds;
(2) burial spaces;
(3) life insurance and other insurance products such as annuities;
(4) income-producing property; and
(5) other financial investment products.
[8. 281.500 .12 NMAC - Rp, 8.281.500.12 NMAC, 8/15/2015; A, 12/1/2022]
8.281.500.13 RESOURCE EXCLUSIONS: Some types of resources can be excluded from the calculation of countable resources if they meet the specific criteria listed below.
A. Burial fund exclusion: Up to $1,500 can be excluded from the countable liquid resources of an applicant or recipient if designated as their burial fund. An additional amount of up to $1,500 can be excluded from countable liquid resources if designated as burial funds for the spouse of the applicant or recipient. The burial fund exclusion is separate from the burial space exclusion.
(1) Retroactive designation of burial funds: An applicant or recipient can retroactively designate funds for burial back to the first day of the month in which the applicant or recipient intended the funds to be set aside for burial. The applicant or recipient must sign a statement indicating the month the funds were set aside for burial.
(2) Limit on exclusion: An applicant or recipient can designate as much of their liquid resources as they wish for burial purposes. However, only one burial fund allowance of up to $1,500 each for the applicant or recipient and their spouse can be excluded from countable resources. A burial fund exclusion does not continue from one period of eligibility to another (i.e., across a period of ineligibility). For each new period of eligibility, any exclusion of burial funds must be developed as for an initial application.
(3) Removal of designation: An applicant or recipient cannot "un-designate" burial funds, unless one of the following occurs:
(a) eligibility terminates;
(b) part, or all, of the funds can no longer be excluded because the applicant or recipient purchased excluded life insurance or an irrevocable burial contract which partially or totally offsets the available burial fund exclusion; or
(c) the applicant or recipient uses the funds or any portion of the funds for another purpose; this action makes the funds countable; any designated burial funds used for another purpose will be counted as income in the month withdrawn and as a resource thereafter.
(4) Reduction of burial fund exclusion: The $1,500 burial fund exclusion is reduced by the following:
(a) the face value of excluded life insurance policies;
(b) assets held in irrevocable burial trusts; irrevocable means the value paid cannot be returned to the applicant or recipient;
(c) assets that are not burial space items held in irrevocable burial contracts;
(d) assets held in other irrevocable burial arrangements; and
(e) assets held in an irrevocable trust available to meet burial expenses.
(5) Interest from burial fund: Interest derived from a burial fund is not considered a countable resource or income if all the following conditions exist:
(a) the original amount is excluded;
(b) the excluded burial fund is not commingled with non-excluded burial funds;
(c) the interest earned remains with the excluded burial funds.
(6) Commingling of burial funds: Burial funds cannot be commingled with non-burial funds. If only part of the funds in an account are designated for burial, the burial fund exclusion cannot be applied until the funds designated for burial expenses are separated from the non-burial funds. Countable and excluded burial funds can be commingled.
(7) Life insurance policy designated as burial fund: An applicant or recipient can designate a life insurance policy as a burial fund at the time of application. The ISD caseworker must first analyze Subsection H of 8.281.500.13 NMAC [of this rule].
(8) Burial contracts: If an applicant or recipient has a prepaid burial contract, the ISD caseworker determines whether it is revocable or irrevocable and whether it is paid for. Until all payments are made on a burial contract, the amounts paid are considered burial funds and no burial space exclusions apply.
(a) An applicant or recipient may have a burial contract which is funded by a life insurance policy. The life insurance may be either revocably or irrevocably assigned to a funeral director or mortuary.
(b) A revocable contract exists if the value can be returned to the applicant or recipient. An irrevocable contract exists when the value cannot be returned. If the contract or insurance policy assignment is revocable, the following apply.
(i) If the burial contract is funded by a life insurance policy, the policy is the resource which must be evaluated. The burial contract itself has no value. It exists only to explain the applicant’s or recipient’s burial arrangements.
(ii) No exclusions can be made for burial space items because the applicant or recipient does not have a right to them if the contract is not paid for or the policy is not paid up.
(c) If the assignment is irrevocable, the life insurance or burial contract is not a countable resource, because the applicant or recipient does not own it.
(i) The burial space exclusions can apply if the applicant or recipient has the right to the burial space items.
(ii) The value of the irrevocable burial arrangement is applied against the $1,500 burial fund exclusion only if the applicant or recipient has other liquid resources to designate for burial.
B. Burial space exclusion: A burial space or an agreement which represents the purchase of a burial space held for the burial of an applicant or recipient, their spouse, or any other member of their immediate family is an excluded resource regardless of value. Interest and accruals on the value of a burial space are excluded from consideration as countable income or resources.
(1) When calculating the value of resources to be deemed to an applicant or recipient from their parent(s) or spouse, the value of spaces held by the parent(s) or spouse which are to be used for the burial of the applicant or recipient, or any member of the applicant’s or recipient’s immediate family, including the deemer parent or spouse, must be excluded.
(2) The burial space exclusion is separate from, and in addition to, the burial fund exclusion.
(3) Burial space definitions: "Burial space" is defined as a burial plot, gravesite, crypt, mausoleum, casket, urn, niche, or other repository customarily used for the deceased's bodily remains.
(a) A burial space also includes necessary and reasonable improvements or additions, such as vaults, headstones, markers, plaques, burial containers (e.g., caskets), arrangements for the opening and closing of a gravesite, and contracts for care and maintenance of the gravesite, sometimes referred to as endowment or perpetual care.
(b) Items that serve the same purpose are excluded once per applicant or recipient, such as excluding a cemetery lot and a casket, but not a casket and an urn.
(4) Burial space contract: An agreement which represents the purchase of a burial space is defined as a contract with a burial provider for a burial space held for the eligible applicant or recipient or a member of their immediate family.
(a) Until all payments are made on the contract, the amounts paid are considered burial funds and no burial space exclusions apply.
(b) An applicant’s or recipient’s immediate family includes:
(i) spouse;
(ii) natural or adoptive parents;
(iii) minor or adult children, including adoptive and stepchildren;
(iv) siblings, including adoptive and stepsiblings; and
(v) spouse of any of the above relatives.
(c) If a relative's relationship to an applicant or recipient is by marriage only, the relationship ceases to exist upon the dissolution of the marriage.
(5) Burial space “held” for an applicant or recipient : A burial space is considered held for an applicant or recipient if:
(a) someone has title to or possesses a burial space intended for the use of the applicant or recipient or a member of their immediate family; or
(b) someone has a contract with a funeral service company for a specified burial space for the applicant or recipient or a member of their immediate family, such as an agreement which represents the applicant’s or recipient’s current right to the use of the items at the amount shown.
(6) Until the purchase price is paid in full, a burial space is not considered “held for” an applicant or recipient under an installment sales contract or similar device if:
(a) the applicant or recipient does not currently own the space;
(b) the applicant or recipient does not currently have the right to use the space; and
(c) the seller is not currently obligated to provide the space.
C. Life estate exclusion: The value of a life estate interest in the applicant’s or recipient’s own home or in the home of another is excluded if the applicant or recipient has continuously resided in the home for a period of 12 months or more from the date of the life estate purchase. The value of the remainderman's interest when a life estate is retained in one's own home is considered a transfer of resources to be evaluated in accordance with 8.281.500.14 NMAC.
D. Settlement exclusions: Agent orange settlement payments made to applicant or recipient veterans or their survivors are excluded from consideration as resources.
(1) Payments made under the Radiation Exposure Compensation Act are excluded from consideration as resources.
(2) Payments received from a state-administered fund established to aid victims of crime are excluded for nine months beginning the month after the month of receipt.
(3) Payments under the foundation called ‘remembrance, responsibility and the future’, excluded from consideration as resources.
E. Exclusions for real property and home: A home is any shelter used by an applicant or recipient, or their spouse, as the principal place of residence. The home is not considered a countable resource while in use by the applicant, recipient, or their spouse as a principal place of residence. If an applicant’s or recipient’s home equity value exceeds the amount allowed under 8.200.510 NMAC, then the entire valued amount of their home is a countable resource. An applicant or recipient with home equity of more than the amount specified shall be placed on restricted coverage for as long as they own the home. The home includes any buildings and contiguous land used in the operation of the home. If the amount is equal to or less than allowed under 8.200.510 NMAC, then their home is excluded during the periods when they reside in an acute care or long-term care medical facility when the applicant or recipient, or their authorized representative, states that the applicant or recipient intends to return to their home.
F. Exclusion of home: If the applicant or recipient or their authorized representative states the applicant or recipient does not intend to return to the home, but the home is the residence of the applicant’s or recipient’s spouse or dependent minor child or adult disabled child, the home is an excluded resource.
G. Income-producing property exclusion: To be excluded from consideration as a countable resource, income-producing property that does not qualify as a bona fide business (e.g., rental property or mineral rights) must have an equity value of no more than $6,000 and an annual rate of return of at least six percent of the equity value. See Subsection F of 8.281.500.13 NMAC if the equity value exceeds $6,000 but the rate of return is at least six percent annually. The $6,000 and six percent limitation does not apply to property used in a trade or bona fide business, or to property used by an applicant or recipient as an employee which is essential to the applicant’s or recipient’s self-support (e.g., tools used in employment as a mechanic, property owned or being purchased in conjunction with operating a business). Existence of a bona fide business can be established by documentation such as business tax returns.
(1) Determination of rate of return: To calculate the annual rate of return for income producing property when the $6,000 and six percent limits apply, the previous year's income tax statement, or at least three months earnings is used to project the rate of return for the year.
(a) If the income is sporadic or has decreased from that needed to maintain a six percent rate of return for the coming year, the property is reevaluated at appropriate intervals.
(b) If the annual rate of return is at least six percent of the equity value but the equity value exceeds $6,000, only the excess equity is a countable resource.
(c) If the annual rate of return is less than six percent but the usual rate of return is more, the property is excluded as a countable resource if all the following conditions are met:
(i) unforeseeable circumstances, such as a fire, cause a temporary reduction in the rate of return;
(ii) the previous year's rate of return, as documented by the income tax statement or several months receipts, is at least six percent; and
(iii) the property is expected to produce a rate of return of at least six percent within 18 months of the end of the year in which the adverse circumstances occurred; the ISD caseworker records in the case narrative the plan of action which is expected to increase the rate of return.
(d) The ISD caseworker notifies the applicant or recipient in writing that the property is excluded based on its expected increase in return and that it will be reevaluated at the end of the 18 month grace period. When this period ends, the property must be producing an annual rate of at least six percent to continue to be excluded as a countable resource.
(2) Types of income-producing property: Income-producing property includes:
(a) a business, such as a farm or store, including necessary capital and operating assets such as land and buildings, inventory or livestock; the property must be in current use or have been used with a reasonable expectation of resumed use within a year of its most recent use; the ISD caseworker must account for the cash actually required to operate the business; liquid business assets of any amount are excluded;
(b) non-business property includes rental property, leased property, land leased for its mineral rights, and property producing items for home consumption; property which produces items solely for home use is assumed to be producing an annual rate of return of at least six percent;
(c) employment-related property, such as tools or equipment; the applicant or recipient must provide a statement from their employer to establish that tools or equipment are required for continued employment when the applicant or recipient leaves the institution; if the applicant or recipient is self-employed, only those tools normally required to perform the job adequately are excluded; the applicant or recipient must obtain a statement from someone in the same line of self-employment to establish what is excludable.
H. Vehicle exclusion: The term “vehicle” includes any mode of transportation such as a passenger car, truck or special vehicle. Included in this definition are vehicles which are unregistered, inoperable, or in need of repair. Vehicles used solely for purposes other than transportation, such as disassembly to resell parts, racing or as an antique, are not included in this definition. Recreational vehicles and boats are classified as personal effects and are evaluated under the household goods and personal effects exclusion. One vehicle is totally excluded if regardless of value if it is used for transportation for the applicant or recipient or a member of their household. Any other automobiles are considered to be non-liquid resources. Equity in the other automobiles is counted as a resource.
I. Life insurance exclusion: The value of life insurance policies is not considered a countable resource if the total cumulative face value of all policies owned by the applicant or recipient does not exceed $1,500. A policy is considered to be “owned” by the applicant or recipient if the applicant or recipient is the only one who can surrender the policy for cash.
(1) Consideration of burial insurance and term insurance: Burial insurance and term insurance are not considered when computing the cumulative face value because this insurance is redeemable only upon death.
(2) Calculation when value exceeds limit: If the total cumulative face value of all countable life insurance policies owned by the applicant or recipient exceeds $1,500, the ISD caseworker:
(a) verifies the total cash surrender value of all policies and considers the total amount a countable resource;
(b) informs the applicant or recipient that the insurance policies can be converted to term insurance or ordinary life insurance of lower face value at their option, if the cash surrender value, alone or in combination with other countable resources, exceeds the resource standard.
J. Qualified State Long-term Care Insurance Partnership (QSLTCIP) program: A resource exclusion equal to the amount of the qualified long-term care insurance benefit payments is made to or on the behalf of the applicant or recipient as determined during their eligibility process.
(1) In order to be considered a QSLTCIP policy it must meet the requirements set forth in 1917(a) of the Social Security Act.
(2) The applicant or recipient:
(a) must have been a beneficiary of a QSLTCIP that was purchased on or after August 15, 2015; or
(b) must have a QSLTCIP policy established in another state with a CMS approved state plan for state long-term care insurance partnerships and the beneficiary must have been a resident of such a state on the date the policy was purchased; or
(c) must be a current New Mexico resident and after August 14, 2015 have purchased a long-term care policy that was converted to a QSLTCIP through an endorsement, exchange, or rider.
(3) Long-term care insurance does not qualify as a QSLTCIP.
(4) Resources excluded in the amount of benefits paid out are also excluded in the estate recovery process.
(5) Resources can be designated for protection when a MAP category of eligibility for either institutional care services or home and community based services is established, while receiving MAD benefits provided through institutional care or home and community based waiver programs, or during the estate recovery process after a recipient dies.
(6) An applicant or recipient may protect assets up to the amount of QSLTCIP benefit payments made to or on the behalf of an applicant or recipient; this is the eligible applicant or recipient’s protected asset limit (PAL). If the value of protected assets exceeds the PAL, the excess value is counted against the asset limit and is not protected in estate recovery.
(7) The following conditions may apply to assets protected under a QSLTCIP:
(a) an applicant or recipient may keep protected resources;
(b) the value of protected assets is updated each year at the MAP eligibility review; the updated value is the counted towards the PAL;
(c) an applicant or recipient may transfer a protected asset to another person without a transfer penalty; a transferred asset is counted against the PAL based on the value of the asset on the day it was transferred;
(d) an applicant or recipient may use a protected asset to obtain another protected asset, which then becomes the protected asset;
(e) an applicant or recipient can spend or deplete a protected asset; the asset continues to be protected and is counted against the PAL even though the applicant or recipient no longer has it;
(f) once an asset is officially designated for protection, it cannot be undesignated in favor of designating another asset;
(g) changes in the status of protected assets must be reported at the recipient’s annual re-determination for MAP eligibility; some examples of changes are transferring, spending, depleting, or replacing an asset; and
(h) new countable assets that are reported in-between MAP eligibility renewals must be evaluated when reported to determine if they can be protected under the QSLTCIP program’s PAL;
(i) the following assets cannot be protected under the QSLTCIP program and must be made available after the death of the recipient to reimburse HSD up to the amount of the paid MAD benefits on the deceased recipient behalf;
(i) special and or supplemental needs, pooled charitable trusts, irrevocable trusts with a reversionary state interest, or income diversion trusts; and
(ii) annuity interest where HSD has been named a reminder beneficiary.
(8) Unused asset protection may result because all available asset protection was not used at the time of designation or when an applicant or recipient PAL has increased because the applicant or recipient continues to receive benefits from a QSLTCIP while receiving MAD benefits.
(9) Unused asset protection will automatically apply to protect assets already officially indicated for protection when the value of the asset has increased and there is unused asset protection.
(10) Unused asset protection may also be used to more fully cover an asset that is only partially protected, protect additional assets that have become available during a recipient’s lifetime, or to protect assets in a recipient’s estate after they die.
K. Produce for home consumption exclusion: The value of produce for home consumption is totally excluded.
L. Exclusion of settlement payments from the federal department of housing and urban development: Payments from the department of housing and urban development (HUD) as defined in Underwood v. Harris are excluded as income and resources. These one-time payments were made in the spring of 1980 to certain eligible tenants of subsidized housing (Section 236 of the National Housing Act).
(1) Segregation of payment: To be excluded as a resource, payments retained by an applicant or recipient must be kept separate; these payments must not be combined with any other countable resources.
(2) I ncome from segregated funds: Interest or dividend income received from segregated payment funds is not excluded from income, or, if retained, is not an excluded resource; this interest or dividend income must be kept separate from excludable payment funds.
M. Lump sum payments exclusion: SSI and social security lump sum payments for retroactive periods are excluded as countable resources for nine months after the month in which they are received. See Subsection B of 8.281.500.15 NMAC for instructions regarding SSI and social security lump sums which are placed into the ownership of a MAD qualifying trust. Social security lump sum payments are considered infrequent income. See Subsection C of 8.281.500.19 NMAC.
N. Home replacement exclusion: The proceeds from a reverse mortgage from the sale of an excluded home is excluded. Additionally, the value of a promissory note or similar installment sales contract which constitutes proceeds from the sale of an excluded home is excluded from countable resources if all of the following conditions are met:
(1) the note results from the sale of the applicant’s or recipient’s home as described in Subsection E of 8.281.500.13 NMAC;
(2) within three months of receipt (execution) of the note, the applicant or recipient purchases a replacement home which meets the definition of a home in Subsection E of 8.281.500.13 NMAC;
(3) all note-generated proceeds are reinvested in the replacement home within three months of receipt;
(4) additional exclusions: in addition to excluding the value of the note itself, the down payment received from the sale of the former home, as well as that portion of any installment amount constituting payment on the principal are also excluded from countable resources;
(5) failure to purchase another excluded home timely: if the applicant or recipient does not purchase another home which can be excluded under the provisions of Subsection E of 8.281.500.13 NMAC and the following paragraphs within three months, the value of the promissory note or similar sales contract received from the sale of an excluded home becomes a countable resource as of the first moment of the first day of the month following the month the note is executed; if the applicant or recipient purchases a replacement home after the expiration of the three month period, the value of the promissory note or similar installment sales contract becomes an excluded resource effective the month following the month of purchase of the replacement home provided that all other proceeds are fully and timely reinvested;
(6) failure to reinvest proceeds timely: if the proceeds from the sale of an excluded home under a promissory note or similar installment sales contract are not reinvested fully within three months of receipt in a replacement home, the following resources become countable as of the first moment of the first day of the month following receipt of the payment:
(a) the fair market value of the note;
(b) the portion of the proceeds, retained by the applicant or recipient which was not timely reinvested;
(c) the fair market value of the note remains a countable resource until the first moment of the first day of the month following the receipt of proceeds that are fully and timely reinvested in the replacement home; failure to reinvest proceeds for a period of time does not permanently preclude exclusion of the promissory note or installment sales contract; however, previously received proceeds that were not timely reinvested remain countable resources to the extent they are retained;
(7) interest payments: if interest is received as part of an installment payment resulting from the sale of an excluded home under a promissory note or similar installment sales contract, the interest payments are considered countable unearned income in accordance with Subsection A of 8.281.500.19 NMAC;
(8) when the home replacement exclusion does not apply: if the home replacement exclusion does not apply, the market value of a promissory note or sales contract as well as the portion of the payment received on the principal are considered countable resources.
O. Household goods and personal effects exclusion: Household goods and personal effects are excluded if they meet one of the following four criteria:
(1) items of personal property, found in or near the home, which are used on a regular basis; items may include but are not limited to furniture, appliances, recreational vehicles (i.e. boats and RVs), electronic equipment (i.e. computers and television sets), and carpeting;
(2) items needed by the householder for maintenance, use and occupancy of the premises as a home; items may include but are not limited to cooking and eating utensils, dishes, appliances, tools, and furniture;
(3) items of personal property ordinarily worn or carried by the applicant or recipient; items may include but are not limited to clothing, shoes, bags, luggage, personal jewelry including wedding and engagement rings, and personal care items;
(4) items otherwise having an intimate relation to the applicant or recipient; items may include but are not limited to prosthetic devices, educational or recreational items such as books or musical instruments, items of cultural or religious significance to an applicant or recipient; or items required because of an applicant or recipient impairment.
[8. 281.500 .13 NMAC - Rp, 8.281.500.13 NMAC, 8/15/2015; A, 12/1/2022]
8.281.500.14 ASSET TRANSFERS: The ISD caseworker must determine whether an applicant or recipient or their spouse transferred assets within a specified period of time (lookback period) before applying for a MAP category of eligibility for institutional care or at any time after approval of the applicant’s or recipient’s application. Then the ISD caseworker must determine if the applicant or recipient or their spouse received fair market value for the asset. If the applicant or recipient or their spouse did not receive fair market value for the asset, then the applicant or recipient may be subject to a penalty. In the case of an asset held by the applicant or recipient in common with another individual or individuals in a joint tenancy, tenancy in common, or similar arrangement including life estate or remainderman relation, the asset (or the affected portion of such asset) is considered to be transferred by the applicant or recipient when any action is taken, either by the applicant or recipient or by any other individual, acting on behalf of the applicant or recipient (including but not limited to a spouse, representative payee, trustee, guardian, conservator, or another authorized representative), that reduces or eliminates the applicant’s or recipient’s ownership or control of such asset. Any asset transferred to a community spouse in excess of the community spouse resource allowance (CSRA) is considered to be totally available to the institutionalized spouse and must be spent down before eligibility can be established.
A. Lookback period: Any transfer of assets made prior to February 8, 2006, is subject to a 36-month lookback period prior to the date of the applicant’s or recipient’s application or at any time subsequent to the approval of an application for a MAP category of eligible for institutional care. Transfers made on or after February 8, 2006, are subject to a 60-month lookback period.
(1) The lookback period is 60 months if the transfer occurred as the result of payments from a trust or portions of a trust that are treated as assets disposed of by the applicant or recipient.
(2) The lookback period starts on the date the applicant or recipient applies for a MAP category of institutional care and is in an institution.
B. Transfer of assets for less than fair market value: If a transfer of assets occurred within the applicable lookback period, or at any time after approval of the applicant’s or recipient’s application, the ISD caseworker must determine whether the applicant or recipient or their spouse received fair market value for the transferred asset(s).
(1) Documentation requirement: The applicant or recipient or their spouse must provide documentation of the transfer, the fair market value of the asset(s) transferred, the circumstances surrounding the transfer and the amount, if any, received as compensation for the transferred asset.
(2) If the applicant or recipient fails to provide this information without good cause within 30 calendar days from the date requested by the ISD caseworker, the ISD caseworker denies the application or closes the applicant’s or recipient’s case, as appropriate.
(a) Good cause is considered to exist if the applicant or recipient or their authorized representative can show that they were effectively precluded from timely reporting because of legal, financial, or other reasons, or because of the existence of a health related problem including death of a family member within the specific degree of relationship during the period of time in which the applicant or recipient, or authorized representative has to report the required information. The health or other problem must have been of such severity and duration as to have effectively precluded the applicant or recipient or their authorized representative from reporting in a timely manner. See 8.291.410 NMAC for a detailed description of degree of relationships.
(b) To document the good cause claim, the applicant or recipient or authorized representative must provide proof of the existence of the health or other problem and must explain the circumstances which precluded provision of the required information.
(c) The ISD caseworker makes the determination of good cause subject to review and approval by the county director or designee.
(3) Restricted coverage: If a transfer of assets occurred within the applicable lookback period, or at any time subsequent to approval for a MAP category of institutional care eligibility, for which the applicant or recipient or their spouse did not receive fair market value, the ISD caseworker determines if a penalty period must be calculated. The penalty for transfers of assets for less than fair market value in a MAP category of eligibility for institutional care is restricted coverage. "Restricted coverage" means that the applicant or recipient is eligible for all MAD services except services furnished in a nursing facility or services considered to be long-term care services.
(a) Determine the current average monthly cost of nursing facilities for private patients. See 8.281.500.13 NMAC.
(b) Divide the total uncompensated value (amount) of the resources transferred for less than fair market value by the current average monthly cost of nursing facilities for private patients.
(c) The result is the number of months and partial months for which the applicant or recipient will be on restricted coverage.
(4) Calculating restricted coverage when the transferred asset is income: If income has been transferred as a lump sum, the period of restricted coverage is calculated based on the lump sum value. For transfers of the right to an income stream, the period of restricted coverage is calculated using the actuarial value of all payments transferred. See 8.200.520 NMAC.
C. Transfer rules based on date of transfer: Two sets of rules govern the calculation of penalty periods if a transfer of assets for less than fair market value has occurred. The date of transfer and approval date for the MAP category of institutional care medicaid applicant or recipient institutional care governs which set of rules is used to calculate the penalty period.
(1) For transfers made on or after August 11, 1993: Periods of restricted coverage are calculated as follows (Omnibus Budget Reconciliation Act of 1993):
(a) the period of restricted coverage begins the month the resources were transferred; the total uncompensated value of the transferred assets divided by the average cost to a private patient for nursing facility services in the state at the time of the applicant’s or recipient’s application is the methodology used to calculate a period of restricted coverage;
(b) transfers for less than fair market value made by an institutionalized SSI applicant or recipient, or a community spouse of institutionalized applicant or recipient may subject the institutionalized applicant or recipient to a period of restricted coverage;
(c) penalty periods are now consecutive rather than concurrent; if multiple transfers occur in different months, the periods of restricted coverage begin with the month of the initial transfer and run consecutively; for example, if an applicant or recipient transfers an asset for less than fair market value in February causing four months of restricted coverage (i.e., February through May) and transfers another asset in April causing three months of restricted coverage, the second period of restricted coverage begins in June and lasts through August; and
(d) if an institutionalized applicant or recipient with a community spouse is placed on restricted coverage as the result of a transfer of assets for less than fair market value and the community spouse subsequently becomes eligible for a MAP category of eligibility for institutional care, any remaining months in the restricted coverage period must be divided equally between the spouses.
(2) For transfers made on or after February 8, 2006: Pursuant to the Deficit Reduction Act of 2005, otherwise eligible institutionalized recipients who transfer assets for less than fair market value after this date are penalized as follows:
(a) the period of restricted coverage begins the first day of the month in which the resources were transferred, or the date on which the individual applicant or recipient meets a MAP category of eligibility, and would otherwise be receiving institutional level of care but for the application of the penalty period, whichever is later, and does not occur during any other period of ineligibility as a result of an asset transfer; see Subsection B of 8.281.500.14 NMAC for the methodology used to calculate a period of restricted coverage;
(b) once eligibility has been determined and a penalty period has begun to run, it continues until expiration, whether or not there is a break in the institutionalized recipient's eligibility;
(c) the beginning date of restricted coverage is the first day of the month in which the resources were transferred provided the applicant or recipient is institutionalized and retains their MAP category of eligibility for institutional care; for current recipients who fail to report a transfer, the recipients will continue to receive benefits until the adverse action notice date, but HSD may seek to recover any MAD benefits paid for long-term care services during what should have been a period of restricted coverage; federal law does not provide a basis to impose a transfer penalty based on date of discovery;
(d) for a non-institutionalized applicant or recipient, the date restricted coverage begins is the month in which the applicant or recipient becomes institutionalized;
(e) transfers for less than fair market value made by an institutionalized SSI applicant or recipient, or a community spouse of the institutionalized applicant or recipient may subject the institutionalized applicant or recipient to a period of restricted coverage; and
(f) multiple transfers occurring in different months are added together and calculated as a single period of ineligibility, that begins on the earliest date that would otherwise apply if the transfer had been made in a single lump sum.
D. Non-excludable transfers: Certain financial instruments must be evaluated before they can be considered a transfer of assets.
(1) Annuities : Annuities belonging to the applicant or recipient or to the spouse of the applicant or recipient must be declared. Annuities must be actuarially sound with no deferral and no balloon payments. Annuities purchased or issued after February 8, 2006, must meet the following additional requirements for exclusion as a transfer of assets:
(a) HSD is named as the remainder beneficiary in the first position for at least the total amount of MAD benefits paid on behalf of the institutionalized applicant or recipient; HSD may be named the remainder beneficiary in the second position if there is a community spouse, or a minor, or a disabled child and is named in the first position if the community spouse or an authorized representative of the child disposes of any such remainder for less than fair market value;
(b) when HSD is a beneficiary of an annuity, issuers of annuities are required to notify MAD of any changes in the disbursement of income or principal from the annuity as well as any changes to HSD’s position as remainder beneficiary; and
(c) it is non-assignable and irrevocable.
(2) Life estates: If an applicant or recipient purchases a life estate in another individual's home, the applicant or recipient must live in that home for a period of at least 12 months after the date of purchase or the transaction will be treated as a transfer of assets for less than fair market value.
(3) Promissory notes: If an applicant or recipient uses funds to purchase a promissory note, the repayment terms must be actuarially sound, provide for equal payment amounts with no deferral or balloon payments, and it must contain a provision that prohibits cancellation of the balance upon the death of the applicant or recipient lender. A promissory note not meeting these requirements shall be treated as a transfer of assets for less than fair market value.
E. Excludable transfers: If certain conditions are met, an applicant or recipient is not placed on restricted coverage for transferring assets for less than fair market value.
(1) Transferred asset was home: The asset transferred was a home and title to the home was transferred to:
(a) the spouse of the applicant or recipient;
(b) the son or daughter of the applicant or recipient who is under 21 years of age or who meets the social security administration's definition of disability or blindness; if the child is receiving benefits based on disability or blindness from a program other than social security or SSI, or is not receiving benefits based on disability or blindness from any program, the ISD caseworker must request a determination of disability or blindness from disability determination services;
(c) sibling of the applicant or recipient who has an equity interest in the home and who was residing in the home for a period of at least one year immediately before the applicant or recipient was institutionalized; or
(d) son or daughter of the applicant or recipient who was residing in the home for a period of at least two years immediately before the applicant or recipient was institutionalized; for this exclusion to apply, the ISD caseworker must determine that the son or daughter provided care to the applicant or recipient which permitted the applicant or recipient to reside at home rather than in a medical facility or nursing home.
(2) Other asset transfers: Sufficient information must be given to the ISD caseworker to establish that either:
(a) the applicant or recipient intended to dispose of the asset at fair market value; or
(b) at the time of the transfer the applicant or recipient had no expectation of applying for a MAP category of eligibility and the resources were transferred exclusively for a purpose other than to qualify for a MAP category of eligibility as demonstrated by a preponderance of evidence; unless these conditions are met, the transfer is presumed to have been for the purpose of qualifying for a MAP category of eligibility; or
(c) HSD determines that the denial of eligibility would work an undue hardship.
(3) Asset transferred to or for the sole benefit of the community spouse: No transfer penalty is assessed when assets are transferred from one spouse to another (e.g., assets are transferred from an institutionalized spouse to a community spouse). Any asset transferred to a community spouse or to another individual for the sole benefit of the community spouse in excess of the CSRA is considered to be totally available to the institutionalized spouse and must be spent down before eligibility can be established. No transfer penalty is assessed when assets are transferred to another for the sole benefit of the community spouse if all of the conditions listed in Subparagraphs (a) through (c) below are met.
(a) a transfer is considered to be for the sole benefit of the community spouse if it is arranged in such a way that no individual or entity except the community spouse can benefit from the assets transferred in any way, whether at the time of the transfer or at any time in the future;
(b) a transfer, or transfer instrument, that provides for funds or property to pass to a beneficiary who is not the community spouse is not considered to be established for the sole benefit of the community spouse; for a transfer to be considered to be for the sole benefit of the community spouse, the instrument or document must provide for the spending of the funds involved for the benefit of the community spouse on a basis that is actuarially sound based on the life expectancy of the community spouse or when the instrument or document does not so provide, any potential exemption from penalty or consideration for eligibility purposes is void;
(c) to determine whether an asset was transferred for the sole benefit of the community spouse, ensure that the transfer was accomplished via a written instrument of transfer (e.g., a trust document) which legally binds the parties to a specified course of action and which clearly sets out the conditions under which the transfer was made, as well as who can benefit from the transfer; a transfer without such a document cannot be said to have been made for the sole benefit of the community spouse since there is no way to establish, without a document, that only the community spouse will benefit from the transfer.
(4) Asset transfers to or for the sole benefit of a blind or disabled child of the institutionalized individual: No transfer penalty is assessed when assets are transferred to a blind or disabled child of the institutionalized applicant or recipient, or to a trust established solely for the benefit of a blind or disabled child of the institutionalized applicant or recipient. For this exemption to apply, the child must meet the social security administration's definition of blindness or disability. The transfer must either meet the criteria set forth in 8.281.500.11 NMAC or meets all of the conditions listed in this section, Subparagraphs (a) through (c) below to be excluded in the eligibility determination process.
(a) A transfer to such a blind or disabled child is considered to be for the sole benefit of that child if the transfer is arranged in such a way that no individual or entity, except the blind or disabled child, can benefit from the assets transferred in any way, whether at the time of the transfer or at any time in the future.
(b) A transfer, or transfer instrument, that provides for funds or property to pass to a beneficiary who is not the blind or disabled child of the institutionalized applicant or recipient is not considered to be established for the sole benefit of the blind or disabled child. For a transfer or trust to be considered to be for the sole benefit of a blind or disabled child, the instrument or document must provide for the spending of the funds involved for the benefit of the blind or disabled child on a basis that is actuarially sound based on the life expectancy of the child. When the instrument or document does not so provide, any potential exemption from penalty or consideration for eligibility purposes is void.
(c) To determine whether an asset was transferred for the sole benefit of the blind or disabled child of the institutionalized applicant or recipient, ensure that the transfer was accomplished via a written instrument of transfer (e.g., a trust document) which legally binds the parties to a specified course of action and which clearly sets out the conditions under which the transfer was made, as well as who can benefit from the transfer. A transfer without such a document cannot be said to have been made for the sole benefit of the blind or disabled child since there is no way to establish, without a document, that only the blind or disabled child will benefit from the transfer.
(5) Asset transfers to a trust for the sole benefit of a disabled individual under age 65: No transfer penalty is assessed when assets are transferred to a trust established for the sole benefit of an individual under age 65 who meets the social security administration's definition of disability. The transfer must either meet the criteria set forth in 8.281.500.11 NMAC or meet all of the conditions listed in Subparagraphs (a) through (c) below to be excluded in the eligibility determination process.
(a) A transfer is considered to be for the sole benefit of a disabled individual under age 65 as described above if the transfer is arranged in such a way that no individual or entity except the disabled individual can benefit from the assets transferred in any way, whether at the time of the transfer or at any time in the future.
(b) A transfer, transfer instrument, or trust that provides for funds or property to pass to a beneficiary who is not a disabled individual under age 65 as described above, is not considered to be established for the sole benefit of the disabled individual. For a transfer or trust to be considered to be for the sole benefit of the disabled individual, the instrument or document must provide for the spending of the funds involved for the benefit of the disabled individual on a basis that is actuarially sound based on the life expectancy of the disabled individual. When the instrument or document does not so provide, any potential exemption from penalty or consideration for eligibility purposes is void.
(c) To determine whether an asset was transferred for the sole benefit of the disabled individual, ensure that the transfer was accomplished via a written instrument of transfer (e.g., a trust document) which legally binds the parties to a specified course of action and which clearly sets out the conditions under which the transfer was made, as well as who can benefit from the transfer. A transfer without such a document cannot be said to have been made for the sole benefit of the disabled individual since there is no way to establish, without a document, that only the disabled individual will benefit from the transfer.
(6) Assets transfers and qualified state long-term care insurance partnerships (QSLTCIP) protected asset limits (PAL) :
(a) No transfer penalty is assessed if at initial determination the applicant or recipient has indicated protection of the transferred asset and there is enough of the PAL to cover the value of the resource at the time of the transfer.
(b) No transfer of assets penalty is assessed if the applicant or recipient has previously indicated an asset for protection and there was enough of the applicant’s or recipient’s PAL to cover the value of the resource at the time of the transfer.
(c) No transfer penalty is assessed for the portion of a resource which has been partially protected. The unprotected portion of the resource is subject to all assets transfer provisions outlined in 8.281.500.14 NMAC.
F . Re-establishing eligibility: If an asset is transferred for less than fair market value and the applicant or recipient is placed on restricted coverage, they have options to re-establish their past MAP category of eligibility.
(1) Reimbursement by transferee: The individual to whom the asset was transferred can reimburse the applicant or recipient for the asset at fair market value or liquidate or sell the asset and spend an amount equal to the uncompensated fair market value on the applicant’s or recipient’s care or other exempt assets as listed in 8.281.500.13 NMAC.
(2) Return asset to applicant: The asset can be transferred back to the applicant or recipient, liquated or sold. The applicant or recipient must determine the use of the asset; such use may include spending down the resource limit on the applicant’s or recipient’s care, classifying the resource as exempt as listed in 8.281.500.13 NMAC, or having the asset become a countable resource.
(3) If the transferred asset is restored to an applicant or recipient, they may become totally ineligible for a MAP category of institutional care eligibility due to excess resources. The ISD caseworker must verify that the applicant’s or recipient’s countable assets do not exceed the standard for a MAP category of institutional care eligibility. If the transferred asset is restored to an applicant or recipient, they may no longer be eligible for a MAP category of institutional care due to the excess resources. The ISD caseworker must verify that the applicant’s or recipient’s countable assets meet the requirements to have a MAP category of institutional care eligibility.
[8. 281.500 .14 NMAC - Rp, 8.281.500.14 NMAC, 8/15/2015; A, 12/1/2022]
8.281.500.15 RESOURCE STANDARDS FOR MARRIED COUPLES:
A. Community property resource determination methodology: Community property resource determination methodology is used in the eligibility determination for a married applicant or recipient who began institutionalization for a continuous period prior to September 30, 1989.
(1) To determine the countable value of resources, the ISD worker must:
(a) add the total value of all resources owned by both spouses;
(b) exclude the separate property of the non- applicant or recipient spouse; and
(c) attribute one-half of the total value of the community property to the applicant or recipient spouse plus the value of [his or her] their separate property;
(d) the resulting figure must be less than $2,000.
(2) Application of community property rules: Under community property rules, all property held by either spouse is presumed to be community property unless successfully rebutted by the applicant or recipient, or representative. To rebut community property status, the applicant or recipient, or representative must document that the property was:
(a) acquired before marriage or after a divorce or legal separation;
(b) designated as separate property by a judgment or decree of any court;
(c) acquired by either spouse as a gift or inheritance; or
(d) designated as separate property by a written agreement between the spouses, including a deed or other written agreement concerning property held by either or both spouses in which the property is designated as separate property.
(i) If one of the parties to this written agreement is incompetent, legal counsel must execute the agreement on behalf of the incompetent spouse.
(ii) Property designated as separate by written agreement is evaluated according to current rules regarding transfer of resources.
(iii) Income cannot be designated as separate by an agreement between spouses; income is considered separate only if it is derived from a resource that has been determined separate.
B. Spousal impoverishment: Spousal impoverishment provisions apply if one spouse of a married couple is institutionalized for a continuous period of at least 30 consecutive days beginning on or after September 30, 1989. See spousal impoverishment provisions of the Medicare Catastrophic Coverage Act of 1988 (MCCA). No comparable treatment of resources and income is required for non-institutionalized applicants or recipients who do not have a spouse remaining in the community. These provisions cease to apply as of the month following the month an applicant or recipient is no longer institutionalized or no longer has a community spouse. If a community spouse or other dependents apply for a MAP category of eligibility they are subject to the rules governing treatment of income and resources for the individual applicant or recipient.
(1) Resource assessment: A resource assessment must be completed to evaluate a couple's resources as of the first moment of the first day of the month one member of the married couple is institutionalized for a continuous period of at least 30 consecutive days beginning on or after September 30, 1989. This process is used to determine the amount of resources which may be protected for the community spouse. See Subparagraph (f) below for resources which must be included in the resource assessment. The resource assessment and computation of spousal shares occurs only once, at the beginning of the first continuous period of institutionalization beginning on or after September 30, 1989. A new resource assessment may be completed if it is later determined that the original resource assessment was inaccurate. Upon the death of the community spouse, the ISD worker may review the applicant’s or recipient’s resources.
(a) A MAP application does not need to be submitted at the time the assessment is requested. A reasonable fee may be charged for completing assessments which are not made in conjunction with the applications. Applications for assessments are available at the ISD offices which determine eligibility for a MAP category of institutional care. Either member of the couple or their authorized representative may request an assessment application.
(b) The ISD worker must complete a resource assessment using the following criteria:
(i) one member of a married couple became institutionalized on or after September 30, 1989 in an acute care hospital or nursing facility for a continuous period of at least 30 consecutive days;
(ii) the institutionalized applicant or recipient has a spouse who remains in the community in a non-institutionalized setting; and
(iii) the institutionalized spouse remains, or is likely to remain, institutionalized for a period of at least 30 consecutive days based on a written statement from their physician and supporting medical documentation; the institutionalized applicant or recipient is considered “likely to remain” even if they do not actually remain in an institution for 30 consecutive days if they met this condition at the beginning of the period of institutionalization.
(c) The ISD worker explains exactly what verification is required to complete the assessment. If the ISD worker requires further information, the individual requesting the assessment is notified in writing and given a reasonable time period of at least 10 working days to provide the additional information.
(d) The institutionalized individual or their spouse or an authorized representative is responsible for providing all verification necessary to complete the assessment.
(e) The ISD worker completes the resource assessment within 45 calendar days of the date of receipt of the completed and signed assessment application unless verification is still pending by the 45th day. In that case, the assessment is not completed until all necessary information is provided by the institutionalized individual or their spouse or authorized representative.
(f) Assessments include the total value of the couple's countable resources held jointly or separately as of the first moment of the first day of the month one spouse became institutionalized for a continuous period of at least 30 consecutive days beginning on or after September 30, 1989. The assessment form identifies the spousal shares and the CSRA. The couple is entitled to all resource exclusions allowed in 8.281.500.13 NMAC except that value limits for the exempt vehicle and household goods of the community spouse do not apply. Assets excluded under the QSLTCIP program are counted in the spousal resource assessment. The disregarded assets are included in determining the amount of the CSRA. The disregarded asset is not counted in determining the applicant’s or recipient’s eligibility.
(g) When the assessment is complete, the ISD worker copies all documentation used to make the determination of countable resources and retains the documents in the case record. The ISD worker also provides complete copies of the assessment forms to the following parties:
(i) institutionalized applicant or recipient;
(ii) community spouse; and
(iii) authorized representative(s) if any.
(h) When the amount of the couple's total countable resources has been determined, the resulting amount is divided by two to determine the spousal shares. The community spouse is entitled to their spousal share or the MAD minimum resource allowance, whichever is greater, up to the applicable federal maximum standard or an amount determined at a HSD administrative hearing or an amount transferred pursuant to a district court order. The CSRA is the amount by which the greatest of the spousal shares or state minimum resource allowance exceeds the amount of resources otherwise available to the community spouse without regard to such an allowance. The CSRA remains in effect until one of the spouses dies. The remainder of the couple's total countable resources in excess of the CSRA is considered available to the institutionalized spouse. If either the institutionalized spouse or the community spouse is dissatisfied with the computation of the spousal share of the resources, the attribution of resources or the determination of the community spouse resource allowance, they can request a HSD administrative hearing pursuant to 8.352.2 NMAC. Refer to 8.352.2 NMAC for a detailed description of the HSD administrative hearing process.
(2) CSRA standards: The state minimum resource allowance and the federal maximum standards vary based on when the applicant or recipient became institutionalized for a continuous period of at least 30 consecutive days. See 8.281.500.10 NMAC for the applicable standards.
(3) CSRA revision: The CSRA can be revised if either of the following occurs:
(a) a different amount is determined by a HSD administrative hearing final decision or district court decision; or
(b) inaccurate information was provided to the ISD worker at the time the spousal share was calculated.
(4) Resource availability after computation of CSRA: Resources of a couple remaining after the computation of the CSRA are considered available to the institutionalized spouse. These remaining resources are compared to the resource limit.
(a) From the time of the initial determination of eligibility until the first regularly scheduled redetermination, the CSRA is not considered available to the institutionalized spouse.
(b) The CSRA may be applied retroactively for the three months prior to the month of application and is not considered available to the institutionalized spouse until the first periodic review following initial approval.
(5) Resource transfer after computation of the CSRA: When eligibility has been approved for an institutionalized spouse, resources equal to the amount of the CSRA may be transferred to the community spouse. This transfer is intended to assist the community spouse in meeting their needs in the community. Couples should transfer resources in the amount of the CSRA to the community spouse as soon as possible after approval for a MAP category of institutional care eligibility. The institutionalized spouse or authorized representative can complete this transfer at any time between the date of the assessment and the first periodic review 12 months after approval.
(6) Resource transfers which exceed the CSRA: Resources transferred to a community spouse at less than fair market value are not subject to transfer penalties. Resources transferred to the community spouse in excess of the computed CSRA are considered available to the institutionalized spouse and must be spent down to below the resource standard before eligibility can be established. Resources transferred to the community spouse may exceed the CSRA if an increased amount is ordered by any court having jurisdiction or by the MAD director as part of a HSD administrative hearing final decision.
(7) Transfer deadlines: If the resource transfer is not completed by the institutionalized spouse by the end of the initial period of eligibility, the resources are considered completely available to the institutionalized spouse beginning with the first periodic review after the initial determination of eligibility.
(8) Newly acquired assets: After a continuous period of institutionalization begins, newly acquired resources or increases in the value of resources owned by the institutionalized spouse are countable. Recalculations of eligibility for the institutionalized spouse based on countable resources are effective at the beginning of the month following the month in which new resources were received or an increase occurred in the value of resources already owned.
(a) The institutionalized spouse may transfer newly acquired resources to the community spouse without a penalty up to the difference between the CSRA and the state minimum resource standard in effect as of the date of institutionalization.
(b) After a continuous period begins, new resources acquired by the community spouse or increases in the value of resources which are part of the CSRA are not considered available to the institutionalized spouse.
[8. 281.500 .15 NMAC - Rp, 8.281.500.16 NMAC, 8/15/2015; A, 3/1/2018; A, 12/1/2022]
8.281.500.16 DEEMING RESOURCES: Deeming of resources applies only during periods when an eligible applicant/recipient under 18 years of age lives at home and during the month the eligible applicant or recipient enters an institution. After the initial month of entry into the institution, only those resources directly attributable to or available to the applicant or recipient are counted and compared to the $2,000 resource limit.
A. Deeming of resources for children who are blind or have a disability: If an applicant or recipient under 18 years of age who is blind or disabled enters an institution, the resources of the parent(s) are deemed to the applicant or recipient if the parent(s) live in the same household. If an ineligible parent receives temporary assistance to needy families (TANF), resources are not deemed to the applicant or recipient.
B. To determine the amount of resources deemed to the applicant or recipient, the following computation is made:
(1) determine parent(s) resources;
(2) allow parent(s) all the resource exclusions that an eligible applicant or recipient would receive;
(3) the remaining resources in excess of $2,000 for one parent or $3,000 for two parents are deemed to the applicant or recipient child; if there is more than one applicant or recipient child, the deemed resources are divided equally; and
(4) the deemed resources are added to whatever countable resources the applicant or recipient child has in their own right; the applicant or recipient child is eligible for a MAP category of institutional care eligibility on the factor of resources if countable resources do not exceed $2,000.
[8. 281.500 .16 NMAC - Rp, 8.281.500.17 NMAC, 8/15/2015; A, 12/1/2022]
8.281.500.17 INCOME: An applicant’s or recipient’s gross countable monthly income must be less than the maximum allowable monthly income standard. If an applicant’s or recipient’s monthly gross countable income is below $50, the application can still be processed; however, the applicant or the recipient must be referred to the social security administration to apply for SSI. Income may be in the form of cash, checks, and money orders, or in-kind, including personal property or food. If income is not received in the form of cash, the cash value of the item is determined and counted as income. The ISD worker verifies all income and obtains appropriate documentation. Income is counted in the month received. Income is considered available throughout the month regardless of the date received.
A. Types of income: Countable income is the sum of unearned income or earned income, less disregards or exclusions, plus deemed income.
B. Earned income: Earned income consists of the total gross income received by an applicant or recipient for services performed as an employee or as a result of self-employment.
(1) Royalties earned in connection with the publication of an applicant’s or recipient’s work and any honorarium or fee received for services rendered are considered earned income.
(2) The self-employed applicant or recipient must provide an estimate of their current income based on the tax return filed for the previous year or current records maintained in the regular course of business. The estimate of net earnings for the entire previous taxable year is prorated equally among all months of the current year, even if the business is seasonal.
(a) Consideration is given to the applicant’s or recipient’s explanation as to why they believe the estimated net earnings for the current year vary substantially from the information shown on their tax return for past years.
(b) A satisfactory explanation is that the business suffered heavy loss or damage from fire, flood, burglary, serious illness or disability of the owner, or other such catastrophic events. Documentation must include copies of newspaper accounts or medical reports and must be filed in the case record to substantiate the need for a reduced estimate of current self-employment income.
C. Unearned income: Unearned income consists of all other income (minus exclusions and disregards) that is not earned in the course of employment or self-employment.
D. Deemed income: Deemed income is income considered available to a minor applicant or recipient from their parents.
E . Community property income methodology: If an applicant or recipient is married, community property income methodology shall be used in the eligibility determination, regardless of the living arrangements, if the one spouse has less income than the other spouse or if using the community property methodology would benefit both spouses. Under this methodology, one-half of the community property income is attributed to each spouse. Income is considered separate if it is earned in and is paid from a non-community property state. Proof of separate income is the burden of the applicant or recipient, spouse, or authorized representative.
[8. 281.500 .17 NMAC - Rp, 8.281.500.18 NMAC, 8/15/2015; A, 12/1/2022]
8.281.500.18 INCOME STANDARDS: The applicable income standard used in the determination of a MAP category of institutional care eligibility for an applicant or recipient who has not been institutionalized for a period of 30 consecutive days is the SSI federal benefit rate (FBR) for a non-institutionalized individual. Participation in the medicaid home and community based waiver program is considered institutionalization and counts toward the calculation of the 30-day period. All income, whether in cash or in-kind, shall be considered in the eligibility determination, unless such income is specifically excluded or disregarded.
A. Institutionalization period of 30 consecutive days: After the applicant or recipient has been institutionalized for 30 consecutive days, the application can be approved as of the first day of the 30-day period. Once an applicant or recipient has been institutionalized for 30 consecutive days, the higher income maximum as specified in 8.200.520 NMAC is used.
B. Institutionalization period less than 30 consecutive days: If the applicant or recipient leaves the facility before 30 consecutive days, the lower income standard (SSI FBR) is used to establish eligibility.
C. Transfer or death: If an applicant or recipient transfers to another institution or dies prior to completing 30 consecutive days of institutionalization, the higher income maximum is used. See 8.200.520 NMAC.
(1) Income exclusions: Income exclusions are applied before income disregards. Exclusions are applied in determining eligibility whether the income belongs to the applicant or recipient or to an individual from whom income is deemed.
(2) Infrequent or irregular income: Exclude the first $30 per calendar quarter of earned income; and the first $60 per calendar quarter of unearned income. The following definitions apply:
(a) “Irregular income” is income received on an unscheduled or unpredictable basis.
(b) “Infrequent income” is income received only once during a calendar quarter from a single source and includes:
(i) proceeds of life insurance policies;
(ii) prizes and awards;
(iii) gifts;
(iv) support and alimony;
(v) inheritances;
(vi) interest and royalties; and
(vii) one-time lump sum payments, such as social security.
(c) “Frequency” is evaluated for the calendar quarter (i.e. January - March, April - June, July - September, October - December) but the dollar amount is considered in the month received.
(3) Foster care: Foster care payments are totally excluded if:
(a) the foster child is not eligible for SSI; and
(b) the child was placed in the applicant’s or recipient’s home by a public or private nonprofit child placement or child care agency.
(4) Domestic volunteer services exclusions: Payments to volunteers under domestic volunteer services (ACTION) programs are excluded from consideration as income in the eligibility determination process. These programs include the following:
(a) volunteers in service to America (VISTA);
(b) university year for action (UYA);
(c) special demonstration and volunteer programs;
(d) retired senior volunteer program (RSVP);
(e) foster grandparent program; and
(f) senior companion program.
(5) Census bureau employment: Wages paid by the census bureau for temporary employment related to the census bureau are excluded from consideration as income in the eligibility determination process.
[8. 281.500 .18 NMAC - Rp, 8.281.500.19 NMAC, 8/15/2015; A, 12/1/2022]
8.281.500.19 UNEARNED INCOME: Unearned income includes all income not earned in the course of employment or self-employment. If payment is made in the name of either or both spouses and another party, only the applicant’s or recipient’s proportionate share is considered available to them. If income is derived from property for which ownership is not established, such as unprobated property, one-half of the income is considered available to each member of a married couple.
A. Standards for unearned income: Unearned income is computed on a monthly basis. If there are no expenses incurred with the receipt of unearned income, such as annuities, pensions, retirement payments or disability benefits, the gross amount is considered countable unearned income.
(1) Social security overpayments: If the social security administration withholds an amount because of an overpayment, the gross social security payment amount is used to determine eligibility. See Subsection B of 8.281.500.22 NMAC for instructions regarding calculation of the medical care credit.
(2) Rental income: If an applicant or recipient has rental property, the ISD worker allows the cost of real estate taxes, maintenance and repairs, advertising, mortgage insurance and interest payments on the mortgage as deductions from the amount received as rent.
(3) Interest on promissory note or sales contract: The portion of the payment representing interest received from a promissory note or sales contract is considered unearned income. The market value of promissory notes or sales contracts and the portion of the payment representing payment of the principal are considered resources. See also Subsection L of 8.281.500.13 NMAC.
(4) Income from annuities, pensions and other periodic payments: Payments from annuities, pensions, social security benefits, disability, veterans benefits, worker compensation, railroad retirement annuities and unemployment insurance benefits and other periodic payments are counted as unearned income.
B. Unearned income exclusions:
(1) Interest from an excluded burial fund: Interest from an excluded burial fund is not considered unearned income if the interest is applied toward the fund balance. If the interest is paid to the applicant or recipient, it is considered unearned income.
(2) Tax refunds and earned income tax credit: Tax refunds from any public agency for property taxes or taxes on food purchases are totally excluded. Any portion of a federal income tax return which constitutes an earned income tax credit is excluded.
(3) Grants, scholarships and fellowships: All grants, scholarships and fellowships used to pay tuition and fees at an educational institution, including vocational and technical schools, are totally excluded. Any portion of a grant, scholarship or fellowship used to pay any other expenses, such as food, clothing or shelter, is not excluded.
(4) Veteran’s pensions: Allowances for aid and attendance (A&A) and unusual medical expenses (UME) are excluded from unearned income for determination of eligibility. If an applicant or recipient receives an augmented VA pension as a veteran or veteran's widow or widower, the pension amount may include an increment for a dependent. If so, the VA must be contacted to provide documentation of the portion of the pension which represents the dependent's increment. When verified, this amount of the VA pension is considered the dependent's income.
(5) Payments by a third party: Third party payments are excluded as income if made directly to the applicant’s or recipient’s creditor.
(a) Third party payments may include mortgage payments by credit life or credit disability insurance and installment payments by a family member on a burial plot or prepaid burial contract.
(b) Interest from a burial contract that is automatically applied to the outstanding balance is excluded from unearned income. If the payment or interest is sent to the applicant or recipient, it is counted as unearned income regardless of the sender's (third party's) intentions. This applies even if the sender specifies the purpose of the payment on the check. This provision does not apply if the signature of the creditor and the applicant or recipient must both be present in order to negotiate the check (two-party check).
(6) Indian tribe per capita payments: Funds held in trust by the secretary of the interior for an Indian tribe and distributed on a per capita basis and any interest and investment income from these funds, are excluded as income and resources in the eligibility determination process and the computation of the medical care credit.
(7) Plans for achieving self-support: Income derived from, or necessary to, an approved plan for achieving self-support for a blind or disabled applicant or recipient under 65 years of age is excluded.
(a) For an applicant or recipient who is blind or disabled and over 65 years of age, this exclusion applies only if they received MAD services for the month preceding their 65th birthday.
(b) The self-support plan must be in writing and contain the following:
(i) designated occupational objective;
(ii) specification of any savings (resource) or earnings needed to complete the plan, such as amounts needed for purchase of equipment or for financial independence;
(iii) identification and segregation of any income saved to meet the occupational goal;
(iv) designation of a time period for completing the plan and achieving the occupational goal.
(c) Plans for achieving self-support are developed by vocational rehabilitation counselors. If a self-support plan is not in place, the ISD worker makes a referral to the division of vocational rehabilitation (DVR).
(d) The ISD worker forwards the written plan and documentation to the MAD eligibility unit. The plan must be approved by that unit.
(e) An approved plan is valid for the following specified time periods:
(i) initial period of no more than 18 months;
(ii) extension period of no more than 18 months;
(iii) final period of no more than 12 months; and
(iv) total period of no more than 48 months.
(8) Agent orange settlement payments: Agent orange settlement payments made to applicant or recipient veterans or their survivors are excluded from consideration as income in determining eligibility.
(9) Radiation Exposure Compensation Act payments: Payments made under the Radiation Exposure Compensation Act are excluded from consideration as income in determining eligibility.
(10) Victims compensation payments: Payments made by a state-administered fund established to aid victims of crime are excluded from consideration as income in determining eligibility. These payments are included as countable income when calculating the medical care credit.
(11) Lump sums for retroactive periods: SSI lump sum payments for retroactive periods are excluded from consideration as countable income in the month received.
(12) Life insurance and other burial benefits: Life insurance and other burial benefits are unearned income to the beneficiary (not the owner). The ISD worker must subtract the amount spent on the insured recipient’s last illness or burial up to $1,500. Any excess is counted as unearned income.
(13) One hundred percent state funded assistance payment: Any one hundred percent-state-funded assistance payment based on need, such as general assistance (GA) is excluded. Any interim payments made by a state or municipality from all state or local funds while an SSI application is pending are excluded.
(14) National vaccine injury compensation program (NVICP) payment: The NVICP funds are excluded as income or a resource until they are actually disbursed by the issuing agent. However, they are counted as income in the month in which they are received and counted as a resource in the following months, provided that the funds in question are not specifically earmarked for medical expenses. If the payment is designated for both living expenses and medical care, a determination must be made to identify how much of the payment is for living expenses, and how much is for medical care. The only portion actually counted then is that amount which is for living expenses. Therefore, a determination must be made as to how the payment is apportioned before making an eligibility determination.
(15) Remembrance, responsibility and the future payments: Payments by the remembrance, responsibility and the future foundation to individual survivors forced into slave labor by the Nazis are excluded as income in determining eligibility.
[8. 281.500 .19 NMAC - Rp, 8.281.500.20 NMAC, 8/15/2015; A, 12/1/2022]
8.281.500.20 DEEMED INCOME:
A. Availability: Deemed income is income considered available to a minor applicant or recipient from their parents. Deeming of resources and income applies only during periods when an applicant or recipient under 18 years of age is living with their parents and during the month of entry into an institution.
B. Situations in which deeming occurs: Deeming of income occurs:
(1) from ineligible parent to eligible child; or
(2) if there is both a MAP eligible parent and a MAP eligible child in the home.
C. Computing deemed income: The ISD worker computes the total monthly amount of parental unearned and earned income and then computes the deemed income available to the applicant or recipient child. If the deemed income plus the child’s separate income exceeds the applicable maximum, the child will not have a MAP category of institutional care eligibility for that month.
(1) Parents and children receiving aid: If one of the applicant or recipient child's parents is receiving any benefit or assistance paid by a governmental agency on the basis of economic need, that benefit plus all the income of that parent is excluded from the deeming process. This exclusion applies only to the income of the parent who receives the benefit. Even if the income of one parent is excluded, that parent is still considered a member of the household for purposes of determining the parental allocation. Provisions for deeming income do not apply to benefits under temporary assistance to needy families (TANF). No income is deemed to a parent or child(ren) if that parent or child(ren) is (are) receiving TANF assistance.
(2) Applicant or recipient parent and their child(ren): If a household is composed of an applicant or recipient parent and an applicant or recipient child(ren), the parent's income is determined according to the methodology appropriate to the MAP category of eligibility which they receive.
(a) If there is enough income to make the applicant or recipient parent ineligible, the remainder of the income is carried over to be deemed to the child(ren).
(b) If there is more than one potentially eligible child, the deemed income is divided equally among them. If total countable income is less than the applicable maximum, the applicant or recipient has a MAP category of institutional care eligibility on the factor of income.
(c) If an applicant or recipient is determined to meet the MAP category of institutional care eligibility, the ISD worker must recompute available income for the following month based on separate income to establish the correct medical care credit. See 8.281.500.23 NMAC, post-eligibility/medical care credit .
[8. 281.500 .20 NMAC - Rp, 8.281.500.21 NMAC, 8/15/2015; A, 12/1/2022]
8.281.500.21 DISREGARDS: Income disregards are determined on an individual basis. Disregards may be applied to any appropriate month of assistance, regardless of which income maximum is used.
A. $20 disregard: The first $20 of unearned or earned income received in a month is disregarded. This disregard is applied first to unearned income and, if any amount remains, to earned income. If there is no unearned income, the entire $20 disregard is applied to earned income. This disregard is not applied to any payment made to the applicant or recipient through government assistance programs or private charitable organizations, where payments are based on need. These payments include financial assistance, TANF, assistance from catholic charities, salvation army, bureau of Indian affairs, and VA pension (not compensation) payments.
B. Additional earned income disregard: After applying the $20 disregard as specified in Subsection A of 8.281.500.21 NMAC if appropriate, the first $65 of monthly earned income plus one-half of the remainder is also disregarded.
C. Work-related expenses of the blind: Work-related expenses of an employed applicant or recipient or couple who are legally blind are disregarded. The dollar amount of expenses which may be disregarded must be reasonable. Expenses are disregarded when paid and must be verified.
(1) This disregard does not apply to an applicant or recipient who is blind and is 65 years or age or older, unless they were receiving SSI payments due to blindness in the month before turning 65 or received payments under a state aid to the blind program.
(2) Types of work-related expenses which may be disregarded include:
(a) federal, state, and local income taxes;
(b) social security contributions;
(c) union dues;
(d) transportation costs, including actual cost of bus/taxi cab fare, or $0.15 per mile for private automobile;
(e) lunches;
(f) child care costs, if not otherwise provided;
(g) uniforms, tools and other necessary equipment; and
(h) special expenses necessary to enable an applicant or recipient who is blind to engage in employment, such as a seeing-eye dog or Braille instructions.
D. Student earned income disregard: Up to $1,200 per quarter or a maximum of $1,620 per calendar year of the earned income of certain students may be disregarded. To qualify for this disregard, the applicant or recipient must meet all of the following requirements:
(1) under 22 years of age;
(2) unmarried;
(3) not head of a household; and
(4) in regular attendance at a college or university, for at least 12 semester hours or vocational or technical training course for at least 20 hours per a calendar week.
(a) This disregard applies only to a student's own earned income and includes all payments made as compensation for services, such as wages from employment or self-employment, or payments from programs such as neighborhood youth corps or work-study.
(b) This disregard is available in addition to any exclusions applied to grants, scholarships or fellowships and in addition to any other allowable disregards.
E. Child support payments: One-third of the amount of child support payments made to a child applying for a MAP category of institutional care eligibility is disregarded. The remainder is considered unearned income, subject to the appropriate disregards outlined below.
[8. 281.500 .21 NMAC - Rp, 8.281.500.22 NMAC, 8/15/2015; A, 12/1/2022]
8.281.500.22 POST ELIGIBILITY/MEDICAL CARE CREDIT: Once financial eligibility for a MAP category of institutional care has been established, the ISD worker must determine the following.
A. M edical care credit: The medical care credit is the amount of the applicant’s or recipient’s income used to reduce the MAD payment to the institution where they reside. An applicant or recipient must make this payment directly to the institution. Applicants or recipients eligible for a MAP category of institutional care due to institutionalization in an acute care hospital or an in-state in-patient rehabilitation center are not charged a medical care credit. The amount of the medical care credit is always determined prospectively. The ISD worker computes a medical care credit starting with the first full month of institutional care. No medical care credit is required for the month the recipient enters the institution if they are admitted after the first moment of the first day of the month.
(1) No medical care credit for the month of discharge or death: An applicant or recipient is not required to pay a medical care credit for the month of discharge from the institution. The medical care credit must be paid if the applicant or recipient is transferred to another institution or makes a short visit outside the institution. No medical care credit is charged for the month in which a recipient who received MAD institutional care services dies. This will prevent a deficit for the institution when a benefit, such as social security, must be returned due to the death of a beneficiary.
(2) Application delay: If there is a delay between application and approval, an applicant or recipient incurs a liability for a medical care credit. The ISD worker notifies the applicant or recipient of this liability during the application process and informs them of the amount of the medical care credit they should pay. The applicant or recipient is encouraged to pay the medical care credit to the institution before approval of the application.
(3) Medical care credit during retroactive months: No medical care credits are applied for any period of retroactive eligibility under this provision.
B. Computing the medical care credit: The current personal needs amount (PNA) of an applicant or recipient monthly income is protected for their personal use in a nursing facility. Each year thereafter, the amount of an applicant’s or recipient’s monthly income shall be adjusted according to the consumer price index as indicated in 8.200.510 NMAC. The excess over the amount protected, subject to other deductions, is applied toward payment for care in the nursing facility as a medical care credit.
(1) See Paragraph (6) of Subsection B of 8.281.500.22 NMAC for personal needs allowance for veterans or surviving spouses.
(2) An applicant’s or recipient’s total income, including amounts disregarded in determining eligibility, is used to compute the medical care credit with the following exceptions:
(a) Indian tribe per capita payments (see Subsection B of 8.281.500.19 NMAC);
(b) German reparation payments; and
(c) social security administration overpayments.
(i) When the social security administration withholds an amount due to an overpayment, the social security gross payment amount is used to determine eligibility per Subsection A of 8.281.500.19 NMAC. To determine the amount used in calculating the medical care credit, the ISD worker ascertains whether a social security (Title II) overpayment is being recouped or whether an SSI overpayment is being recouped from a social security benefit check (a cross-program recoupment). Cross-program recoupments are at the recipient's option so the gross benefit amount is used to calculate the medical care credit.
(ii) Recoupment of a social security overpayment from a social security benefit check is mandatory. In such cases, the net social security benefit amount is used to calculate the medical care credit.
(d) payments from the Radiation Exposure Compensation Act.
(e) ‘remembrance, responsibility and the future’ payments.
(3) Dependent children at home: If an institutionalized applicant or recipient with no spouse has dependent children at home who are ineligible for TANF or assistance from any other program, or are eligible for an amount less than the TANF need standard, an allowance for each child of up to the current TANF standard of need may be deducted from the institutionalized applicant’s or recipient’s income which is in excess of the applicant’s or recipient’s personal allowance.
(4) Expenses not subject to third party payment 42 CFR 435.725(4): Amounts for incurred expenses for medical or remedial care that are not subject to payment by a third party, including:
(a) medicare and other health insurance premiums, deductibles, or coinsurance charges; and
(b) necessary medical or remedial care recognized under state law but not covered under the state medicaid plan, subject to reasonable limits on amounts of these expenses. HSD has the following reasonable limits on amounts for necessary medical or remedial care not covered under medicaid:
(i) For expenses not covered under the state plan or expenses covered under the state plan, but not paid for by medicaid, the amount of the deduction is the billed amount not to exceed the provider’s usual and customary charges except for unpaid nursing facility expenses.
(ii) To be deducted, an expense must be for medically necessary medical or remedial care rendered to the applicant or beneficiary and prescribed by a health care practitioner acting within their scope of practice who meet the qualifications of an eligible medicaid provider as listed in the New Mexico Administrative Code (NMAC) 8.310.3.9 NMAC, even if such practitioner is not a medicaid provider.
(iii) A deduction for incurred medically necessary non-covered medical or remedial care expenses will be allowed when the bill is incurred during a period which is no more than three months prior to the month of the current application. For each month of unpaid nursing facility services incurred during this period, deductions are allowed at an amount not to exceed the average monthly private rate of nursing facility services, as used to calculate asset transfer penalties and which is updated annually in 8.200.510.13 NMAC (or a prorated amount of this figure, for unpaid nursing facility services that are for less than a full month.
(iv) The deduction for medical and remedial care expenses that were incurred as the result of a transfer penalty period is limited to zero.
(v) Expenses for cosmetic/elective procedures (e.g., face lifts or liposuction etc.) are not allowed as deductions except when prescribed by a health care practitioner.
(vi) Expenses from medical or remedial procedures that were denied coverage by an insurer, including medicaid, on the basis of a lack of medical necessity are not allowed.
(5) Court-ordered support: A deduction for the full amount of court-ordered child or spousal support is also allowed for the applicant or recipient.
(6) Personal needs allowance for recipients in an ICF-IID: If an applicant or recipient who is institutionalized in an intermediate care facility for individuals with intellectual disabilities (ICF-IID) has a monthly income from employment in a sheltered workshop or other work activity program, up to the first $100 of this earned income is protected for the applicant’s or recipient’s personal needs. This amount is in addition to the applicant’s or recipient’s personal needs allowance protected from income from any source. If the applicant’s or recipient’s income is from any other source, the personal needs allowance is set at the amount as set forth in 8.281.500.12 NMAC.
(7) Veterans administration (VA) benefits: The ISD worker must contact the VA on each veteran’s case to verify how much of the benefit is for pension, aid and attendance (A&A) or unusual medical expenses (UME).
(a) For MAP eligible veterans with no spouse or dependent children, and for surviving spouses of veterans without dependent children who do not reside in a state veteran’s home (Fort Bayard or Truth or Consequences):
(i) exclude the A&A and UME in the medical care credit computation;
(ii) allow the personal needs allowance as set forth in 8.281.500.12 NMAC;
(iii) the benefit for applicant or recipient will be reduced to $90 per month effective the latest of the following;
(iv) the last day of the calendar month in which medicaid coverage begins;
(v) the last date of the month following 60 calendar days after issuance of a reduction notice;
(vi) the earliest date on which payment may be reduced without creating an overpayment;
(vii) when the benefit is reduced to $90, recomputed the medical care credit to allow $90 for personal needs.
(b) For MAP eligible veterans with no spouse or dependent children, and for surviving spouses of veterans without dependent children who do reside in a state veteran’s home (Fort Bayard or Truth or Consequences):
(i) include the A&A and UME in the medical care credit computation;
(ii) allow $90 for their personal needs;
(iii) the benefit for the applicant or recipient is not reduced to $90.
(c) Benefits for the following applicants or recipients are not reduced to $90 a month, regardless of whether or not they reside in a state veteran’s home:
(i) veterans who have a spouse or dependent child(ren);
(ii) surviving spouses of veterans who have dependent child(ren).
(d) The ISD worker allows these applicants or recipients the allowance as set forth in 8.281.500.12 NMAC, for personal needs.
C. Computing medical care credits for married institutionalized applicants or recipients: To calculate the medical care credit for a married institutionalized applicant or recipient, the “name-on-the-check” rule applies. The ISD worker uses only the income belonging to the institutionalized applicant or recipient to compute their medical care credit. Total gross income before any deductions is used in this process.
(1) Treatment of VA aid and attendance (A&A) and unusual medical expenses (UME): Allowances for A&A and UME are considered when computing the medical credit in accordance with Subsection B of 8.281.500.22 NMAC.
(2) Court-ordered support: A deduction for the full amount of court-ordered child or spousal support is also allowed for the applicant or recipient.
D. Computing medical care credits for an institutionalized couple: To compute medical care credits for each of an eligible institutionalized couple, the ISD worker totals the couple's gross income and divides by two. The personal needs allowance as set forth in Subsection B of 8.281.500.22 NMAC is subtracted from each amount for each applicant’s or recipient’s personal needs and added to any allowable amount(s) paid by that applicant or recipient for noncovered medical expenses.
E. Medical care credit deductions: The ISD worker applies the deductions listed below in the following order when determining the medical care credit:
(1) institutionalized spouse's personal needs allowance as set forth in 8.281.500.12 NMAC;
(2) community spouse monthly income allowance (CSMIA); the CSMIA deduction is permitted only to the extent that the income is available and is actually contributed to and accepted by the community spouse or other dependent family members:
(a) the CSMIA is calculated by starting with the minimum monthly maintenance needs allowance (MMMNA) and subtracting the community spouse's total gross income;
(b) both spouses shall be given notice of the amount of the CSMIA;
(c) if either spouse is dissatisfied with the amount of the CSMIA, [he or she] they can request a HSD administrative hearing pursuant to 8.352.2 NMAC, to establish that the community spouse needs income above the minimum monthly maintenance needs allowance; the spouse must demonstrate that the community spouse needs the additional income above the level otherwise provided by the minimum monthly maintenance needs allowance due to exceptional circumstances resulting in significant financial duress; if the spouse establishes that the community spouse needs additional income due to exceptional circumstances resulting in significant financial duress, there shall be substituted for the CSMIA such amount as is necessary to alleviate the financial duress and for so long as the exceptional circumstances exist; if as a result of a HSD administrative hearing final decision or district court hearing, additional income is granted to the community spouse for a specified period of time, when that time expires, the original CSMIA, as calculated by the ISD worker is reinstated; the exceptional circumstances can include medical, remedial or other support expenses that jeopardize the ability of the community spouse to remain self-sufficient in the community;
(d) if as a result of a district court hearing or a HSD administrative hearing final decision, a request for a revision of the CSMIA is granted, the revised amount shall be substituted for the CSMIA calculated by the ISD worker; and
(e) when the institutionalized applicant’s or recipient’s income is insufficient to provide the minimum authorized deduction for the community spouse, either spouse can request a HSD administrative hearing pursuant to 8.352.2.NMAC if either spouse establishes that the CSRA (in relation to the amount of income generated by such an allowance) is inadequate to raise the community spouse's income to the MMMNA, there shall be substituted, for the CSRA, an amount adequate to provide the MMMNA.
(3) an excess shelter allowance for allowable expenses of the community spouse which exceed thirty percent of the MMMNA standard up to a specified maximum; the following expenses are allowed for the primary residence of the community spouse:
(a) rent or mortgage payment, including interest or principal;
(b) home taxes and insurance;
(c) maintenance charges for a condominium or cooperative; and
(d) amount equal to the standard utility allowance used by the food stamp program if the community spouse incurs a heating or cooling expense; utility expenses included in the rent or the basic maintenance fee for a condominium or cooperative, are not allowed.
(4) The total CSMIA and excess shelter allowance combined may not exceed the standard amount per month, unless the MAD director or a district court orders the institutionalized spouse to pay an increased amount.
(5) An allowance for each eligible family member equal to one-third of the balance obtained after deducting the family member's gross income from the MMMNA. Family members include the couple's minor child(ren) under the age of 18 years, disabled adult child(ren) of the couple who meet the social security administration's definition of disability and dependent sibling(s) or parent(s) of the couple. These family members must reside with the community spouse. The dependency requirements are met if either member of the couple could claim the family member as a dependent for tax purposes.
(6) The deductions for the community spouse and dependent family members apply only so long as there is a community spouse. Deductions for the community spouse and other family members shall cease in the first full calendar month after the community spouse dies, becomes divorced, or is institutionalized.
(7) Health insurance premiums and non-covered medical expense deduction.
F. Reporting requirements: An applicant or recipient, spouse, or authorized representative is required to report to the ISD worker any change in circumstances which may affect eligibility or the medical care credit amount within 10 working days after the date the change occurs. Changes which cause adjustments in an applicant’s or recipient’s medical care credit amount are effective the month after the change occurs. Family members receiving allowances must also report all changes of gross income and residence within 10 working days after the date the change occurs. Changes must be reported when the institutionalized spouse stops making all or part of a maintenance allowance available to the community spouse or other family member(s), or when the recipient of a maintenance allowance begins to refuse all or part of the income.
G. Changes in income and recipient medical care credit: Payments received by an applicant or recipient, such as social security, VA, retirement or other benefits, are applied to billing for services for the same month in which the payment is received. If the income increases, the institution must continue to collect the amount indicated on the medical care credit report in the eligible recipient's file and immediately advise the ISD worker of the change. The ISD worker processes the change, notifies the institution and the eligible recipient of the new medical care credit amount and indicates the month in which the higher amount is to be collected. The difference between the medical care credit amounts is deposited in the eligible recipient's personal fund account until the change is effective.
[8. 281.500 .22 NMAC - Rp, 8.281.500.23 NMAC, 8/15/2015; A, 12/1/2022]
8.281.500.23 UNDUE HARDSHIP: An applicant or recipient subject to a penalty for transfer of assets for less than fair market value may apply for a waiver of the regulation regarding transfer of assets as constituting an undue hardship. The facility where an institutionalized applicant or recipient resides may file an application for waiver of the requirement on behalf of the applicant or recipient with the applicant’s or recipient’s or authorized representative’s consent.
A. The transfer must have been made to someone other than a family member. “Family member” includes son, daughter, grandson, granddaughter, step-son, step-daughter, in-laws, mother, father, step-mother, step-father, half-brother, half-sister, niece, nephew, grandmother, grandfather, aunt, uncle, sister, brother, step-sister, step-brother.
B. The applicant or recipient must demonstrate that the application of the transfer of assets regulation would deprive the applicant or recipient of:
(1) medical care such that the applicant’s or recipient’s health or life would be endangered; or
(2) food, clothing, shelter or other necessities of life.
C. The applicant or recipient or the facility where the applicant or recipient resides must submit any documentation to support the claim that application of the transfer of assets requirement would constitute an undue hardship within 30 calendar days of the date of the notice regarding the penalty to the ISD county office.
D. Undue hardship does not exist when the application of a transfer penalty causes an applicant or recipient or [his or her] their family members inconvenience or restricts their lifestyle.
E. The county director of the ISD office will make a decision regarding an application for waiver of the transfer of assets requirements within 30 calendar days of receipt of the application.
(1) Notice of the decision shall be mailed to the applicant or recipient or [his or her] their authorized representative.
(2) MAD may make payments to the nursing facility for an applicant or recipient who is a resident of the facility while an application for waiver of the requirement is pending to hold the bed for the applicant or recipient. HSD may make payments for no more than 30 calendar days.
F. If the applicant’s or recipient’s application for waiver of the transfer of assets requirement is granted, MAD shall pay for long-term care services prospective from the date of the application. MAD shall pay for long-term care services as long as the circumstances constituting the basis for waiver of the application of the requirement exist. If the applicant’s or recipient’s application for waiver of the transfer of assets requirement is denied, the applicant or recipient can request a HSD administrative hearing pursuant to 8.352.2 NMAC within 90 calendar days of the date of the notice of denial.
G. The applicant or recipient or their authorized representative must notify the ISD worker of any change in circumstances which affects the application of the undue hardship waiver exception within 10 working days of the change in circumstances. MAD will review the change of circumstances and determine the next appropriate action, which may include withdrawal of the waiver.
[8. 281.500 .23 NMAC - Rp, 8.281.500.24 NMAC, 8/15/2015; A, 12/1/2022]
HISTORY OF 8.281.500 NMAC: The material in this part was derived from that previously filed with the Commission of Public Records - State Records Center and Archives:
ISD Rule 380.0000, Medical Assistance for Persons Requiring Institutional Care, 12/29/1983.
ISD Rule 380.0000, Medical Assistance for Persons Requiring Institutional Care, 8/11/1987.
MAD Rule 380.0000, Medical Assistance for Persons Requiring Institutional Care, 2/5/1988.
MAD Rule 380.0000, Medical Assistance for Persons Requiring Institutional Care, 2/25/1988.
MAD Rule 380.0000, Medical Assistance for Persons Requiring Institutional Care, 6/1/1988.
MAD Rule 380.0000, Medical Assistance for Persons Requiring Institutional Care, 1/31/1989.
MAD Rule 380.0000, Medical Assistance for Persons Requiring Institutional Care, 6/21/1989.
MAD Rule 880.0000, Medical Assistance for Persons Requiring Institutional Care, 3/21/1990.
MAD Rule 880, Medical Assistance for Persons Requiring Institutional Care, 5/3/1991.
MAD Rule 880, Medical Assistance for Persons Requiring Institutional Care, 6/12/1992.
MAD Rule 880, Medical Assistance for Persons Requiring Institutional Care, 11/16/1994.
MAD Rule 889, Spousal Impoverishment, 8/17/1992.
MAD Rule 889, Spousal Impoverishment, 2/17/1994.
MAD Rule 882, Resources - Medical Assistance for Persons Requiring Institutional Care, 3/9/1993.
MAD Rule 882, Medical Assistance for Persons Requiring Institutional Care, 11/16/1994.
MAD Rule 882, Resources, 12/29/1994.
MAD Rule 883, Income - Medical Assistance for Persons Requiring Institutional Care, 3/18/1993.
MAD Rule 883, Income - Medical Assistance for Persons Requiring Institutional Care, 11/16/1994.
MAD Rule 883, Income, 12/29/1994.
MAD Rule 888, Medicare Catastrophic Coverage Act of 1988 Regarding Transfers of Assets, 3/10/1994.
MAD Rule 888, Transfers of Assets, 12/27/1994.
MAD Rule 885, Medical Care Credit, 11/16/1994.
History of Repealed Material: 8.281.500 NMAC, Income and Resource Standards, filed 2/15/2001 - Repealed effective 8/15/2015.
TITLE 8 SOCIAL SERVICES
CHAPTER 281 MEDICAID ELIGIBILIY - INSTITUTIONAL CARE (CATEGORIES 081, 083, AND 084)
PART 510 TRUST STANDARDS
8.281.510.1 ISSUING AGENCY: New Mexico Health Care Authority.
[8.281.510.1 NMAC - N, 10/1/2012; A,7/1/2024]
8.281.510.2 SCOPE: The rule applies to the general public .
[8.281.510.2 NMAC - N, 10/1/2012]
8.281.510.3 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 health care authority pursuant to state statute. See Sections 27-2-12 et seq ., NMSA 1978. 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.
[8.281.510.3 NMAC - N, 10/1/ 2012 ; A, 7/1/2024 ]
8.281.510.4 DURATION: Permanent.
[8.281.510.4 NMAC - N, 10/1/2012]
8.281.510.5 EFFECTIVE DATE: October 1, 2012, unless a later date is cited at the end of a section.
[8.281.510.5 NMAC - N, 10/1/2012]
8.281.510.6 OBJECTIVE: The objective of this rule is to provide eligibility criteria and procedures for the medicaid programs.
[8.281.510.6 NMAC - N, 10/1/2012]
8.281.510.7 DEFINITIONS:
A. “Assets” include all income and resources as described in Section 8.281.500 NMAC of an applicant/recipient and his/her spouse. Assets not in a trust are considered under the applicable rule to determine if they are countable or excludable for the purposes of medicaid eligibility.
B. “Beneficiary” is the individual(s) for whose benefit the assets are held by the trustee.
C. “Benefit” is something to the advantage of or profit to the recipient.
D. “Community spouse” is an individual as described in Subsection E of Section 8.281.500.7 NMAC, definitions .
E. “Corporate trustee” means a bank, trust company, or company whose primary business is trust services. A corporate trustee may not have any affiliation with the beneficiary either through relatives working for the corporate trustee or investments by the beneficiary with the company other than for administrative fees.
F. “Corpus” is the body of the trust or the original asset used to establish the trust (to include principal, interest, and subsequent additions), such as a sum of money or real property.
G. “Department” is the New Mexico human services department or successor agency.
H. “Grantor” is the owner of or has legal control over the assets placed into a trust. A grantor may also be referred to as a settlor or trustor.
I. “Institutionalized individual” is an individual as described in Subsection K of 8.281.500.7 NMAC.
J. “Irrevocable trust” is created when the grantor does not reserve any right to cancel or revoke any provision of the trust.
(1) Although termed irrevocable, a trust which provides that the trust can only be modified or terminated by a court is a revocable trust because the applicant/recipient (or his/her responsible party) or the trustee can petition the court to amend or terminate the trust.
(2) Although termed irrevocable, a trust that will terminate if a certain circumstance occurs during the lifetime of the applicant/recipient, such as the applicant/recipient leaving the nursing facility and returning home, is a revocable trust.
(3) Although termed irrevocable, a trust that can be revoked or terminated upon the agreement of any or all beneficiaries (including residual beneficiaries) is a revocable trust.
K. “Payment” means any disbursal from the corpus of the trust or from income generated by the trust which benefits the party receiving it. A payment may include actual cash, as well as non-cash or property disbursements, such as the right to use and occupy real property.
L. “Residual beneficiary” is a person or entity that receives the remaining trust principal upon the death of the original trust beneficiary.
M. “Revocable trust” is created when the grantor reserves any right to cancel any provision of the trust.
N. “Sole benefit of” means that no individual or entity, except the person for whom the trust was established, may benefit from the assets in any way whether at the time the trust is created or at any time in the future except after medicaid is reimbursed.
O. “Trust” includes any legal instrument, device or arrangement, that is reduced to writing, signed and executed, which may not be called a trust under state law, or which is similar to a trust. A trust is a legal device in which property (real or personal ) or other assets are held by one or more individuals for the benefit of others. A trust is usually created by a transfer of assets from the owner (grantor) to the trustee. Assets are not part of a trust and are considered outside of the trust until the date they are actually transferred into the trust, as demonstrated by verifiable documentation, regardless of the effective date of the trust. The transfer may be made while the grantor is alive or it may be made by will. The transfer of assets into a trust divests the original owner of legal title or restricts access to those assets. Trusts may also include structured settlements meeting the requirements stated above.
P. “Trust records” include, but are not limited to verifiable documentation of all transactions paid by or paid into a trust. Minimal documentation of distributions includes date of transaction, amount of payment (or if not paid by cash or other legal tender, type of asset distributed), person or entity receiving distribution, purpose of distribution, if distribution was made to acquire a non-consumable good, the location of that non-consumable good, and person or entity authorizing the distribution. Minimal documentation of additions to the trust includes the date of the transaction and a description of or amount of the asset transferred into the trust. The department shall not pay any costs or fees for obtaining trust records from the applicant/recipient or the trustee.
Q. “Trustee” is a person or entity who holds and controls the assets in the trust. The trustee usually has legal title to the assets held in the trust and is considered the owner of the trust assets in most dealings with third parties.
[8.281.510.7 NMAC - N, 10/1/2012]
8.281.510.8 [RESERVED]
8.281.510.9 MEDICAID QUALIFYING TRUSTS (MQT): An MQT is a trust created prior to August 11, 1993. An MQT is a trust, or similar legal device, established (other than by will) by an applicant/recipient or an applicant/recipient's spouse, under which the applicant/recipient may be the beneficiary of all or part of the distributions from the trust and such distributions are determined by one or more trustees who are permitted to exercise any discretion with respect to distributions to the applicant/recipient. A trust established by an applicant/recipient or an applicant/recipient's spouse includes trusts created or approved by a representative of the applicant/recipient (parent, guardian or person holding power of attorney) or the court where the property placed in trust is intended to satisfy or settle a claim made by or on behalf of the applicant/recipient or the applicant/recipient's spouse. This includes trust accounts or similar devices established for a minor child. In addition, a trust established jointly by at least one of the applicant/recipients who can establish an MQT and another party or parties (who do not qualify as one of these applicant/recipients) is an MQT as long as it meets the other MQT criteria. The provisions regarding MQTs apply even though an MQT is irrevocable or is established for purposes other than enabling an applicant/recipient to qualify for medicaid ; and, whether or not discretion is actually exercised.
A. Similar legal device: MQT rules listed in this subsection also apply to “similar legal devices” or arrangements having all the characteristics of an MQT except that there is no actual trust document. The determination whether a given document or arrangement constitutes a “similar legal device” shall be made by the department.
B. MQT resource treatment: For revocable MQTs, the entire principal is an available resource to the applicant/recipient. For irrevocable MQTs, the countable amount of the principal is the maximum amount the trustee can disburse to (or for the benefit of) the applicant/recipient, using his/her full discretionary powers under the terms of the trust. If the trustee has unrestricted access to the principal and has discretionary power to disburse the entire principal to the applicant/recipient (or to use it for the applicant/recipient's benefit), the entire principal is an available resource to the applicant/recipient. Placement of an asset excluded by Section 8.281.500.13 NMAC, resource exclusions , into a trust does not change the nature of the asset. The asset remains excluded, except for the home of an institutionalized individual. If the home of an institutionalized individual is placed in a trust, it becomes a countable resource. The value of the property is included in the value of the principal. If the MQT permits a specified amount of trust income to be distributed periodically to the applicant/recipient (or to be used for his/her benefit), but those distributions are not made, the applicant/recipient's countable resources increase cumulatively by the undistributed amount.
C. Income treatment: Amounts of MQT income distributed to the applicant/recipient or to third parties for the applicant/recipient’s benefit are countable income when distributed.
D. Transfer of resources: If the MQT is irrevocable, a transfer of resources has occurred to the extent that the applicant/ recipient or grantor’s access to the principal is restricted (e.g., if the trust states that the trustee cannot access the principal, but must distribute the income produced by that principal to the applicant/recipient, the principal is not an available resource and has, therefore, been transferred). See 8.281.500.14 NMAC.
E. Beneficiary of trust lives in an ICF-MR: If the beneficiary of a trust is an applicant/recipient who is mentally retarded and resides in an intermediate care facility for the mentally retarded (ICF-MR), that applicant/recipient's trust is not considered an MQT if the trust or trust decree was established prior to April 7, 1986, and is solely for the benefit of that applicant/recipient.
F. Treatment of SSI or social security lump sum payments: SSI or social security lump sum payments for retroactive periods which are placed in an MQT do not qualify for the nine-month exclusion from countable resources. The trust is evaluated as an MQT for purposes of medicaid eligibility.
G. Trust records shall be open at all reasonable times to inspection by the department and copies shall be provided upon the request of an authorized representative of the department.
[8.281.510.9 NMAC - Rp, 8.281.510.15 NMAC, 10/1/2012]
8.281.510.10 TRUSTS ESTABLISHED ON OR AFTER AUGUST 11, 1993: Trusts established on or after August 11, 1993 are evaluated using the provisions of OBRA 93. The term “ medicaid qualifying trust” or MQT is no longer used after that date. Any trust which meets the basic definition of a trust can be counted in determining eligibility for medicaid . No clause or requirement in a trust, no matter how specifically it applies to medicaid or other federal or state programs (i.e. exculpatory clauses) precludes a trust from being considered under 8.281.500 NMAC. Depending on how the trust is structured, the amounts in the trust may count as resources, income, or a transfer of assets. All trusts submitted for review by the department must be in writing, signed, and fully executed. Trusts that are not signed and executed will not be considered as effective trusts until they are signed and executed. Assets are not part of a trust and are considered outside of the trust until the date they are actually transferred into the trust, as demonstrated by verifiable documentation, regardless of the effective date of the trust.
A. The standards set forth in this section shall apply to trusts or similar legal devices without regard to:
(1) the purposes for which the trust is established;
(2) whether the trustee(s) has discretion or exercises such discretion under the trust;
(3) any restrictions on when or whether distributions can be made from the trust; and
(4) or any restrictions on the use of distributions from the trust.
B. Trust establishment: An applicant/recipient is considered to have established a trust and that trust is considered to belong to that applicant/recipient if his/her assets were used to form all or part of the corpus of the trust. Applicants/recipients to whom the trust provisions apply shall include any applicant/recipient who establishes a trust and who is an applicant/recipient for medicaid services. An applicant/recipient shall be considered to have established a trust if any of his/her assets, regardless of the amount, were used to form part or all of the corpus of the trust.
(1) The trust must have been established, other than by will, by any of the following individuals:
(a) applicant/recipient;
(b) applicant/recipient's spouse;
(c) an individual, including a court or administrative body, with legal authority to act in place of, or on behalf of, the applicant/recipient or his/her spouse; or
(d) an individual, including a court or administrative body, acting at the direction of, or upon the request of, the applicant/recipient or his/her spouse.
(2) When the corpus of a trust includes assets of another person or persons not described in Subparagraphs (a) through (d) above, as well as assets of the applicant/recipient, the rules apply only to the portion of the trust attributable to the assets of the applicant/recipient. Thus, in determining countable income and resources in the trust for eligibility and post-eligibility purposes, the ISD caseworker shall prorate any amounts of income and resources, based on the proportion of the applicant/recipient's assets in the trust to those of other persons. (For example: if the applicant/recipient and his two sisters create a trust and each sister contributes a total value of fifty thousand dollars ($50,000) and the applicant contributes twenty five thousand dollars ($25,000), the applicant’s prorated share is twenty percent of the entire value of the trust.)
C. Treatment of trusts: For purposes of determining medicaid eligibility, the treatment of trusts shall be dependent on the characteristics of the trust.
D. Revocable trusts:
(1) the entire corpus of the trust shall be counted as a resource available to the applicant/recipient; and
(2) any payments from the trust made to or for the benefit of the applicant/recipient shall be counted as income (unless otherwise excludable, see Section 8.281.500.20 NMAC, unearned income , and Section 8.281.500.21 NMAC, deemed income ); and
(3) any payments from the trust which are not made to or for the benefit of the applicant/recipient shall be considered as assets transferred for less than fair market value (see Section 8.281.500.14 NMAC, asset transfers ).
E. Irrevocable trusts: In an irrevocable trust from which payment can be made under the terms of the trust to or for the benefit of the applicant/recipient from all or a portion of the trust.
(1) The following shall apply to that trust or that portion of the trust:
(a) payments from income or from the corpus made to or for the benefit of the applicant/recipient shall be treated as income to the applicant/recipient unless otherwise excludable (see Section 8.281.500.20 NMAC and Section 8.281.500.21 NMAC);
(b) income on the corpus of the trust which could be paid to or for the benefit of the applicant/recipient shall be counted as a resource available to the applicant/recipient;
(c) the portion of the corpus that could be paid to or for the benefit of the applicant/recipient shall be treated as a resource available to the applicant/recipient; and
(d) payments from income or from the corpus that are made, but not to or for the benefit of the applicant/recipient, shall be treated as a transfer of assets for less than fair market value (see Section 8.281.500.14 NMAC).
(2) In the case of an irrevocable trust from which payments from all or a portion of the trust cannot, under any circumstances, be made to or for the benefit of the applicant/recipient, all of the trust, or any such portion or income thereof, shall be treated as a transfer of assets for less than fair market value (see Section 8.281.500.14 NMAC).
(a) In treating these portions as a transfer of assets, the date of transfer shall be considered to be the date the trust was established, or, if later, the date on which the applicant/recipient no longer had a right of payment.
(b) For transfer of assets purposes, in determining the value of the portion of the trust which cannot be paid to the applicant/recipient, amounts that have been paid, for whatever purpose, shall not be subtracted from the value of the trust on the date the trust was created or, if later, the date that payment could no longer be made. The value of the transferred amount shall be no less than the value on the date the trust is established or, if later, on the date that payment could no longer be made. If additional funds are added to this portion of the trust, those funds shall be treated as a new transfer of assets for less than fair market value, as of the date the additional funds were added to the trust (See Section 8.281.500.14 NMAC).
F. Payments are considered countable to the applicant/recipient when made from a revocable or irrevocable trust to or on behalf of the applicant/recipient including payments of any sort, including an amount from the corpus or income produced by the corpus, paid to another person or entity such that the applicant/recipient derives some benefit from the payment.
G. In determining whether payments can or cannot be made from a trust to or for an applicant/recipient, the department shall take into account any restrictions on payments, such as use restrictions, exculpatory clauses, or limits on trustee discretion that may be included in the trust. Any amount in a trust for which payment can be made, no matter how unlikely the circumstance of payment might be or how distant in the future, shall be considered a payment that can be made under some circumstances. For example, if an irrevocable trust provides that the trustee can disburse only one thousand dollars ($1,000) to or for the applicant/recipient out of a ten thousand dollars ($10,000) trust, only the one thousand dollars ($1,000) is treated as a payment that could be made. The remaining nine thousand dollars ($9,000) is treated as an amount which cannot, under any circumstances, be paid to or for the benefit of the applicant/recipient and may be subject to a transfer penalty. On the other hand, if a trust contains twenty five thousand dollars ($25,000) that the trustee can pay to the applicant/recipient only in the event that the applicant/recipient needs, for example, a heart transplant, this full amount is considered as a payment that could be made under some circumstance, even though the likelihood of payment is remote. Similarly, if a payment cannot be made until some point in the distant future, it is still payment that can be made under some circumstances and the funds are counted as a resource.
H. Institutionalized individuals with a community spouse: A transfer to a trust (or similar instrument) for the sole benefit of a community spouse shall be treated in accordance with the provisions above. If the trust is established by either spouse (using at least some of the couple's assets) the trust shall be reviewed by the department for availability of resources, in accordance with the provisions above. If the payment from such a trust shall be considered an available resource to either spouse, the trust shall be included as a countable resource in determining medicaid eligibility for the institutionalized spouse.
I. Trust records shall be open at all reasonable times to inspection by the department and copies shall be provided upon the request of an authorized representative of the department. The department shall not be charged any fees or costs associated with providing trust records to the department.
[8.281.510.10 NMAC - Rp, 8.281.500.15 NMAC, 10/1/2012]
8.281.510.11 RECOGNIZED MEDICAID TRUSTS: The trust provisions set forth in 8.281.510.9 NMAC and 8.281.510.10 NMAC shall not apply to the following trusts so long as the trust document meets all the requirements set forth in this section.
A. The recognized medicaid trusts described in this section (special needs trusts and non-profit trusts for certain disabled individuals) are subject to the following.
(1) Only income and resources distributed directly to the applicant/recipient or to a third party on the applicant/recipient's behalf by the trustee are considered available to the applicant/recipient in determining medicaid eligibility if the applicant/recipient could use the payment for food or shelter for him/herself .
(2) The trusts are reversionary trusts meaning the trust must provide that, upon the death of the applicant/recipient, any funds remaining in the trust revert to the state medicaid agency, up to the amount paid in medicaid benefits on the applicant/recipient's behalf. If the applicant/recipient has resided in more than one state, the trust must provide that the funds remaining in the trust are distributed to each state in which the applicant/recipient received medicaid , based on the state's proportionate share of the total amount of medicaid benefits paid by all of the states on the applicant/recipient's behalf.
(3) All trusts submitted for review to the department must be in writing, signed, and fully executed. Trusts that are not signed and executed will not be considered as effective trusts until they are signed and executed. Trusts must also be funded as demonstrated by verifiable documentation prior to review by the department.
(4) Assets are not part of a trust and are considered outside of the trust until the date they are actually transferred into the trust, as demonstrated by verifiable documentation, regardless of the effective date of the trust. Assets outside of a trust will be evaluated according to the applicable regulations regarding the counting of resources.
(5) Since the department is a reversionary beneficiary for all of the trusts described in the rest of this section, any legal action concerning one of these trusts must name the department as an interested party and the department must be notified by service of process in accordance with the New Mexico Rules of Civil Procedure.
(6) The applicant/recipient may not be the trustee and may not have any ability, access, or authority to manage or control the trust account.
(7) Each trust document must identify the person or organization that drafted the trust document.
(8) If the department approves or previously approved a recognized medicaid trust, the trust and administration of the trust are subject to review by the department, at least annually, and more frequently upon the request of the department, to determine if the trust remains a valid trust for the purposes of meeting the requirements of a recognized medicaid trust.
(9) If the department determines that a trust is invalid under Paragraph (8) above, the department will evaluate the applicant/recipient’s medicaid eligibility, applying the provisions of Section 8.281.500 NMAC to the corpus of any existing trust. If the corpus of the trust is not disclosed, or cannot be identified by the department due to a lack of documentation, the department will presume that the corpus of the trust is a countable resource in excess and will be counted toward the allowable resource limit in 8.281.500.11 NMAC, applicable resource standards .
(10) The trustee and any alternate trustees shall be specifically identified by name and address.
(11) The department shall not be charged any fees or costs for obtaining trust records or documents.
(12) The trust may not under any circumstances provide a loan to the beneficiary or any other individual or entity.
(13) The trust must be in compliance with all applicable criteria as set forth in 8.281.510.11 NMAC.
(14) All trusts under Subsection B below must terminate upon the death of the beneficiary and provision made to immediately disburse the remaining corpus in accordance with the terms of the trust.
B. Special needs trusts: A special needs trust is a trust containing the assets of a disabled applicant/recipient established and funded prior to the time the disabled applicant/recipient reaches the age of 65 and which is established for the sole benefit of the disabled applicant/recipient by a parent, grandparent, legal guardian of the disabled applicant/recipient, or a court. A trust established on or after December 13, 2016, by an individual (i.e. the trust beneficiary) with a disability under age 65 for his or her own benefit can qualify as a special needs trust, conferring the same benefits as a special needs trust set up by a parent, grandparent, legal guardian, or court. To qualify as a special needs trust, the trust shall contain the following provisions.
(1) The trust shall be identified as an OBRA '93 trust established pursuant to 42 U.S.C. Section 1396p(d)(4)(A).
(2) The trust shall not contain any provisions to automatically alter the form of the trust from an individual trust to a “pooled trust” under 42 U.S.C. Section 1396p(d)(4)(C). The special needs trust should be properly dissolved and a pooled trust should be created in accordance with federal and state laws.
(3) The trust shall specifically state that the trust is for the sole benefit of the trust beneficiary. Only trusts which are intended for the sole benefit of the disabled applicant/recipient are special needs trusts. Any trust which provides benefits to other persons is not for the sole benefit of the trust beneficiary and shall not be considered a special needs trust. The trust may provide for reasonable compensation to a trustee and shall provide for the reimbursement to the department on the death of the trust beneficiary.
(4) The trust shall specifically state that its purpose is to permit the use of trust assets to supplement, and not to supplant, impair or diminish, any benefits or assistance of any federal, state or other governmental entity for which the beneficiary may otherwise be eligible or for which the beneficiary may be receiving.
(5) Parents shall not be relieved of their duty to support a minor child. A minor's funds in a trust shall not be expended on routine support that should be provided by the parents.
(6) The trust shall specifically state the age of the trust beneficiary, whether the trust beneficiary is disabled within the definition of 42 U.S.C. Section 1382c(a)(3), and whether the trust beneficiary is competent at the time the trust is established.
(7) If the trust beneficiary is a minor, the trustee shall execute a bond to protect the child's funds or shall get a court's written order exempting him/her from the bond requirement.
(8) If there is some question about the trust beneficiary's disability, independent proof may be required.
(9) If the trust beneficiary is a minor, the trust shall state whether the trust beneficiary is expected to be competent at his or her majority.
(10) The trust shall specifically identify, in an attached schedule, the source of the initial trust property and all assets of the trust. If the trust is being established with funds from the proceeds of a settlement or judgment subsequent to the bringing of a legal cause of action, medicaid's claim for its expenditures that are related to the cause of action shall be repaid immediately upon the receipt of such proceeds and prior to the establishment of the trust.
(11) Subsequent additions made to the trust corpus shall be reported to the ISD caseworker upon application and recertification. Subsequent additions to the trust (other than interest on the corpus) after the applicant/recipient reaches age 65 may be subject to transfer of asset provisions (unless an exception to transfer of asset provisions applies).
(12) If subsequent additions are to be made to the trust corpus with funds not belonging to the trust beneficiary, it shall be understood that those funds are a gift to the trust beneficiary and cannot be reclaimed by the donor.
(13) If the trust makes provisions which are intended to limit invasion by creditors or to insulate the trust from liens or encumbrances, the trust shall state that such provisions are not intended to limit the state's right to reimbursement or to recoup incorrectly paid benefits.
(14) The special needs trust shall identify the grantor by name, indicate his/her relationship to the primary beneficiary, and state that it is established by a parent, grandparent, or legal guardian of the trust beneficiary, or by a court. A court can be named as the grantor, if the trust is established pursuant to a settlement of a case before it, or if the court is otherwise involved in the creation of the trust.
(15) The trust may pay administration fees and legal bills incurred by the beneficiary related to the trust administration.
(16) The trust shall specifically state that it is irrevocable. Neither the grantor, nor the beneficiary, or any remainder beneficiaries shall have any right or power, whether alone or in conjunction with others, in whatever capacity, to revoke or terminate the trust or to designate the persons who shall possess or enjoy the trust estate during his/her lifetime. However, the trustee may seek an amendment for the limited purpose of ensuring that the trust complies with any changes to the laws governing the trust, per the agreement of all interested parties, to include the department. All such amendments shall be reviewed, consented to, and approved in writing by the department or its successor agency prior to finalizing the amendments. Any amendments not agreed to in writing by the department are void. Trust records shall be open at all reasonable times to inspection by the department and copies shall be provided, at no cost to the department, upon the request of an authorized representative of the department.
(17) The trustee shall be specifically identified by name and address. The trust shall state that the original trust beneficiary cannot be the trustee. The trust shall make provisions for naming a successor trustee in the event that any trustee is unable or unwilling to serve. The department as well as the trust beneficiary or guardian (if applicable), shall be given prior notice if there is a change in the trustee.
(18) The trust shall specifically state that the trustee shall fully comply with all state laws and regulations, including prudent administration per, Section 46A-8-804 (2003) NMSA 1978. The trust shall provide that the trustee cannot take any actions not authorized by, or without regard to, state laws and regulations.
(19) The trust shall specifically state that the trustee shall be compensated only as provided by law. The costs of administration must comply with Section 46A-8-805 (2003) NMSA 1978. If the trust identifies a guardian, the trust shall specifically identify him or her by name. A guardian shall be compensated only as provided by law. The parent of a minor child shall not be compensated from the trust as the child's guardian.
(20) The trust shall specifically name the department as a remainder beneficiary with priority over any other beneficiaries except the primary beneficiary for whom the trust was created. The trust shall specifically state that, upon the death of the primary beneficiary, the department will be immediately notified by the trustee in writing, and shall be paid all amounts remaining in the trust up to the total value of all medical assistance paid on behalf of the primary beneficiary. The trustee shall comply fully with this obligation to first repay the department, without requiring the department to take any action except to establish the amount to be repaid. Repayment shall be made by the trustee to the department or to any successor agency within 30 days after receiving written notification by the department of the amounts expended on behalf of the primary beneficiary.
(a) Allowable administrative expenses: The following types of administrative expenses may be paid from the trust prior to reimbursement to the department for medical assistance paid: taxes due from the trust to the state or federal government because of the death of the beneficiary, and reasonable fees for administration of the trust estate such as an accounting of the trust to a court, completion and filing of documents, or other required actions associated with termination and wrapping up of the trust. Payment of such expenses must be fully documented and copies of the documentation provided to the department within seven calendar days of making such payments.
(b) Prohibited expenses and payments: Examples of some types of expenses that are not permitted prior to reimbursement to the department for medical assistance, include but are not limited to: taxes due from the estate of the beneficiary other than those arising from inclusion of the trust in the estate, inheritance taxes due for residual beneficiaries, payment of debts owed to third parties other than the department, funeral expenses, and payments to residual beneficiaries.
(21) If there is a provision for repayment of other assistance programs, the trust shall specifically state that the medicaid program shall be repaid prior to making repayment to any other assistance programs.
(22) The trust shall specifically state that if the beneficiary has received medicaid benefits in more than one state, each state that provided medicaid benefits shall be repaid. If there is an insufficient amount left to cover all benefits paid, then each state shall be paid its proportionate share of the amount left in the trust, based upon the amount of support provided by each state to the beneficiary.
(23) No provisions in the trust shall permit the trustee or the estate's representative to first repay other persons or creditors at the death of the beneficiary. Only what remains in the trust after the repayments specified in Paragraphs (20) through (22) above have been made shall be considered available for other expenses or beneficiaries of the estate.
(24) The trust shall specify that an accounting of all additions and expenditures made by or into the trust shall be submitted to the department on an annual basis, or more frequently upon the request of the department. The department shall not be charged any fees or costs for obtaining these records.
(25) The trust shall not create other trusts within it.
(26) If the trust is funded, in whole or in part, with an annuity or other periodic payment arrangement, the department must be named in the controlling documents as the primary remainder beneficiary up to the total amount of medical assistance paid on behalf of the individual.
(27) Distributions from the trust made to or for the benefit of a third party that are not for the sole primary benefit of the disabled individual are treated as a transfer of assets for less than fair market value and may create a period of ineligibility for certain medicaid services.
C. Income diversion trusts: An applicant/recipient whose income exceeds the income standard may be eligible to receive medicaid through the creation and funding of an income diversion trust. The trust terminates upon the death of the beneficiary. An income diversion trust must meet all of the following requirements.
(1) The trust is composed only of pension, social security, and other income to the applicant/recipient, including accumulated income in the trust.
(2) Only income distributed directly to the applicant/recipient or to a third party on the applicant/recipient's behalf by the trustee are considered available to the applicant/recipient in determining medicaid eligibility if the applicant/recipient could use the payment for food or shelter for him/herself.
(3) An income diversion trust is a reversionary trust meaning the trust must provide that, upon the death of the applicant/recipient, any funds remaining in the trust revert to the state medicaid agency, up to the amount paid in medicaid benefits on the applicant/recipient's behalf.
(4) If the applicant/recipient has resided in more than one state, the trust must provide that the funds remaining in the trust are distributed to each state in which the applicant/recipient received medicaid , based on the state's proportionate share of the total amount of medicaid benefits paid by all the states on the applicant/recipient's behalf.
(5) The trustee may, upon the death of the beneficiary, pay the expenses of the beneficiary's burial or cremation up to the amount then authorized for burial expenses under federal and state medicaid law and regulations, to the extent other resources are not so designated.
(6) The trusts described in this section are also known in New Mexico as Maxwell v. Heim income diversion trusts; those trusts executed on or after August 11, 1993 no longer have to be court ordered or approved.
D. Non-profit trusts for certain disabled individuals: Trusts containing the assets of applicants/recipients who meet the social security administration's definition of disability.
(1) The trust must meet all the following criteria to be considered a non-profit trust for certain disabled individuals:
(a) the trust is established and managed by a non-profit association;
(b) a separate account is maintained for each beneficiary of the trust but, for purposes of investment and management of funds, the trust pools these accounts;
(c) accounts in the trust are established solely for the benefit of applicants/recipients who meet the social security administration's definition of disability and are established by the parent, grandparent, or legal guardian of such applicants/recipients, by such applicants/recipients themselves, or by a court;
(d) to the extent that any amounts remaining in the applicant/recipient’s trust account upon his/her death are not retained by the trust, the trust pays to the department an amount equal to the total amount of medicaid benefits paid on behalf of the applicant/recipient;
( i ) allowable administrative expenses: the following types of administrative expenses may be paid from the trust prior to reimbursement to the department for medical assistance paid: taxes due from the trust to the state or federal government because of the death of the beneficiary, and reasonable fees for administration of the trust estate such as an accounting of the trust to a court, completion and filing of documents, or other required actions associated with termination and wrapping up of the trust; payment of such expenses must be fully documented and copies of the documentation provided to the department within seven calendar days of making such payments;
(ii) prohibited expenses and payments: examples of some types of expenses that are not permitted prior to reimbursement to the department for medical assistance, include but are not limited to: taxes due from the estate of the beneficiary other than those arising from inclusion of the trust in the estate, inheritance taxes due for residual beneficiaries, payment of debts owed to third parties, funeral expenses, and payments to residual beneficiaries; and
(iii) any income or resources added to the trust after the applicant/recipient reaches 65 years of age may subject him or her to a transfer of assets penalty.
(2) A trustee of a non-profit trust, in order to fulfill his or her fiduciary obligations with respect to the state's remainder interest in the trust, must:
(a) notify the department, in writing, of the creation or funding of the trust for the benefit of an applicant/recipient; and
(b) notify the department, in writing, of the death of the beneficiary of the trust; and
(c) notify the department, in writing, in advance of any transactions involving transfers from the trust principal for less than fair market value.
(3) Trust records shall be open at all reasonable times to inspection by the department and copies shall be provided, at no cost to the department, upon the request of an authorized representative of the department.
[8.281.510.11 NMAC - Rp, 8.281.500.15 NMAC, 10/1/2012; A, 3/1/2018]
8.281.510.12 OTHER TRUSTS:
A. Limited partnerships : A limited partnership is a “similar legal device” to a trust. Trust provisions of the Omnibus Budget Reconciliation Act of 1993 (OBRA 93) direct that the term “trust” includes any legal device similar to a trust. Therefore, OBRA 93 trust provisions of this section apply to limited partnerships. The general partners act as trustee, and the limited partners are the equivalent of beneficiaries of an irrevocable trust. To the extent that the general partners can make each limited partner's ownership interest available to him, that interest is a countable resource and not a transfer of assets. However, a transfer of assets has occurred to the extent that:
(1) the value of the share of ownership purchased by the limited partner is less than the amount he invested;
(2) the general partners cannot make the limited partner's share available to him;
(3) if transfer-of-assets provisions apply, the look-back period is 60 months.
B. Trusts created by will: Trusts that are created by will, but are not in effect (i.e., the testator is not deceased) are not considered as countable resources. Once a trust created by will is in effect and funded (i.e., the testator is deceased), the trust will be reviewed according to Subsection C, below.
C. Third party trusts:
(1) Third party trusts are trusts which are established with assets contributed by individuals other than the applicant/recipient or the applicant/recipient's spouse for the benefit of an applicant/recipient.
(2) The terms of the trust will determine whether the trust fund is countable as a resource or income for medicaid eligibility.
(a) Trusts which limit distributions to non-support or supplemental needs will not be considered as a countable resource in their entirety.
(b) If the applicant/recipient has the right to demand a distribution, the amount that may be demanded is countable, whether or not it is actually distributed.
(c) If the trustee may exercise discretion in distributing income or resources to the applicant/recipient or on behalf of the applicant/recipient, only the actual distributions of income or resources are countable in determining eligibility.
(d) If the applicant/recipient as the beneficiary of the trust may revoke or direct distributions from the trust, the trust is considered a countable resource.
(3) Trust records shall be open at all reasonable times to inspection by the department and copies shall be provided, at no cost to the department, upon the request of an authorized representative of the department.
[8.281.510.12 NMAC - Rp, 8.281.500.15 NMAC, 10/1/2012]
8.281.510.13 UNDUE HARDSHIP: An applicant/recipients who has excess resources and is unable to access resources from an existing trust will not be found ineligible for medicaid where the department determines, on a case by case basis, that denial of eligibility on the basis of excess resources would work an undue hardship.
A. The applicant/recipient must demonstrate that the application of the trust regulation would deprive the applicant/recipient or his/her spouse of:
(1) medical care such that the applicant/recipient’s health or life would be endangered; or
(2) food, clothing, shelter or other necessities of life.
B. The applicant/recipient must submit any documentation to support the claim that application of the trust regulation would constitute an undue hardship within 30 days of the date of the notice regarding eligibility for medicaid .
C. Undue hardship does not exist when the application of the trust regulation causes an applicant/recipient or his/her family members inconvenience or restricts their lifestyle.
D. The county director of the ISD office will make a decision regarding an application for waiver of the trust regulation within 30 days of receipt of the application. The decision to grant a waiver shall be reviewed at every re-certification to determine if the circumstances justifying a waiver are still applicable.
E. Notice of the decision shall be mailed to the applicant/recipient or his/her representative.
F. The applicant/recipient or his/her representative must notify the ISD caseworker of any change in circumstances which affects the application of the undue hardship waiver exception within ten days of the change in circumstances. The department will review the change of circumstances and determine the next appropriate action, which may include withdrawal of the waiver.
[8.281.510.13 NMAC - Rp, 8.281.500.15 NMAC, 10/1/2012]
8.281.510.14 USE OF TRUST V. TRANSFER RULES FOR ASSETS PLACED IN TRUST: When a non-excluded asset is placed in a trust, a transfer of assets for less than fair market value generally takes place. An applicant/recipient (or someone acting on behalf of the applicant/recipient) placing an asset in a trust generally gives up ownership of the asset to the trust. If the applicant/recipient does not receive fair compensation in return, a penalty is imposed under the transfer of assets provisions. However, the trust provisions contain specific requirements for treatment of assets placed in trusts. These requirements indicate when assets are considered countable as income or resources, and as a transfer of assets depending on the specific circumstances of the particular trust . Application of the trust regulations, along with the imposition of a penalty for the transfer of the assets into the trust, could result in the applicant/recipient being penalized twice for actions involving the same asset. If an asset is subject to the trust regulations and a transfer of asset penalty, the requirements of the trust regulations take precedence over a transfer of assets penalty for the same asset.
[8.281.510.14 NMAC - N, 10/1/2012]
8.281.510.15 EXCLUDED ASSETS PLACED IN A TRUST: Placement of excluded assets in a trust, with the exception of a home, shall not result in a penalty of ineligibility because the transferred asset is not an asset for transfer purposes. However, a home, whether excluded or not, when transferred into a trust shall be considered a resource unless:
A. the trust is for the sole benefit for the applicant/recipient’s spouse; or
B. was transferred to a trust that is in compliance with Subsection B or D of Section 8.281.510.11 NMAC that is established for the sole benefit of the applicant/recipient’s disabled child, or
C. was transferred to a trust that is in compliance with Subsection B or D of Section 8.281.510.11 NMAC that is established solely for the benefit of an individual who is under 65 years of age and who is disabled.
[8.281.510.15 NMAC - N, 10/1/2012]
8.281.510.16 DOCUMENTATION OF TRUSTS AND TRUST RECORDS: Applicants/recipients shall disclose the existence of any trust to which they have contributed income, resources, or are a beneficiary. Upon learning of the existence of a trust, the ISD caseworker must obtain a copy of the trust document, including all attachments, and forward it to the MAD eligibility unit so that it may be reviewed by MAD for a determination on how the trust may affect medicaid eligibility. Trust records shall be open at all reasonable times to inspection by the department and copies shall be provided upon the request of an authorized representative of the department. The department shall not be charged any fees or costs associated with providing trust records to the department. Any records relating to a trust that are sealed by a court order or settlement agreement shall be produced to the department by the applicant/recipient or trustee upon request. Failure to provide such records will result in the presumption that the applicant/recipient’s trust is a countable resource that exceeds the resource limitation at 8.281.500 NMAC.
[8.281.510.16 NMAC - N, 10/1/2012]
8.281.510.17 COMMENCEMENT OF PROCEEDINGS: The department may commence a proceeding against the trustee of a trust, if the department considers any acts, omissions, or failures of the trustee to be inconsistent with the terms of the trust, contrary to applicable laws or regulations, or contrary to the fiduciary obligations of the trustee.
[8.281.510.17 NMAC - N, 10/1/2012]
8.281.510.18 NON-COMPLIANCE WITH TERMS OF TRUST: If the department suspects or determines that the trustee is not complying with the terms of a trust that has been approved by the department, the department will send a letter to the recipient of services or his or her representative requesting more information or describing the specific actions that are not in compliance with the trust which may include but is not limited to proper management of the funds in the trust. The recipient will have 15 days to provide the requested information or demonstrate, through documentation, that the actions of the trustee are not in violation of the terms of the trust. Failure to respond or to adequately demonstrate that the terms of the trust have not been violated may result in a transfer of assets penalty, disqualification from eligibility to receive benefits, and legal action, as appropriate. If the department identifies that the violation of the terms of the trust has been to inadequately fund the trust, the recipient shall immediately obtain a corporate trustee and amend the trust to be managed by that corporate trustee.
[8.281.510.18 NMAC - N, 10/1/2012]
8.281.510.19 AMENDMENTS TO CERTAIN TRUSTS: A special needs trust, income diversion trust, or pooled charitable trust that was created prior to the effective date of these regulations must fully comply with these regulations as part of any subsequent amendments made to those trusts on or after the effective date of these regulations.
[8.281.510.19 NMAC - N, 10/1/2012]
HISTORY OF 8.281.510 NMAC:
NMAC History:
8 NMAC 4.ICM.500, Eligibility Policy, Income and Resource Standards, filed 12/30/1994.
8 NMAC 4.ICM.500, Eligibility Policy, Income and Resource Standards, filed 7/17/1997.
8.281.500 NMAC, Income and Resource Standards, filed 2/15/2001.
8.281.500.15 NMAC, Trusts, filed 2/15/2001- Replaced by 8.281.510 NMAC, Trust Standards, effective 10/1/2012.
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.
TITLE 8 SOCIAL SERVICES
CHAPTER 285 MEDICAL ASSISTANCE PROGRAM ELIGIBILITY – EMERGENCY MEDICAL SERVICES FOR NON-CITIZENS
PART 400 RECIPIENT REQUIREMENTS
8.285.400.1 ISSUING AGENCY: New Mexico Health Care Authority .
[8.285.400.1 NMAC - Rp, 8.285.400.1 NMAC, 1/1/2014; A, 7/1/2024]
8.285.400.2 SCOPE: The rule applies to the general public .
[8.285.400.2 NMAC - Rp, 8.285.400.2 NMAC, 1/1/2014]
8.285.400.3 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. 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.
[8.285.400.3 NMAC - Rp, 8.285.400.3 NMAC, 1/1/2014; A, 7/1/2024]
8.285.400.4 DURATION: Permanent.
[8.285.400.4 NMAC - Rp, 8.285.400.4 NMAC, 1/1/2014]
8.285.400.5 EFFECTIVE DATE: January 1, 2014, unless a later date is cited at the end of a section.
[8.285.400.5 NMAC - Rp, 8.285.400.5 NMAC, 1/1/2014]
8.285.400.6 OBJECTIVE: The objective of this rule is to provide specific instructions when determining eligibility for the medicaid program and other health care programs.
[8.285.400.6 NMAC - Rp, 8.285.400.6 NMAC, 1/1/2014]
8.285.400.7 DEFINITIONS: [ RESERVED ]
8.285.400.8 MISSION: To transform lives. Working with our partners, we design and deliver innovative, high quality health and human services that improve the security and promote independence for New Mexicans in their communities.
[8.285.400.8 NMAC - N, 1/1/2014; A, 5/1/2020 ]
8.285.400.9 EMERGENCY MEDICAL SERVICES FOR NON-CITIZENS - CATEGORY 085: Certain non-citizens who are undocumented or who do not meet the qualifying immigration criteria specified in 8.200.410 NMAC, but who meet all eligibility criteria for the following medical assistance categories of eligibility (COEs): other adults (COE 100), parent/caretaker (COE 200), pregnant women (COE 300), pregnancy-related services (COE 301), children under age 19 (COEs 400, 401, 402, 403, 420, and 421) or supplemental security income (COEs 001, 003, and 004) can receive coverage for emergency services. See 42 CFR Section 440.225.
[8.285.400.9 NMAC - Rp, 8.285.400.9 NMAC, 1/1/2014; A, 5/1/2020; A, 1/1/2022]
8.285.400.10 BASIS FOR DEFINING THE GROUP: The definition of an emergency medical condition is found at 8.325.10.13 NMAC.
[8.285.400.10 NMAC - Rp, 8.285.400.10 NMAC, 1/1/2014; A, 5/1/2020]
8.285.400.11 [ RESERVED ]
8.285.400.12 ENUMERATION: A non-citizen applicant is exempt from the requirement to provide a social security number (SSN). If the applicant is found eligible for coverage of emergency services, the claims are paid using an eligibility system generated identification number.
[8.285.400.12 NMAC - Rp, 8.285.400.12 NMAC, 1/1/2014; A, 5/1/2020]
8.285.400.13 CITIZENSHIP: An applicant must be a non-citizen who is undocumented or who does not meet the qualifying immigration criteria specified in 8.200.410 NMAC . Per 42 CFR 440.255(c), effective January 1, 1987, non-citizens who are not lawfully admitted for permanent residence in the United States or permanently residing in the United States under the color of law must receive the services necessary to treat the condition defined at 8.325.10.13 NMAC.
[8.285.400.13 NMAC - Rp, 8.285.400.13 NMAC, 1/1/2014; A, 5/1/2020]
8.285.400.14 RESIDENCE: An applicant must be a resident of the state of New Mexico in accordance with 8.200.410.14 and 8.291.410.15 NMAC.
[8.285.400.14 NMAC - Rp, 8.285.400.14 NMAC, 1/1/2014; A, 5/1/2020]
8.285.400.15 EMPLOYMENT, TRAINING, AND WORK REGISTRATION: Registration for employment or training is not a factor of eligibility.
[8.285.400.15 NMAC - Rp, 8.285.400.15 NMAC, 1/1/2014]
8.285.400.16 [ RESERVED ]
8.285.400.17 SSI STATUS: Applicants who apply under supplemental security income (SSI) coverage must meet the income and resource limits. Eligibility is determined using the SSI methodology contained in 8.215 NMAC. Disability is determined by disability determination services.
[8.285.400.17 NMAC - Rp, 8.285.400.17 NMAC, 1/1/2014]
8.285.400.18 RECIPIENT RIGHTS AND RESPONSIBILITIES: It is the responsibility of the applicant to provide the required information, documents or undertake the actions necessary for HSD to establish eligibility. The applicant must grant HSD permission to contact other persons, agencies or sources of information which are necessary in the establishment of eligibility. Failure of the applicant to provide or take action will result in a HSD action to deny eligibility.
[8.285.400.18 NMAC - Rp, 8.285.400.18 NMAC, 1/1/2014]
8.285.400.19 ASSIGNMENT OF SUPPORT: See 8.200.430 NMAC.
[8.285.400.19 NMAC - Rp, 8.285.400.19 NMAC, 1/1/2014]
HISTORY OF 8.285.400 NMAC:
History of Repealed Material:
8.285.400 NMAC, Recipient Policies, filed 11-17-08 - Repealed effective 1/1/2014.
TITLE 8 SOCIAL SERVICES
CHAPTER 285 MEDICAID ELIGIBILITY - EMERGENCY MEDICAL SERVICES FOR NON-CITIZENS
PART 500 INCOME AND RESOURCE STANDARDS
8.285.500.1 ISSUING AGENCY: New Mexico Health Care Authority.
[8.285.500.1 NMAC - Rp 8.285.500.1 NMAC, 7/1/2024]
8.285.500.2 SCOPE: The rule applies to the general public .
[8.285.500.2 NMAC - Rp 8.285.500.2 NMAC, 7/1/2024]
8.285.500.3 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.
[8.285.500.3 NMAC - Rp 8.285.500.3 NMAC, 7/1/2024]
8.285.500.4 DURATION: Permanent.
[8.285.500.4 NMAC - Rp 8.285.500.4 NMAC, 7/1/2024]
8.285.500.5 EFFECTIVE DATE: July 1, 2024, unless a later date was cited at the end of a section.
[8.285.500.5 NMAC - Rp 8.285.500.5 NMAC, 7/1/2024]
8.285.500.6 OBJECTIVE: The objective of these regulations is to provide eligibility policy and procedures for the medicaid program.
[8.285.500.6 NMAC - Rp 8.285.500.6 NMAC, 7/1/2024]
8.285.500.7 DEFINITIONS: [ RESERVED ]
8.285.500.8 MISSION: To transform lives. Working with our partners, we design and deliver innovative, high quality health and human services that improve the security and promote independence for New Mexicans in their communities.
[8.285.500.8 NMAC - Rp 8.285.500.8 NMAC, 7/1/2024]
8.285.500.9 NEED DETERMINATION: [ RESERVED ]
[8.285.500.9 NMAC - Rp 8.285.500.9 NMAC, 7/1/2024]
8.285.500.10 RESOURCE STANDARDS: Non-citizens who receive emergency services must meet the applicable resource standards for an existing medicaid category.
[8.285.500.10 NMAC - Rp 8.285.500.10 NMAC, 7/1/2024]
8.285.500.11 INCOME STANDARDS: Non-citizens who receive emergency services must meet the income standards for an existing medicaid category.
[8.285.500.11 NMAC - Rp 8.285.500.11 NMAC, 7/1/2024]
HISTORY OF 8.285.500 NMAC: [ RESERVED ]
History of Repealed Material: 8.285.500 NMAC - Income And Resource Standards (filed 11/17/2008) Repealed effective 7/1/2024.
Other: 8.285.500 NMAC - Income And Resource Standards (filed 11/17/2008) Replaced by 8.285.500 NMAC - Income And Resource Standards effective 7/1/2024.
TITLE 8 SOCIAL SERVICES
CHAPTER 285 MEDICAID ELIGIBILITY - EMERGENCY MEDICAL SERVICES FOR
NON-CITIZENS
PART 600 BENEFIT DESCRIPTION
8.285.600.1 ISSUING AGENCY: New Mexico Human Services Department.
[2/1/1995; 8.285.600.1 NMAC - Rn, 8 NMAC 4.ESA.000.1, 12/1/2008]
8.285.600.2 SCOPE: The rule applies to the general public.
[2/1/1995; 8.285.600.2 NMAC - Rn, 8 NMAC 4.ESA.000.2, 12/1/2008]
8.285.600.3 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 human services department pursuant to state statute. See Section 27-2-12 et seq. NMSA 1978 (Repl. Pamp. 1991).
[2/1/1995; 8.285.600.3 NMAC - Rn, 8 NMAC 4.ESA.000.3, 12/1/2008]
8.285.600.4 DURATION: Permanent.
[2/1/1995; 8.285.600.4 NMAC - Rn, 8 NMAC 4.ESA.000.4, 12/1/2008]
8.285.600.5 EFFECTIVE DATE: February 1, 1995, unless a later date is cited at the end of a section.
[2/1/1995; 8.285.600.5 NMAC - Rn, 8 NMAC 4.ESA.000.5 & A, 12/1/2008]
8.285.600.6 OBJECTIVE : The objective of these regulations is to provide eligibility policy and procedures for the medicaid program.
[2/1/1995; 8.285.600.6 NMAC - Rn, 8 NMAC 4.ESA.000.6, 12/1/2008]
8.285.600.7 DEFINITIONS: [ RESERVED ]
8.285.600.8 MISSION STATEMENT: To transform lives. Working with our partners, we design and deliver innovative, high quality health and human services that improve the security and promote independence for New Mexicans in their communities.
[8.285.600.8 NMAC - A, 5/1/2020]
8.285.600.9 BENEFIT DESCRIPTION: An applicant/recipient who is eligible for medicaid under this category is eligible for emergency services coverage only for the duration of the emergency.
[2/1/1995; 8.285.600.9 NMAC - Rn, 8 NMAC 4.ESA.600 & A, 12/1/2008]
8.285.600.10 BENEFIT DETERMINATION:
A. Subsequent to the receipt of emergency services, an applicant must apply through the local county income support division (ISD) office. The application must be filed at the ISD office no later than the last day of the third month following the month the presumed emergency services were received.
B. Documentation requirements: The applicant must bring a completed emergency medical services for non-citizens (EMSNC) referral for eligibility determination form (MAD 308) to the ISD office for the financial eligibility determination. The emergency services provider must complete the referral form.
C. Financial documents: The applicant must provide all necessary documentation to prove that they meet all financial and non-financial eligibility standards. Medical providers cannot submit eligibility applications on behalf of the applicant. The applicant is financially responsible for any services not covered by medicaid. A completed and signed application form must be submitted for each request for EMSNC.
[2/1/1995; 4/30/1998; 8.285.600.10 NMAC - Rn, 8 NMAC 4.ESA.620 & A, 12/1/2008; A, 5/1/2020; A, 1/1/2022]
8.285.600.11 INITIAL BENEFITS: Applications for medicaid must be acted on within 45 days of the date of application.
A. If an applicant is eligible for medicaid, the individual is sent a notice of case action (NOCA) form. The approval of financial eligibility is not a guarantee that medicaid will pay for the services. The NOCA form also serves as notice of case closure, since medicaid covers only emergency services received during the specified term of the emergency. The provider is sent the decision for emergency medical services for non-citizens (EMSNC) application (MAD 778) form. The provider must use the MAD 778 form to submit claims to the medicaid utilization review contractor for emergency review.
B. If an applicant is ineligible for medicaid or a decision on the application is delayed beyond the 45 day time limit, the individual is sent a NOCA form regarding the application for EMSNC. The NOCA form explains the reason for denial or delay and informs the applicant of their right to an administrative hearing. If the application is denied, the applicant must notify providers of the denial.
C. The applicant is responsible for payment for the medical services if they fail to apply promptly for coverage, verify eligibility for coverage, or notify the provider of the approval or denial of the application.
[2/1/1995; 4/30/1998; 8.285.600.11 NMAC - Rn, 8 NMAC 4.ESA.623 & A, 12/1/2008; A, 5/1/2020; A, 1/1/2022]
8.285.600.12 ONGOING BENEFITS: No periodic review is necessary, since this category does not result in continuous eligibility. The eligibility for the specific period will only cover the bona fide emergency services. A medicaid card is not issued. No separate notice of case closure is necessary. Notice of approval serves as notice of closure as it indicates the specific period of eligibility. Medicaid covers emergency services only for the duration of the emergency, as determined by medicaid utilization review contractor.
[2/1/1995; 4/30/1998; 8.285.600.12 NMAC - Rn, 8 NMAC 4.ESA.624 & A, 12/1/2008]
8.285.600.13 RETROACTIVE COVERAGE: There is no retroactive coverage for this category.
[2/1/1995; 8.285.600.13 NMAC - Rn, 8 NMAC 4.ESA.625 & A, 12/1/2008]
HISTORY OF 8.285.600 NMAC: [ RESERVED ]
TITLE 8 SOCIAL SERVICES
CHAPTER 290 MEDICAID ELIGIBILITY - HOME AND COMMUNITY-BASED SERVICES WAIVER (CATEGORIES 090, 091, 092, 093, 094, 095 AND 096)
PART 400 RECIPIENT POLICIES
8.290.400.1 ISSUING AGENCY: New Mexico Health Care Authority.
[8.290.400.1 NMAC - Rp, 8.290.400.1 NMAC, 1/1/2019; A, 7/1/2024]
8.290.400.2 SCOPE: The rule applies to the general public .
[8.290.400.2 NMAC - Rp, 8.290.400.2 NMAC, 1/1/2019]
8.290.400.3 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. 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.
[8.290.400.3 NMAC - Rp, 8.290.400.3 NMAC, 1/1/2019; A, 7/1/2024]
8.290.400.4 DURATION: Permanent.
[8.290.400.4 NMAC - Rp, 8.290.400.4 NMAC, 1/1/2019]
8.290.400.5 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.
[8.290.400.5 NMAC - Rp, 8.290.400.5 NMAC, 1/1/2019]
8.290.400.6 OBJECTIVE: The objective of this rule is to provide eligibility criteria for the medicaid program.
[8.290.400.6 NMAC - Rp, 8.290.400.6 NMAC, 1/1/2019]
8.290.400.7 DEFINITIONS:
A. Adaptive behavior: The effectiveness or degree with which individuals meet the standards of personal independence and social responsibility expected for their age and cultural group.
B. Comprehensive care plan (CCP): The comprehensive care plan of services that meets the member’s physical, behavioral and long-term care needs in managed care.
C. Developmental disability: For the purposes of the developmental disabilities (DD) waiver, a developmental disability is limited to an intellectual disability or a related condition as defined by the department of health/developmental disabilities supports division (DOH/DDSD) that is likely to continue indefinitely and results in substantial functional limitations in three or more of the following areas of major life activity: self-care, receptive and expressive language, learning, mobility, self-direction, capacity for independent living and economic self-sufficiency.
D. Developmental period: The time between birth and the 18 th birthday.
E. Disability determination unit (DDU): The unit that determines disability as described in Section 8.200.420.11 NMAC.
F. General intellectual functioning: The results of one or more individually administered general intelligence tests developed for the purpose of assessing intellectual functioning.
G. Individual service plan (ISP): A treatment plan for an eligible recipient that includes the eligible recipient's needs, functional level, intermediate and long range goals, statement for achieving the goals and specifies responsibilities for the care needs. The plan determines the services allocated to the eligible recipient within program allowances.
H. Intermediate care facility for individuals with intellectual disabilities (ICF/IID): This term replaces all references to intermediate care facility for mental retardation (ICF/MR).
I. Intellectual disability (ID): Refers to significantly sub-average general intellectual functioning existing concurrently with deficits in adaptive behavior and manifested during the developmental period. Intellectual disability replaces all references to mental retardation.
J. Letter of allocation: Written notice to the applicant that they may proceed with the home and community-based services (HCBS) waiver application process.
K. Level of care: The level of institutional care needed by the eligible recipient.
L. Medically Fragile: For the purposes of the medically fragile waiver (MFW), medically fragile is a chronic physical condition, which results in a prolonged dependency on medical care for which daily skilled (nursing) intervention is medically necessary.
M. Primary Freedom of Choice (PFOC): The form included in the allocation packet that allows a registrant to confirm his or her interest in pursuing the opportunity to apply for community benefits.
N. Prospective: A period of time starting with the date of application going forward.
O. Restricted coverage: Medicaid eligibility without long term care services coverage.
P. Significantly subaverage intellectual functioning: IQ of 70 or below.
Q. Unduplicated recipient positions (UDR): Space available in a particular HCBS waiver program.
R. Waiver: Permission from the centers for medicare and medicaid services (CMS) to waive certain medicaid requirements in order for a state to furnish an array of home and community-based services to state-specified target group(s) of medicaid recipients who need a level of institutional care.
[8.290.400.7 NMAC - Rp, 8.290.400.7 NMAC, 1/1/2019; A, 5/1/2021]
8.290.400.8 MISSION STATEMENT: To transform lives. Working with our partners, we design and deliver innovative, high quality health and human services that improve the security and promote independence for New Mexicans in their communities.
[8.290.400.8 NMAC - A/E, 12/15/2020; A, 5/1/2021 ]
8.290.400.9 HOME AND COMMUNITY-BASED SERVICES WAIVER - Category 091, 093, 094, 095, 096: The human services department (HSD) is the single state agency designated to administer the medicaid program in New Mexico. HSD is charged with developing and implementing the community benefit to elderly, blind, and disabled individuals who meet both financial and medical criteria for nursing facility (NF) level of care (categories 091, 093, and 094). The department of health (DOH) and HSD are charged with developing and implementing HCBS waivers to medicaid applicants/recipients who meet both financial and medical criteria for intermediate care facility for individuals with intellectual disabilities (ICF/IID) level of care, for medically fragile (category 095) and developmentally disabled (category 096) individuals. Provision of these services under a waiver allows applicants/recipients to receive the care required at home at less cost than in an institution. The services to be furnished under the waiver must be cost-effective. This means the aggregate cost of care must be an amount less than the cost of maintaining individuals in institutions at the appropriate level of care. The types of services for which recipients are eligible vary based on the individual waiver.
[8.290.400.9 NMAC - Rp, 8.290.400.9 NMAC, 1/1/2019]
8.290.400.10 BASIS FOR DEFINING THE GROUP: Eligibility for applicants/recipients who apply for waiver services is determined as if he or she were actually institutionalized , although this requirement has been waived. Entry into some of the waiver programs may be based upon the number of UDRs (i.e., slots) available. The individual waiver program manager notifies the income support division (ISD) when a UDR is available.
A. Elderly, blind, and disabled individuals (categories 091, 093, and 094): For applicants/recipients who are under age 65 to qualify as disabled or blind, disability or blindness must have been determined to exist by the social security administration or the DDU. To qualify as an elderly person, the applicant/recipient must be 65 years of age or older. Applicants/recipients must also meet both the financial and non-financial eligibility requirements and meet the medical level of care for nursing facility services.
B. Developmental disabilities (DD) waiver: The DD waiver identified as category 096 was approved effective July 1984, subject to renewal. DD waiver services are intended for eligible recipients who have developmental disabilities limited to intellectual disability (IID) or a related condition as determined by the DOH/DDSD. The developmental disability must reflect the person's need for a combination and sequence of special interdisciplinary or generic treatment or other supports and services that are lifelong or of extended duration and are individually planned and coordinated. The eligible recipient must also require the level of care provided in an intermediate care facility for individuals with developmental disabilities (ICF/IID), in accordance with Section 8.313.2 NMAC, and meet all other applicable financial and non-financial eligibility requirements.
(1) Intellectual disability: An individual is considered to have an intellectual disability if she/he has significantly sub-average general intellectual functioning existing concurrently with deficits in adaptive behavior and manifested during the developmental period.
(a) General intellectual functioning is defined as the results obtained by assessment with one or more of the individually administered general intelligence tests developed for the purpose of assessing intellectual functioning.
(b) Significantly sub-average is defined as an intelligence quotient (IQ) of 70 or below.
(c) Adaptive behavior is defined as the effectiveness or degree with which individuals meet the standards of personal independence and social responsibility expected for age and cultural group.
(d) The developmental period is defined as the period of time between birth and the 18 th birthday.
(2) Related condition: An individual is considered to have a related condition if she/he has a severe chronic disability, other than mental illness, that meets all of the following:
(a) is attributable to a condition, other than mental illness, found to be closely related to ID because this condition results in limitations in general intellectual functioning or adaptive behavior similar to that of persons with ID and requires similar treatment or services;
(b) is manifested before the person reaches age 22 years, is likely to continue indefinitely; and
(c) results in substantial functional limitations (adaptive behavior scores ≤ 70) in three or more of the following areas:
( i ) self-care;
(ii) receptive and expressive language;
(iii) learning;
(iv) mobility;
(v) self-direction;
(vi) capacity for independent living; and
(v) economic self-sufficiency.
C. Medically fragile (MF) waiver: The medically fragile (MF) waiver identified as category 095 was established effective August, 1984 subject to renewal. Medically fragile is characterized by one or more of the following: a life threatening condition characterized by reasonable frequent periods of acute exacerbation which require frequent medical supervision, or physician consultation and which in the absence of such supervision or consultation would require hospitalization; a condition requiring frequent, time consuming administration of specialized treatments which are medically necessary; or dependence on medical technology such that without the technology a reasonable level of health could not be maintained; examples include but are not limited to ventilators, dialysis machines, enteral or parenteral nutrition support and supplemental oxygen. The eligible recipient must require the level of care provided in an ICF/IID, in accordance with 8.313.2 NMAC, and meet all other applicable financial and non-financial eligibility requirements and must have:
(1) a developmental disability, developmental delay, or be at risk for developmental delay as determined by the DDU, and
(2) a diagnosed medically fragile condition prior to the age of 22, defined as a chronic physical condition, which results in a prolonged dependency on medical care for which daily skilled (nursing) intervention is medically necessary, and which is characterized by one or more of the following:
(a) a life threatening condition characterized by reasonably frequent periods of acute exacerbation, which require frequent medical supervision or physician consultation and which, in the absence of such supervision or consultation, would require hospitalization;
(b) frequent, time-consuming administration of specialized treatments, which are medically necessary;
(c) dependency on medical technology such that without the technology a reasonable level of health could not be maintained; examples include, but are not limited to, ventilators, dialysis machines, enteral or parenteral nutrition support and continuous oxygen; and
(d) periods of acute exacerbation of a life-threatening condition, the need for extraordinary supervision or observation, frequent or time-consuming administration of specialized treatments, dependency on mechanical (life) support devices, and developmental delay or disability.
D. Acquired immunodeficiency syndrome (AIDS) and AIDS related condition (ARC) waiver: The acquired immunodeficiency syndrome (AIDS) and AIDS related condition waiver designated as category 090, was established effective July 1987, subject to renewal. The AIDS and AIDS related condition waiver stopped covering new individuals effective January 01, 2014 as the waiver was sunset and not renewed. Individuals already on the AIDS and AIDS related condition waiver are grandfathered and remain eligible as long as eligibility requirements are met.
E. Brain injury (BI): The brain injury category 092 stopped covering new individuals effective January 01, 2014. Individuals already on the brain injury category are grandfathered and remain eligible as long as eligibility requirements are met.
[8.290.400.10 NMAC - Rp, 8.290.400.10 NMAC, 1/1/2019; A/E, 12/15/2020; A, 5/1/2021]
8.290.400.11 GENERAL RECIPIENT REQUIREMENTS: Eligibility for the waiver programs is always prospective per 8.290.600.11 NMAC. Applicants/recipients must meet, or expect to meet, all non-financial eligibility criteria in the month for which determination of eligibility is made including any mandatory income or resources deemed to a minor child per 8.290.500.17 and 8.290.500.21 NMAC.
A. Enumeration: An applicant/recipient must furnish his social security number in accordance with 8.200.410.10 NMAC.
B. Citizenship: Refer to 8.200.410.11 NMAC for citizenship requirements.
C. Residence: To be eligible for medicaid , an applicant/recipient must be physically present in New Mexico on the date of application or final determination of eligibility and must have declared an intent to remain in the state. If the applicant/recipient does not have the present mental capacity to declare intent, the applicant’s/recipient's representative may assume responsibility for the declaration of intent. If the applicant/recipient does not have the mental capacity to declare intent and there is no representative to assume this responsibility, the state where the applicant/recipient is living will be recognized as the state of residence. If waiver services are suspended because the recipient is temporarily absent from the state but is expected to return within 90 consecutive days at which time waiver services will resume, the medicaid case remains open. If waiver services are suspended for any other reason for 90 consecutive days, the medicaid case is closed after appropriate notice is provided to the recipient.
D. Non-concurrent receipt of assistance: HCBS waiver services furnish medicaid benefits to an applicant/recipient who qualifies both financially and medically for institutional care but who, with provision of waiver services, can receive the care he needs in the community at less cost to the medicaid program than the appropriate level of institutional care. Individuals receiving services under a HCBS waiver may not receive concurrent services under nursing facility (NF), ICF/IID, personal care or any other HCBS waiver.
(1) SSI recipients: Applicants receiving supplemental security income (SSI) benefits are categorically eligible for waiver services. No further verification of income, resources, citizenship, age, disability, or blindness is required. The applicant must, however, meet the level of care requirement. (An SSI recipient must meet the assignment of rights and TPL requirements and not be ineligible because of a trust).
(2) Married SSI couples: All married SSI couples where neither member is institutionalized in a medicaid -certified facility are treated as separate individuals for purposes of determining eligibility and benefit amounts beginning the month after the month they began living apart. See Section 8012 of the Omnibus Budget Reconciliation Act of 1989. In the case of an initial application, or reinstatement following a period of ineligibility, when members of a married couple are not living together on the date of application or date of request for reinstatement, each member of the couple is considered separately as of the date of application or request, regardless of how recently the separation occurred.
E. INTERVIEW REQUIREMENTS: An interview is not required in accordance with 8.281.400.11 NMAC.
[8.290.400.11 NMAC - Rp, 8.290.400.11 NMAC, 1/1/2019; A/E, 12/15/2020; A, 5/1/2021]
8.290.400.12 SPECIAL RECIPIENT REQUIREMENTS:
A. Age: To be considered elderly, an applicant/recipient must be 65 years of age or older. See Section 8.281.400.16 NMAC, AGE, for information on verification of age.
B. Blind: To be considered blind, an applicant/recipient must have central visual acuity of 20/200 or less with corrective lenses or must be considered blind for practical purposes. The ISD worker is responsible for submitting medical reports to the DDU, if necessary. See Section 8.281.400.17 NMAC, Blind , For Information on documentation and verification of blindness.
C. Disability: To be considered disabled, an applicant/recipient must be unable to engage in any substantial gainful activity because of any medical determinable physical, developmental, or mental impairment, which has lasted, or is expected to last, for a continuous period of at least 12 months. The ISD worker is responsible for submitting medical reports to the DDU, if necessary. See Section 8.281.400.18 NMAC, Disability , for information on documentation and verification of disability.
D. Requires institutional care: An institutional level of care must be recommended for the applicant/recipient by a physician, nurse practitioner or a doctor of osteopathy, licensed to practice in the state of New Mexico. Institutions are defined as acute care hospitals, nursing facilities (either high NF or low NF as defined by medicaid regulations) and ICF/IID. Level of care reviews are completed by the medical assistance division (MAD) utilization review contractor or a member’s selected or assigned managed care organization (MCO), as applicable to the applicant’s HCBS program.
[8.290.400.12 NMAC - Rp, 8.290.400.12 NMAC, 1/1/2019]
8.290.400.13 RECIPIENT RIGHTS AND RESPONSIBILITIES: An applicant/recipient is responsible for establishing his eligibility for medicaid . As part of this responsibility, the applicant/recipient must provide required information and documents or take the actions necessary to establish eligibility. Failure to do so must result in a decision that eligibility does not exist. An applicant/recipient must also grant the human services department (HSD) permission to contact other persons, agencies or sources of information, which are necessary to establish eligibility. See 8.200.430 NMAC, Recipient Rights And Responsibilities for specific information.
[8.290.400.13 NMAC - Rp, 8.290.400.13 NMAC, 1/1/2019]
8.290.400.14 REPORTING REQUIREMENTS: A medicaid applicant/recipient, case manager, direct service provider or any other responsible party must report any changes in circumstances which may affect the applicant’s/recipient's eligibility within 10 days of the date of the change to the county income support division (ISD) office. These changes include but are not limited to: changes in income, resources, living arrangements, or marital status. The ISD worker must evaluate the effect of the change and take any required action as soon as possible; however, the action must take effect no later than the end of the month following the month in which the change took place.
[8.290.400.14 NMAC - Rp, 8.290.400.14 NMAC, 1/1/2019]
HISTORY OF 8.290.400 NMAC:
Pre-NMAC History: The material in this part was derived from that previously filed with the Commission of Public Records-State Records Center and Archives:
MAD Rule 898, Transfers Of Assets, 12/29/1994.
History of Repealed Material:
8.290.400 NMAC - Recipient Policies, filed 4/16/2002 Repealed effective 1/1/2019.
TITLE 8 SOCIAL SERVICES
CHAPTER 290 MEDICAID ELIGIBILITY - HOME AND COMMUNITY-BASED SERVICES WAIVER (CATEGORIES 090, 091, 092, 093, 094, 095 AND 096)
PART 500 INCOME AND RESOURCE STANDARDS
8.290.500.1 ISSUING AGENCY: New Mexico Health Care Authority.
[8.290.500.1 NMAC - Rp 8.290.500.1 NMAC, 7/1/2024]
8.290.500.2 SCOPE: The rule applies to the general public .
[8.290.500.2 NMAC - Rp 8.290.500.2 NMAC, 7/1/2024]
8.290.500.3 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 Sections 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.
[8.290.500.3 NMAC - Rp 8.290.500.3 NMAC, 7/1/2024]
8.290.500.4 DURATION: Permanent.
[8.290.500.4 NMAC - Rp 8.290.500.4 NMAC, 7/1/2024]
8.290.500.5 EFFECTIVE DATE: July 1, 2024, unless a later date is cited at the end of a section.
[8.290.500.5 NMAC - Rp 8.290.500.5 NMAC, 7/1/2024]
8.290.500.6 OBJECTIVE: The objective of these regulations is to provide eligibility criteria for the medicaid program.
[8.290.500.6 NMAC - Rp 8.290.500.6 NMAC, 7/1/2024]
8.290.500.7 DEFINITIONS: See 8.290.400.7 NMAC.
[8.290.500.7 NMAC - Rp 8.290.500.7 NMAC, 7/1/2024]
8.290.500.8 MISSION: To reduce the impact of poverty on people living in New Mexico and to assure low income and disabled individuals in New Mexico equal participation in the life of their communities.
[8.290.500.8 NMAC - Rp 8.290.500.8 NMAC, 7/1/2024]
8.290.500.9 NEED DETERMINATION: Eligibility for the home and community-based services waiver programs is always prospective. Applicants/recipients must meet, or expect to meet, all financial eligibility criteria in the month for which a determination of eligibility is made. Applicants for and recipients of medicaid through one of the waiver programs must apply for, and take all necessary steps to obtain, any income or resources to which they may be entitled. Such steps must be taken within 30 days of the date the HCA furnishes notice of the potential entitlement.
A. Failure to apply for and take steps to determine eligibility for other benefits: Failure or refusal to apply for and take all necessary steps to determine eligibility for other benefits after notice is received results in an applicant/recipient becoming ineligible for medicaid.
B. Exceptions to general requirement: Applicants /recipients who have elected a lower VA payment do not need to reapply for veterans administration improved pension (VAIP) benefits. Crime victims are not required to accept victims compensation payments from a state-administered fund as a condition of medicaid eligibility.
[8.290.500.9 NMAC - Rp 8.290.500.9 NMAC, 7/1/2024]
8.290.500.10 RESOURCE STANDARDS: See 8.281.500.10 NMAC and following subsections.
[8.290.500.10 NMAC - Rp 8.290.500.10 NMAC, 7/1/2024]
8.290.500.11 APPLICABLE RESOURCE STANDARDS: An applicant/recipient is eligible for medicaid on the factor of resources if countable resources do not exceed $2,000.
A. Liquid resources: See Subsection A of 8.281.500.11 NMAC.
B. Nonliquid resources: See Subsection B of 8.281.500.11 NMAC and following subsections.
[8.290.500.11 NMAC - Rp 8.290.500.11 NMAC, 7/1/2024]
8.290.500.12 COUNTABLE RESOURCES: See 8.281.500.12 NMAC and following subsections.
[8.290.500.12 NMAC - Rp 8.290.500.12 NMAC, 7/1/2024]
8.290.500.13 RESOURCE EXCLUSIONS: See 8.281.500.13 NMAC and following subsections.
[8.290.500.13 NMAC - Rp 8.290.500.13 NMAC, 7/1/2024]
8.290.500.14 ASSET TRANSFERS: See 8.281.500.14 NMAC, asset transfers , and following subsections for rules governing transfers of assets. All provisions pertaining to transfers under institutional care medicaid apply to transfers under the waiver programs with the exception of the penalty for transfers of assets for less than fair market value. The penalty for transfers of assets for less than fair market value for waiver applicants/recipients is ineligibility for long term care medicaid services under the waiver programs. Federal regulations specify that, to be eligible for a waiver program, an individual must be receiving the waiver or long term care services. Because a waiver applicant/recipient is not eligible to receive these services under the medicaid program, they are ineligible for the HCBS waiver program. The period of ineligibility is based on when the assets were transferred during the look back period. After February 8, 2006, the look back period for transfers is 60 months prior to the date of application. As soon as the HCBS waiver applicant has no transfers for less than fair market value during the 60 months look back period, they are eligible to be reconsidered for HCBS provided all financial and non-financial criteria are met. If the transfer for less than fair market value is discovered after the applicant is approved for HCBS, the period of ineligibility begins the first day of the month in which the resources were transferred. If the applicant or recipient enters a nursing facility, a penalty period for the transfer of assets for less than fair market value is calculated based on 8.281.500.14, asset transfers . This penalty period runs whether or not the individual remains in the nursing facility.
[8.290.500.14 NMAC - Rp 8.290.500.14 NMAC, 7/1/2024]
8.290.500.15 TRUSTS: See 8.281.500.15 NMAC and following subsections.
[8.290.500.15 NMAC - Rp 8.290.500.15 NMAC, 7/1/2024]
8.290.500.16 RESOURCE STANDARDS FOR MARRIED COUPLES:
A. Community property resource determination methodology: See Subsection A of 8.281.500.16 NMAC and Paragraph (2) of Subsection A of 8.281.500.16 NMAC for methodology used in the determination of eligibility for married applicants/recipients who began receiving waiver services for a continuous period prior to September 30, 1989.
B. Spousal impoverishment: See Subsection B of 8.281.500.16 NMAC and following subsections for spousal impoverishment methodology used in the determination of eligibility for married applicants/recipients with a spouse in the home who began receiving waiver services on or after September 30, 1989. The resource assessment is completed as of the first moment of the first day of the month in which the level of care is approved.
[8.290.500.16 NMAC - Rp 8.290.500.16 NMAC, 7/1/2024]
8.290.500.17 DEEMING RESOURCES: See 8.281.500.17 NMAC. The resources of the custodial parent(s) are deemed available to the applicant/recipient for the entire calendar month in which the allocation letter is issued by the waiver program manager or the representative notifies the ISD worker that a UDR is available for the applicant/recipient. Beginning with the month following the month in which the allocation letter was issued, only the resources directly attributable and available to the applicant/recipient are counted and compared to the resource limit.
[8.290.500.17 NMAC - Rp 8.290.500.17 NMAC, 7/1/2024]
8.290.500.18 INCOME: To qualify for medicaid under any of the waiver programs, the gross countable income of the applicant/recipient must be less than the maximum allowable monthly income standard. See 8.200.520.16 NMAC, Income Standards. See 8.281.500.18 NMAC and following subsections.
[8.290.500.18 NMAC - Rp 8.290.500.18 NMAC, 7/1/2024]
8.290.500.19 INCOME STANDARDS. Income exclusions: See 8.281.500.19 NMAC and following subsections.
[8.290.500.19 NMAC - Rp 8.290.500.19 NMAC, 7/1/2024]
8.290.500.20 UNEARNED INCOME: See 8.281.500.20 NMAC and following subsections.
[8.290.500.20 NMAC - Rp 8.290.500.20 NMAC, 7/1/2024]
8.290.500.21 DEEMED INCOME: See 8.281.500.21 NMAC and following subsections. The income of the custodial parent(s) is deemed available to the applicant/recipient for the entire calendar month in which the allocation letter is issued by the waiver program manager or the representative notifies the ISD worker that a UDR is available for the applicant/recipient. Beginning with the month following the month in which the allocation letter was issued, only the income directly attributable and available to the applicant/recipient is counted and compared to the income limit.
[8.290.500.21 NMAC - Rp 8.290.500.21 NMAC, 7/1/2024]
8.290.500.22 DISREGARDS: See 8.281.500.22 NMAC and following subsections.
[8.290.500.22 NMAC - Rp 8.290.500.22 NMAC, 7/1/2024]
8.290.500.23 POST ELIGIBILITY/MEDICAL CARE CREDIT: There are no medical care credits in the waiver programs. The applicant/recipient is allowed to keep all of their income to maintain their household in the community.
[8.290.500.23 NMAC - Rp 8.290.500.23 NMAC, 7/1/2024]
HISTORY OF 8.290.500 NMAC:
Pre-NMAC History: The material in this part was derived from that previously filed with the Commission of Public Records-State Records Center and Archives:
MAD Rule 898, Transfers Of Assets, 12/29/94.
History of Repealed Material: 8.290.500 NMAC - Income And Resource Standards (filed 4/16/2002) Repealed effective 7/1/2024.
Other : 8.290.500 NMAC - Income And Resource Standards (filed 4/16/2002) Replaced by 8.290.500 NMAC - Income And Resource Standards effective 7/1/2024.
TITLE 8 SOCIAL SERVICES
CHAPTER 290 MEDICAID ELIGIBILITY - HOME AND COMMUNITY-BASED SERVICES WAIVER (CATEGORIES 090, 091, 092, 093, 094, 095 AND 096)
PART 600 BENEFIT DESCRIPTION
8.290.600.1 ISSUING AGENCY: New Mexico Health Care Authority.
[8.290.600.1 NMAC - Rp, 8.290.600.1 NMAC, 1/1/2019 ; A, 7/1/2024 ]
8.290.600.2 SCOPE: The rule applies to the general public .
[8.290.600.2 NMAC - Rp, 8.290.600.2 NMAC, 1/1/2019]
8.290.600.3 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 (HCA) pursuant to state statute. See Section 27-2-12 et seq. , NMSA 1978. Section 9-8-1 et seq. NMSA 1978 establishes the HCA as a single, unified department to administer laws and exercise functions relating to health care facility licensure and health care purchasing and regulation.
[8.290.600.3 NMAC - Rp, 8.290.600.3 NMAC, 1/1/2019; A, 7/1/2024]
8.290.600.4 DURATION: Permanent.
[8.290.600.4 NMAC - Rp, 8.290.600.4 NMAC, 1/1/2019]
8.290.600.5 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.
[8.290.600.5 NMAC - Rp, 8.290.600.5 NMAC, 1/1/2019]
8.290.600.6 OBJECTIVE: The objective of this rule is to provide eligibility criteria for the medical assistance division (MAD) programs.
[8.290.600.6 NMAC - Rp, 8.290.600.6 NMAC, 1/1/2019]
8.290.600.7 DEFINITIONS: See Section 8.290.400.7 NMAC.
[8.290.600.7 NMAC - Rp, 8.290.600.7 NMAC, 1/1/2019]
8.290.600.8 [ RESERVED ]
8.290.600.9 BENEFIT DESCRIPTION: Eligible recipients are eligible for specified services available under the particular waiver and ancillary services available under the general medicaid program. See specific program policy sections for covered services.
[8.290.600.9 NMAC - Rp, 8.290.600.9 NMAC, 1/1/2019]
8.290.600.10 BENEFIT DETERMINATION: Application for the waiver programs is made using the HSD 100 application. Upon notification by the appropriate program manager that an unduplicated recipient (UDR) is available for waiver services, applicants are registered on the income support division (ISD) eligibility system. Applications must be acted upon and notice of approval, denial, or delay sent out within 45 calendar days from the date of application, or within 90 calendar days if a disability determination is required from the disability determination unit (DDU). The eligible recipients must assist in completing the application, may complete the form themselves, or may receive help from a relative, friend, guardian, or other designated representative.
A. Representatives applying on behalf of individuals: If a representative makes application on behalf of the eligible recipient, that representative will continue to be relied upon for information regarding the eligible recipient's circumstances. The ISD caseworker will send all notices to the eligible recipient in care of the representative.
B. Additional forms: The following forms are also required as part of the application process:
(1) the eligible recipient or representative must complete and sign the primary freedom of choice (PFOC) form at the time of allocation; and
(2) the eligible recipient or representative must sign the applicant's statement of understanding at the time waiver services are declined or terminated.
C. Additional information furnished during application: The ISD caseworker provides an explanation of the waiver programs, including, but not limited to, income and resource limits and possible alternatives, such as institutionalization. The ISD caseworker refers potentially eligible recipients to the social security administration to apply for supplemental security income (SSI) benefits. If a disability decision by the DDU is required, but has not been made, the ISD caseworker must follow established procedures to refer the case for evaluation.
[8.290.600.10 NMAC - Rp, 8.290.600.10 NMAC, 1/1/2019]
8.290.600.11 INITIAL BENEFITS:
A. The application process begins once the letter of allocation and the medicaid application for assistance are received by ISD. Once ISD has confirmed the applicant/recipient meets all eligibility criteria, the application can be approved effective the first month for which an approved level of care has been established. Medicaid eligibility covers acute and ancillary medicaid services that are effective immediately on the first day of the first month of medicaid eligibility. Home and community-based waiver services are prospective and are only available once the individual services plan (ISP) or comprehensive care plan (CCP) is approved and implemented. Following initial approval, waiver services must be provided when appropriate to eligible waiver recipients within 90 calendar days of approval. Medicaid eligibility under the waiver program is contingent on the receipt of waiver services. If an applicant/recipient is transitioning from one home and community-based services (HCBS) waiver program to another, ISD must be contacted to coordinate the start date based on the month the ISP or CCP is established for the new program. This is to ensure there is no interruption in services for the recipient.
B. Notice of determination: Applicants determined to be ineligible for waiver services are notified of the reason for the denial and provided with an explanation of appeal rights.
C. Applicants determined to be eligible for waiver services are notified of the approval.
[8.290.600.11 NMAC - Rp, 8.290.600.11 NMAC, 1/1/2019]
8.290.600.12 ONGOING BENEFITS:
A. A complete redetermination of eligibility must be performed annually by the ISD caseworker for each open case.
B. Level of care determinations are made by the utilization review contractor or a member’s selected or assigned managed care organization, as applicable to the centennial care, community benefit program. Level of care reviews are required to be completed at least annually except for certain community benefit members whose chronic condition is not expected to improve. These individuals may be eligible for an ongoing nursing facility (NF) level of care (LOC). To qualify for ongoing NF LOC, the community benefit member must have met a NF LOC for the previous three years. The ongoing NF LOC status must be reviewed and approved annually by the managed care organization’s medical director and must be supported in documentation by the member’s physician. The complete criteria for an ongoing NF LOC can be found in the New Mexico medicaid nursing facility level of care criteria and instructions document.
C. 90 day reconsideration period : HSD will reconsider in a timely manner the waiver eligibility of an individual who is terminated for failure to submit the renewal form or necessary information, if the individual subsequently submits the renewal form within 90 days after the date of termination without requiring a new application per 42 CFR 435.916(C)(iii).
[8.290.600.12 NMAC - Rp, 8.290.600.12 NMAC, 1/1/2019]
8.290.600.13 RETROACTIVE BENEFITS: Eligibility for these categories is prospective so retroactive coverage is not available in accordance with 8.200.400.14 NMAC.
[8.290.600.13 NMAC - Rp, 8.290.600.13 NMAC, 1/1/2019]
8.290.600.14 CHANGES IN ELIGIBILITY: If the eligible recipient ceases to meet any of the eligibility criteria, the case is closed following provision of advance notice as appropriate. See Section 8.200.430.9 NMAC and following subsections for information about notices and hearing rights.
A. Non-provision of waiver services: To continue to be eligible for waiver services, an eligible recipient must be receiving waiver services, early and periodic screening, diagnostic and treatment (EPSDT) benefits or managed care services, other than case management, (42 CFR Section 435.217). If at any time waiver services are no longer being provided (e.g., a suspension) and are not expected to be provided for 90 consecutive days, the recipient is ineligible for the waiver category and the case must be closed after appropriate notice is provided by the ISD caseworker.
B. Admission to a hospital, nursing facility, or intermediate care facility for individuals with intellectual disabilities (ICF-IID): If an eligible waiver recipient enters an acute care hospital, a nursing facility, or an ICF-IID and remains for more than 90 consecutive days, the waiver case must be closed and an application for institutional care medicaid (ICM) must be processed. The eligible recipient is not required to complete a new application if the periodic review on the waiver case is not due in either the month of entry into the institution or the following month. If the waiver recipient is institutionalized within less than 90 consecutive days and still receives waiver services within that time frame, the waiver case is not closed and an application for ICM need not be processed.
C. Reporting changes in circumstances: The primary responsibility for reporting changes in the eligible recipient's circumstances rests with the eligible recipient or his/her representative. At the initial eligibility determination and all on-going eligibility redeterminations, the ISD caseworker must explain the reporting responsibilities requirement to the eligible recipient or his/her representative and document that such explanation was given. In the event that waiver services cease to be provided, the case manager or the waiver program manager (or designee ) must immediately notify the income support division office of that fact by telephone. The telephone call is to be followed by a written notice to the ISD caseworker.
[8.290.600.14 NMAC - Rp, 8.290.600.14 NMAC, 1/1/2019]
HISTORY OF 8.290.600 NMAC:
Pre-NMAC History : The material in this part was derived from that previously filed with the Commission of Public Records-State Records Center and Archives:
MAD Rule 898, Transfers Of Assets, 12/29/1994.
History of Repealed Material:
8.290.600 NMAC - Benefit Description, filed 4/12/2002 Repealed effective 1/1/2019.
TITLE 8 SOCIAL SERVICES
CHAPTER 291 MEDICAID ELIGIBILITY - AFFORDABLE CARE
PART 400 ELIGIBILITY REQUIREMENTS
8.291.400 .1 ISSUING AGENCY: New Mexico Health Care Authority.
[8.291.400.1 NMAC - Rp, 8.291.400.1 NMAC, 10/1/2017 ; A, 7/1/2024 ]
8.291.400 .2 SCOPE: The rule applies to the general public .
[8.291.400.2 NMAC - Rp, 8.291.400.2 NMAC, 10/1/2017]
8.291.400 .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 or by state statute. See Section 27-1-12 et seq ., NMSA 1978. 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.
[8.291.400.3 NMAC - Rp , 8.291.400.3 NMAC, 10/1/ 2017 ; A, 7/1/2024 ]
8.291.400 .4 DURATION: Permanent.
[8.291.400.4 NMAC - Rp, 8.291.400.4 NMAC, 10/1/2017]
8.291.400 .5 EFFECTIVE DATE: October 1, 2017, unless a later date is cited at the end of a section.
[8.291.400.5 NMAC - Rp, 8.291.400.5 NMAC, 10/1/2017]
8.291.400 .6 OBJECTIVE: The objective of this rule is to provide eligibility guidelines when determining eligibility for the medical assistance division (MAD) medicaid program and other health care programs it administers. Processes for establishing and maintaining this category of eligibility are found in the affordable care general provision chapter located at 8.291.400 NMAC through 8.291.430 NMAC.
[8.291.400.6 NMAC - Rp, 8.291.400.6 NMAC, 10/1/2017]
8.291.400 .7 DEFINITIONS:
A. Action: an approval, termination, suspension, or reduction of medicaid eligibility or a reduction in the level of benefits and services, including a determination of income for the purposes of imposing any premiums, enrollment fees, or cost-sharing. It also means determinations made by skilled nursing facilities and nursing facilities to transfer or discharge residents and adverse determination made by a state with regard to the preadmission screening and resident review requirements.
B. Advance payments of the premium tax credit (APTC): payment of the tax credits specified in Section 36B of the Internal Revenue Code which are provided on an advance basis to an eligible individual enrolled in a qualified health plan through an exchange.
C. Affordable Care Act (ACA): the Patient Protection and Affordable Care Act of 2010 (Public Law 111-148), as amended by the Health Care and Education Reconciliation Act of 2010 (Public Law 111-152) and the Three Percent Withholding Repeal and Job Creation Act (Public Law 112-56).
D. Affordable insurance exchanges (exchanges): a governmental agency or non-profit entity that meets the applicable requirements and makes qualified health plans available to qualified individuals and qualified employers. Unless otherwise identified, this term refers to state exchanges, regional exchanges, subsidiary exchanges, and a federally-facilitated exchange.
E. Agency: the single state agency designated or established by a state to administer or supervise the administration of the medicaid state plan. This designation includes a certification by the state attorney general, citing the legal authority for the single state agency to make rules and regulations that it follows in administering the plan or that are binding upon local agencies that administer the plan.
F. Appeal record: the appeal decision, all papers and requests filed in the proceeding, and if a hearing was held, the transcript or recording of hearing testimony or an official report containing the substance of what happened at the hearing, and any exhibits introduced at the hearing.
G. Appeal request: a clear expression, either verbally or in writing, by an applicant, enrollee, employer, or small business employer or employee to have any eligibility determination or redetermination contained in a notice issued reviewed by an appeals entity.
H. Appeals entity: a body designated to hear appeals of eligibility determinations or redeterminations contained in notices, or notices issued in accordance with future guidance on exemptions.
I. Appeals decision: a decision made by a hearing officer adjudicating a fair hearing, including by a hearing officer employed by an exchange appeals entity to which the agency has delegated authority to conduct such hearings.
J. Applicable modified adjusted gross income (MAGI) standard: the income standard for each category of ACA eligibility.
K. Application: the single streamlined application required by ACA and other medicaid applications used by the agency.
L. Authorized representative: the agency must permit applicants and beneficiaries to designate an individual or organization to act responsibly on their behalf in assisting with the individual’s application and renewal of eligibility and other ongoing communications with the agency.
(1) Such a designation must be in writing including the applicant’s signature, and must be permitted at the time of application and at other times. Legal documentation of authority to act on behalf of an applicant or beneficiary under state law, such as a court order establishing legal guardianship or a power of attorney, shall serve in the place of written authorization by the applicant or beneficiary.
(2) Representatives may be authorized to:
(a) sign an application on the applicant’s behalf;
(b) complete and submit a renewal form;
(c) receive copies of the applicant or beneficiary’s notices and other communications from the agency; and
(d) act on behalf of the applicant or beneficiary in all other matters with the agency.
(3) The power to act as an authorized representative is valid until the applicant or beneficiary modifies the authorization or notifies the agency that the representative is no longer authorized to act on their behalf, or the authorized representative informs the agency that they are no longer acting in such capacity, or there is a change in the legal authority upon which the individual’s or organization’s authority was based. Such notice must be in writing and should include the applicant or authorized representative’s signature as appropriate.
(4) The authorized representative is responsible for fulfilling all responsibilities encompassed within the scope of the authorized representation to the same extent as the individual they represent, and must agree to maintain, or be legally bound to maintain, the confidentiality of any information regarding the applicant or beneficiary provided by the agency.
(5) As a condition of serving as an authorized representative, a provider, staff member or volunteer of an organization must sign an agreement that they will adhere to the regulations relating to confidentiality (relating to the prohibition against reassignment of provider claims as appropriate for a health facility or an organization acting on the facility’s behalf), as well as other relevant state and federal laws concerning conflicts of interest and confidentiality of information.
M. Beneficiary: an individual who has been determined eligible and is currently receiving medicaid .
N. Citizenship: a national of the United States means a citizen of the United States or a person who, though not a citizen of the United States, owes permanent allegiance to the United States.
O. Code : the internal revenue code.
P. Coordinated content: information included in an eligibility notice regarding the transfer of the individual’s or households electronic account to another insurance affordability program for a determination of eligibility.
Q. Current beneficiaries: individuals who have been determined financially eligible for medicaid using MAGI-based methods.
R. Dependent child: an un-emancipated child who is under the age of 19.
S. Documentary evidence: a photocopy facsimile, scanned or other copy of a document must be accepted to the same extent as an original document.
T. Electronic account: an electronic file that includes all information collected and generated by the state regarding each individual’s medicaid eligibility and enrollment, including all documentation required to support the agency’s decision on the case.
U. Expedited appeals: the agency must establish and maintain an expedited review process for hearings when an individual requests or a provider requests, or supports the individual’s request, that the time otherwise permitted for a hearing could jeopardize the individual’s life or health or ability to attain, maintain, or regain maximum function. If the agency denies a request for an expedited appeal, it must use the standard appeal timeframe.
V. Family size: the number of persons counted as members of an individual’s household. In the case of determining the family size of a pregnant individual, the pregnant individual is counted as themselves plus the number of children they are expected to deliver. In the case of determining the family size of other individuals who have a pregnant individual in their household, the pregnant individual is counted as themselves plus the number of children they are expected to deliver.
W. Insurance affordability program: a state medicaid program under Title XIX of the act, state children’s health insurance program (CHIP) under Title XXI of the act, a state basic health program established under ACA and coverage in a qualified health plan through the exchange with cost-sharing reductions established under Section 1402 of ACA.
X. MAGI-based income: For the purposes of this section, MAGI-based income means income calculated using the same financial methodologies used to determine a modified adjusted gross income as defined in Section 36B(d)(2) (B) of the Internal Revenue Code, with the certain exceptions.
Y. Managed care organization (MCO): an organization licensed or authorized through an agreement among state entities to manage, coordinate and receive payment for the delivery of specified services to medicaid eligible members.
Z. Modified adjusted gross income (MAGI): has the meaning of 26 CFR 1.36B-1 Section (2).
AA. Non-applicant: an individual who is not seeking an eligibility determination for themselves and is included in an applicant’s or beneficiary’s household to determine eligibility for such applicant or beneficiary.
BB. Non-citizen: an individual who is not a citizen or national of the United States (8 USC 1101(a)(22).
CC. Parent caretaker: a relative of a dependent child by blood, adoption, or marriage with whom the child is living, who assumes primary responsibility for the child’s care (as may, but is not required to, be indicated by claiming the child as a tax dependent for federal income tax purposes) and who is one of the following:
(1) the child’s father, mother, grandfather, grandmother, brother, sister, stepfather, stepmother, stepbrother, stepsister, uncle, aunt, first cousin, nephew, or niece;
(2) the spouse of such parent or relative, even after the marriage is terminated by death or divorce; or
(3) other relatives within the fifth degree of relationship (42 CFR 435.4).
DD. Patient Protection and Affordable Care Act (PPACA): also known as the Affordable Care Act (ACA) and is the health reform legislation passed by the 111th congress and signed into law in March of 2010.
EE. Tax dependent: has the same meaning as the term “dependent” under Section 152 of the Internal Revenue Code, as an individual for whom another individual claims a deduction for a personal exemption under Section 151 of the Internal Revenue Code for a taxable year.
[8.291.400.7 NMAC - Rp, 8.291.400.7 NMAC, 10/1/2017; A, 4/5/2022]
8.291.400 .8 MISSION: To transform lives. Working with our partners, we design and deliver innovative, high quality health and human services that improve the security and promote independence for New Mexicans in their communities.
[8.291.400.8 NMAC - Rp, 8.291.400.8 NMAC, 10/1/2017; A, 4/5/2022]
8.291.400.9 LEGAL BASIS: HSD is the single state agency designated to administer the New Mexico Title XIX medicaid program in accordance with 42 CFR 431.10, single state agency. State authority is provided by Section 27-2-12 NMSA 1978 (Repl. 1984). Title XIX of the Social Security Act and United States department of health and human services rules establish the requirements for state plans for medical assistance.
[8.291.400.9 NMAC - Rp, 8.291.400.9 NMAC, 10/1/2017]
8.291.400.10 BASIS FOR DEFINING GROUP: Medicaid is a federally matched program that makes certain essential health care services available to eligible New Mexico residents who otherwise would not have the financial resources to obtain them. With certain exceptions, medicaid benefits are provided through the department's medicaid managed care program.
A. Requirements outlined in 8.291.400 through 8.298.600 NMAC provides eligibility requirements for the ACA related categories listed below.
B. ACA related categories include the following:
(1) other adult;
(2) parent caretaker;
(3) pregnant women;
(4) pregnancy-related services;
(5) children under 19 years of age;
(6) adult caretaker recipients who are in transition to self-support due to the amount of spousal support; and
(7) adult caretaker recipients who are in transition to self-support due to the amount of earned income.
[8.291.400.10 NMAC - Rp, 8.291.400.10 NMAC, 10/1/2017]
8.291.400.11 CONTINUOUS ELIGIBILITY FOR CHILDREN (42 CFR 435.926) :
A. HSD provides continuous eligibility for the period specified in Subsection B and C of 8.291.400.11 NMAC for an individual who is:
(1) under age 19; and
(2) eligible and enrolled for mandatory or optional coverage under the state plan.
B. The continuous eligibility period is up to six years for children from birth until turning age six. A child enrolled for less than 12 months before turning age six is eligible for 12 months of continuous eligibility. The continuous eligibility period begins on the effective date of the individual's eligibility or most recent redetermination or renewal of eligibility.
C. The continuous eligibility period is 12 months for children age six until turning age 19. The continuous eligibility period begins on the effective date of the individual's eligibility or most recent redetermination or renewal of eligibility.
D. A child's eligibility may not be terminated during a continuous eligibility period, regardless of any changes in circumstances, unless:
(1) the child attains the maximum age of 19;
(2) the child or child's representative requests a voluntary termination of eligibility;
(3) the child ceases to be a resident of New Mexico;
(4) the agency determines that eligibility was erroneously granted at the most recent determination, redetermination or renewal of eligibility because of agency error or fraud, abuse, or perjury attributed to the child or the child's representative; or
(5) the child dies.
[8.291.400.11 NMAC - Rp, 8.291.400.11 NMAC, 10/1/2017; A, 9/1/2024]
8.291.400.12 REPORTING REQUIREMENTS: A medicaid eligible recipient is required to report certain changes which might affect their eligibility to ISD within 10 calendar days from the date the change occurred. A timely change that is reported within 10 calendar days that may result in a more beneficial medicaid eligibility category shall be evaluated in the month the change occurred. An untimely change that is reported after 10 calendar days that may result in a more beneficial medicaid eligibility category shall be evaluated in the month the change was reported. A reported change that does not result in the same or a more beneficial medicaid category is considered an adverse action and is applied prospectively in accordance with 8.100.180.10 NMAC. See 8.100.110.9 NMAC for the various ways applicants and recipients can submit changes to the HSD. The following changes must be reported to ISD:
A. living arrangements or change of address: any change in where an individual lives or receives mail must be reported;
B. household size: any change in the household size must be reported, this includes the death of an individual included in the assistance unit or budget group;
C. enumeration: any new social security number must be reported; or
D. income: any increase or decrease in the amount of income or change in the source of income must be reported.
[8.291.400.12 NMAC - Rp, 8.291.400.12 NMAC, 10/1/2017; A, 4/5/2022]
8.291.400.13 PRESUMPTIVE ELIGIBILITY: Presumptive eligibility (PE) provides medicaid benefits under one of the eligible groups outlined in Subsection B of 8.291.400.10 NMAC, starting with the date of the PE determination and ending with the last day of the following month or, if an ongoing application is submitted at the time the PE is granted or at any time during the approved PE period, the PE will remain open until the ongoing application is approved or denied.
A. Only one PE approval is allowed per pregnancy or per 12-month period for other ACA related categories.
B. Determinations can only be made by individuals employed by eligible entities and certified as presumptive eligibility determiners (PEDs) by the medical assistance division (MAD).
(1) Processing PE information: PEDs must notify MAD within 24 hours of the determination of presumptive eligibility.
(2) PE: The PED must process the presumptive eligibility and encourage clients to submit an ongoing application for medicaid eligibility. If the client elects to do so, the PED must assist the client with the submission of an application for medical assistance.
(3) Provider eligibility: Entities who may participate in the PE program must be:
(a) a qualified hospital that participates as a provider under the medicaid state plan or a medicaid 1115 demonstration who notifies the medicaid agency of its election to make presumptive eligibility determinations and agrees to make PE determinations consistent with state policies and procedures; or
(b) an entity or provider that has not been disqualified by the medicaid agency for failure to make PE determinations in accordance with applicable state policies and procedures or for failure to meet any standards that may have been established by the medicaid agency; or
(c) a federally qualified health center (FQHC), an Indian health service (IHS) facility, a state of New Mexico agency, a school, or a head start agency or a primary care provider who is contracted with at least one HSD contracted MCO; or
(d) other entities HSD has determined as an eligible presumptive participant.
C. PE approval limitations:
(1) all MAD authorized PE determiners can approve PE for children and pregnant women ACA categories;
(2) hospitals opting to participate in the PE program and correctional facilities (state prisons and county jails), health facilities operated by the Indian health service, a tribe, or tribal organization or an urban Indian organization can approve PE for all ACA related categories.
D. If, at the time of a PE approval, the client agrees to submit an application for ongoing coverage, the PED must submit the application within ten days of the PE approval .
E. A pregnant individual who has been approved for PE can receive ambulatory prenatal care during the PE approval period as defined in 8.291.400.13 NMAC.
(1) For PE, an approved PED must accept self-attestation of pregnancy.
(2) The needs and income of the unborn child(ren) are considered when determining the woman’s countable family size.
[8.291.400.13 NMAC - Rp, 8.291.400.13 NMAC, 10/1/2017; A, 4/5/2022]
8.291.400.14 PREGNANT INDIVIDUALS ELIGIBLE FOR EXTENDED OR CONTINUOUS ELIGIBILITY (42 CFR 435.170):
A. Extended eligibility for pregnant individuals: For a pregnant individual who was eligible and enrolled for mandatory or optional coverage under the state plan on the date their pregnancy ends (regardless of the reason the pregnancy ends), HSD provides full medicaid coverage through the last day of the month in which the 12-month postpartum period ends.
B. Continuous eligibility for pregnant individuals: For a pregnant individual who was eligible and enrolled for mandatory or optional coverage under the state plan and who, because of a change in circumstance (e.g., income, household, composition, aging out etc.), will not otherwise remain eligible, HSD provides full medicaid coverage through the last day of the month in which the 12-month postpartum period ends.
(1) The following populations are provided continuous eligibility effective April 1, 2022:
(a) Current medicaid recipients who are pregnant as of April 1, 2022 or who enroll based on pregnancy or become pregnant after April 1, 2022.
(b) Current medicaid recipients who are receiving medicaid while pregnant and who are no longer pregnant as of April 1, 2022, but who are still within a 12-month postpartum period; and
(c) Individuals who apply for medicaid after their pregnancy ends, who received medicaid -covered services while pregnant on or after April 1, 2022 if such services were received during an approved period of retroactive eligibility.
(2) The following applies to certain categories or individuals:
(a) An individual approved on the other adult category who becomes pregnant may remain on the adult category and receive services under the alternative benefit plan (ABP). The ABP is considered full benefits for the purpose of the 12-month extended postpartum period. An individual on the other adult category who becomes pregnant may also transition to another full coverage medicaid category such as pregnant women or parent/caretaker and will remain eligible until their 12-month postpartum period expires.
(b) Children turning age 19 aging out of a children’s medicaid category will remain on a children’s medicaid category until their 12-month postpartum period expires.
(c) An individual covered on the parent/caretaker category during a 12-month postpartum period and who has increased earnings or spousal support above the parent/caretaker category limit will remain on the parent/caretaker category until their 12-month postpartum period expires and then can transition to a four or 12-month transitional medical assistance period.
(d) An individual who becomes pregnant during the 12-month postpartum period is entitled to 12-months continuous coverage through the end of the second pregnancy and the 12-month postpartum period following.
(e) The extended 12-month postpartum period applies to individuals receiving medicaid who are lawfully residing children under age 21 and pregnant individuals referred to as “CHIPRA 214”.
C. Renewals: Medicaid renewals are conducted at the end of the individual’s 12-month postpartum period. Individuals remain enrolled in the eligibility group in which the individual was enrolled during pregnancy through the end of the 12-month postpartum period as described in Subsection B of 8.291.400.14 NMAC.
D. There is not extended or continuous medicaid eligibility for a pregnant individual covered during a presumptive eligibility period under section 1920 of the ACT.
E. An individual’s eligibility may not be terminated during a continuous eligibility period, regardless of any changes in circumstances, unless:
(1) the individual or their representative requests a voluntary termination of eligibility;
(2) the individual ceases to be a resident of New Mexico;
(3) eligibility was determined incorrectly at the most recent determination or redetermination of eligibility because of HSD error or fraud, abuse, or perjury attributed to the individual; or
(4) the individual dies.
[8.291.400.14 NMAC - N, 4/5/2022]
HISTORY OF 8.291.400 NMAC:
History of Repealed Material:
8.291.400 NMAC, Eligibility Requirements, filed 9/17/2013 - Duration expired 12/31/2013.
8.291.400 NMAC, Eligibility Requirements, filed 12/2/2013 - Repealed effective 10/1/2017.
NMAC History:
8.291.400 NMAC, Eligibility Requirements, filed 9/17/2013 was replaced by 8.291.400 NMAC, Eligibility Requirements effective 10/1/2017.
TITLE 8 SOCIAL SERVICES
CHAPTER 291 MEDICAID ELIGIBILITY - AFFORDABLE CARE
PART 410 GENERAL RECIPIENT REQUIREMENTS
8.291.410.1 ISSUING AGENCY: New Mexico Health Care Authority (HCA).
[8.291.410.1 NMAC - Rp, 8.291.410.1 NMAC, 10/1/2017 ; A, 7/1/2024 ]
8.291.410.2 SCOPE: The rule applies to the general public.
[8.291.410.2 NMAC - Rp, 8.291.410.2 NMAC, 10/1/2017]
8.291.410.3 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 or by state statute. See Section 27-1-12 et seq., NMSA 1978. 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.
[8.291.410.3 NMAC - Rp, 8.291.410.3 NMAC, 10/1/2017 ; A, 7/1/2024 ]
8.291.410.4 DURATION: Permanent.
[8.291.410.4 NMAC - Rp, 8.291.410.4 NMAC, 10/1/2017]
8.291.410.5 EFFECTIVE DATE: October 1, 2017, unless a later date is cited at the end of a section.
[8.291.410.5 NMAC - Rp, 8.291.410.5 NMAC, 10/1/2017]
8.291.410.6 OBJECTIVE: The objective of this rule is to provide eligibility guidelines when determining eligibility for the medical assistance division (MAD) medical assistance programs (MAP) and other health care programs it administers. Processes for establishing and maintaining this category of eligibility are found in the affordable care general provision chapter located at 8.291.400 NMAC through 8.291.430 NMAC.
[8.291.410.6 NMAC - Rp, 8.291.410.6 NMAC, 10/1/2017]
8.291.410.7 DEFINITIONS: Refer to 8.291.400.7 NMAC.
[8.291.410.7 NMAC - Rp, 8.291.410.7 NMAC, 10/1/2017]
8.291.410.8 MISSION: To transform lives. Working with our partners, we design and deliver innovative, high quality health and human services that improve the security and promote independence for New Mexicans in their communities.
[8.291.410.8 NMAC - Rp, 8.291.410.8 NMAC, 10/1/2017; A, 1/1/2022]
8.291.410.9 GENERAL RECIPIENT REQUIREMENTS: To be eligible for MAP, applicants or recipients must meet specific requirements as outlined in this part.
[8.291.410.9 NMAC - Rp, 8.291.410.9 NMAC, 10/1/2017]
8.291.410.10 USE OF SOCIAL SECURITY NUMBER: Refer to 8.200.410.10 NMAC.
[8.291.410.10 NMAC - Rp, 8.291.410.10 NMAC, 10/1/2017]
8.291.410.11 AGE: The age of the applicant recipient is verified to determine if he or she is under or over the specified age limit.
A. Age of child: Verification of age, including self-attestation of an applicant or recipient under 21 years of age is mandatory for MAP enrollment.
B. Age of adults: Age of an applicant or recipient 21 years of age or older is verified if questionable.
C. Documents that can be used to verify age can be found in 8.100.130 NMAC.
[8.291.410.11 NMAC - Rp, 8.291.410.11 NMAC, 10/1/2017]
8.291.410.12 RELATIONSHIP: Verification of relationship is mandatory, see 8.291.410.20 NMAC
A. Documents that can be used to verify relationship can be found at 8.100.130 NMAC.
B. The documentary evidence must contain the names of related individuals in question.
(1) If the relative is other than a parent, the relationship must be traced if questionable.
(2) In situations in which both parents are living in the home and the father’s paternity has not been established by operation of law or determined through court order, it will be necessary to establish the relationship of the applicant or recipient under 21 years of age to the father by completion of the HSD child support enforcement division (CSED) acknowledgment of paternity packet.
(3) If the child is living with a relative, it will be necessary to establish the relationship of the absent parents. A CSED acknowledgement of paternity will be an acceptable means of establishing relationship.
C. The following relatives are within the fifth degree of relationship:
(1) father (biological or adoptive);
(2) mother (biological or adoptive);
(3) grandfather, great grandfather, great great grandfather, great great great grandfather;
(4) grandmother, great grandmother, great great grandmother, great great great grandmother;
(5) spouse of child's parent (stepparent);
(6) spouse of child's grandparent, great grandparent, great great grandparent, great great great grandparent (step grandparent);
(7) brother, half-brother, brother-in-law, step-brother;
(8) sister, half-sister, sister-in-law, step-sister;
(9) uncle of the whole or half blood, uncle-in-law, great uncle, great great uncle;
(10) aunt of the whole or half blood, aunt-in-law, great aunt, great great aunt;
(11) first cousin and spouse of first cousin;
(12) son or daughter of first cousin (first cousin once removed);
(13) son or daughter of great aunt or great uncle (first cousin once removed) and spouse; or
(14) nephew or niece and spouses.
D. Effect of divorce or death on relationship: A relationship based upon marriage, such as the "in-law" or "step" relationships, continues to exist following the dissolution of the marriage by divorce or death.
[8.291.410.12 NMAC - Rp, 8.291.410.12 NMAC, 10/1/2017]
8.291.410.13 IDENTITY: Refer to 8.200.410.12 NMAC.
[8.291.410.13 NMAC - Rp, 8.291.410.13 NMAC, 10/1/2017]
8.291.410.14 CITIZENSHIP/NON-CITIZEN STATUS : Refer to 8.200.410.12 NMAC.
[8.291.410.14 NMAC - Rp, 8.291.410.14 NMAC, 10/1/2017; A, 1/1/2022]
8.291.410.15 RESIDENCE: To meet MAP requirements for eligibility, applicants or recipients must be living in New Mexico on the date of application or final determination of eligibility and have demonstrated an intention to remain in the state.
A. Establishing residence: Residence in New Mexico is established by living in the state and carrying out the types of activities associated with day-to-day living, such as occupying a home, enrolling child(ren) in school, getting a state driver’s license, or renting a post office box. An applicant or recipient who is homeless is considered to have met the residence requirements if he or she intends to remain in the state.
B. Recipients receiving benefits out-of-state: Applicants or recipients who receive financial or medical assistance in another state which makes residence in that state a condition of eligibility are considered residents of that state until the ISD office receives verification from the other state agency indicating that it has been notified by an applicant or recipient of the abandonment of residence in that state.
C. Applicants or recipients court ordered into full or partial responsibility of the state children youth and families department (CYFD): When CYFD places an applicant or recipient in a new state of residence, the new state of residence is responsible for the provision of medicaid; however, New Mexico must provide limited coverage for services that are part of the New Mexico MAD benefit package and not available in the new state of residence.
D. Abandonment: Residence is not abandoned by temporary absences. Temporary absences occur when applicants or recipients leave New Mexico for specific purposes with time-limited goals. An applicant or recipient may be temporarily absent from the state is the person intends to return when the purpose of the absence has been accomplished, unless another state has determined he or she is a resident there for the purposes of MAP enrollment. Residence is considered abandoned when the applicant or recipient leaves New Mexico for any of the following reasons:
(1) intends to establish residence in another state;
(2) for no specific purpose with no clear intention of returning;
(3) applies for financial, food or medical assistance in another state which makes residence in that state a condition of eligibility; or
(4) for more than 30 calendar days, without notifying HSD of his or her departure or intention of returning.
E. Dispute in residency: If there is a dispute in state residency, the applicant or recipient may be considered a resident in the state in which he or she is physically located.
F. Evidence of immigration status may not be used to determine that an individual is not a state resident per 42 CFR. 435.956 (c)(2).
[8.291.410.15 NMAC - Rp, 8.291.410.15 NMAC, 10/1/2017]
8.291.410.16 NON-CONCURRENT RECEIPT OF ASSISTANCE: A MAP applicant or recipient receiving medicaid in another state is not eligible for MAP enrollment in accordance with 8.200.410 NMAC.
[8.291.410.16 NMAC - Rp, 8.291.410.16 NMAC, 10/1/2017]
8.291.410.17 APPLICATIONS FOR OTHER BENEFITS: As a condition of eligibility, a MAP applicant or recipient must take all necessary steps to obtain any benefits he or she is entitled to in accordance with 8.200.410 NMAC.
[8.291.410.17 NMAC - Rp, 8.291.410.17 NMAC, 10/1/2017]
8.291.410.18 APPLICATIONS (42 CFR 435.907):
A. Basis and implementation . In accordance with section 1413(b)(1)(A) of the Affordable Care Act, HSD will accept an application from the applicant, an adult who is in the applicant's household, as defined in 42 CFR 435.603, or family, as defined in section 36B(d)(1) of the Code, an authorized representative, or if the applicant is a minor or incapacitated, someone acting responsibly for the applicant, and any documentation required to establish eligibility:
(1) Via the internet web site;
(2) By telephone;
(3) Via mail;
(4) In person; and
(5) Through other commonly available electronic means.
B. The application must be:
(1) The single, streamlined application for all insurance affordability programs or
(2) An alternative single, streamlined application for all insurance affordability programs, which may be no more burdensome on the applicant than the application described in Paragraph (1) of Subsection B of 8.291.410.18 NMAC. HSD uses the HSD 100 and MAD 100 application forms, and Your Eligibility System NM (Yes NM).
C. For individuals applying, or who may be eligible, for assistance on a basis other than the applicable modified adjusted gross income (MAGI) standard in accordance with 42 CFR435.911 HSD will use an application described in Subsection B of 8.291.410.18 NMAC and supplemental forms to collect additional information needed to determine eligibility on such other basis.
D. HSD may not require an in-person interview as part of the application process for a determination of eligibility using MAGI-based income.
E. Limits on information: HSD will only require an applicant to provide the information necessary to make an eligibility determination or for a purpose directly connected to the administration of the state plan.
F. HSD accepts on applications electronic, including telephonically recorded, signatures and handwritten signatures transmitted via any other electronic transmission.
[8.291.410.18 NMAC - Rp, 8.291.410.18 NMAC, 10/1/2017]
8.291.410.19 Periodic renewal of medicaid eligibility (42 CFR 435.916):
A. Renewal of individuals whose medicaid eligibility is based on MAGI.
(1) Except as provided in Subsection D of 8.291.410.19 NMAC, the eligibility of medicaid beneficiaries whose financial eligibility is determined using MAGI-based income must be renewed once every 12 months, and no more frequently than once every 12 months.
(2) Renewal on basis of information available to HSD. HSD will make a redetermination of eligibility without requiring information from the individual if able to do so based on reliable information contained in the individual's account or other more current information available to HSD, including but not limited to information accessed through any data bases accessed by HSD under 42 CFR 435.948, 435.949 and 435.956. If the HSD is able to renew eligibility based on such information, HSD will notify the individual:
(a) Of the eligibility determination, and basis; and
(b) That the individual must inform the HSD, through any of the modes permitted for submission of applications under 42 CFR 435.907(a) and Subsection A of 8.291.410.18 NMAC, if any of the information contained in such notice is inaccurate, but that the individual is not required to sign and return such notice if all information provided on such notice is accurate.
(3) Use of a pre-populated renewal form. If HSD cannot renew eligibility in accordance with Paragraph (2) of Subsection A of 8.291.410.19 NMAC, HSD will:
(a) Provide the individual with:
(i) A renewal form containing information available to HSD that is needed to renew eligibility.
(ii) At least 30 days from the date of the renewal form to respond and provide any necessary information through any of the modes of submission specified in 42 CFR 435.907(a) and 8.291.410.18(A) NMAC and to sign the renewal form in a manner consistent with 42 CFR 435.907(f) and Subsection F of 8.291.410.18 NMAC.
(iii) Notice of the HSD decision concerning the renewal of eligibility.
(b) Verify any information provided by the beneficiary in accordance with 42 CFR 435.945 through 435.956.
(c) Reconsider in a timely manner the eligibility of an individual who is terminated for failure to submit the renewal form or necessary information, if the individual subsequently submits the renewal form within 90 days after the date of termination without requiring a new application;
(d) Not require an individual to complete an in-person interview as part of the renewal process.
B. Redetermination of individuals whose medicaid eligibility is determined on a basis other than modified adjusted gross income: HSD will redetermine the eligibility of medicaid beneficiaries excepted from modified adjusted gross income per 42 CFR 435.603, for circumstances that may change, at least every 12 months. HSD will make a redetermination of eligibility in accordance with the provisions of Paragraph (2) of Subsection A of 8.291.410.19 NMAC, if sufficient information is available to do so. HSD adopts the procedures described at 42 CFR 435.916(a)(3) for individuals whose eligibility cannot be renewed in accordance with Paragraph (3) of Subsection A of 8.291.410.19 NMAC.
(1) HSD will consider blindness as continuing until the reviewing physician under 42 CFR 435.531 determines that a beneficiary's vision has improved beyond the definition of blindness contained in the plan; and
(2) HSD will consider disability as continuing until the review team, under 42 CFR 435.541, determines that a beneficiary's disability no longer meets the definition of disability contained in the plan.
C. Procedures for reporting changes: HSD has procedures designed to ensure that beneficiaries make timely and accurate reports of any change in circumstances that may affect their eligibility and that such changes may be reported through any of the modes for submission of applications described in 43 CFR 435.907(a) and Subsection A of 8.291.410.18 NMAC.
D. HSD action on information about changes: Consistent with the requirements of 42 CFR 435.952, HSD will promptly redetermine eligibility between regular renewals of eligibility described in Subsections B and C of 8.291.410.19 NMAC whenever it receives information about a change in a beneficiary's circumstances that may affect eligibility. Auto renewal is only applicable to the following medicaid categories: working disabled individuals, qualified medicare beneficiaries, specified low income medicare beneficiary, qualified individuals, parent caretaker, pregnant women, children’s medicaid, children’s health insurance program (CHIP), pregnancy related services, other adult and family planning.
(1) For renewals of medicaid beneficiaries whose financial eligibility is determined using MAGI-based income, the agency must limit any requests for additional information from the individual to information relating to such change in circumstance.
(2) If HSD has enough information available to it to renew eligibility with respect to all eligibility criteria, the HSD will begin a new 12-month renewal period.
(3) If HSD has information about anticipated changes in a beneficiary's circumstances that may affect his or her eligibility, HSD will redetermine eligibility at the appropriate time based on such changes.
E . HSD will request from beneficiaries only the information needed to renew eligibility. Requests for non-applicant information must be conducted in accordance with 42 CFR 435.907.
F . Determination of ineligibility and transmission of data pertaining to individuals no longer eligible for medicaid.
(1) Prior to making a determination of ineligibility, HSD will consider all bases of eligibility, consistent with 42 CFR 435.911.
(2) For individuals determined ineligible for medicaid, the agency must determine potential eligibility for other insurance affordability programs and comply with the procedures set forth in 42 CFR 435.1200.
G. Any renewal form or notice will be accessible to persons who are limited english proficient and persons with disabilities, consistent with 42 CFR 435.905.
[8.291.410.19 NMAC - N, 10/1/2017]
8.291.410.20 VERIFICATION METHODS: Verification will be obtained through various methods. Not all methods will necessarily be used in each case. This section details the specific types of methods to be used in establishing the applicant or recipient’s eligibility.
A. Prior case data not subject to change: Verification of an eligibility factor not subject to change, which previously has been verified and accepted, will not be subject to re-verification. The caseworker shall not ask an applicant or recipient for verification of any eligibility factors which have previously been established through documents in HSD’s possession and are not subject to change. Such factors include U.S. citizenship, birth date, relationship and enumeration.
B. Electronic data: Every applicant or recipient shall be informed that the information provided is subject to verification through state, federal and contracted data systems. The caseworker shall not require further verification of such information unless it is disputed by the applicant or recipient, or the information is otherwise questionable as defined in 8.100.130 NMAC.
C. Self-attestation is the information that an applicant or recipient reports on an application and is certifying as true and correct to the best of their knowledge.
D. Documentary evidence is the primary source of verification for information not established in prior case information or electronic source data. Obtaining necessary verification through documentary evidence readily available to the applicant or recipient shall always be explored before collateral contacts or sworn statements are used. Documentary evidence consists of a written confirmation of a household's circumstances. Acceptable verification is not limited to any single type of document. The types of documents which may be accepted as verification are specified under the sections pertaining to verification methods later in this chapter. The caseworker shall provide applicants or recipients with receipts for verification documents provided subsequent to the interview.
E. Collateral contact is defined at 8.100.130 NMAC.
F. Sworn statement is defined at 8.100.130 NMAC.
[8.291.410.20 - Rp, 8.291.410.19, 10/1/2017]
8.291.410.21 VERIFICATION STANDARDS: Below is a list of standards HSD will utilize to determine eligibility for MAP categories defined at 8.291.400.10 NMAC. If verification cannot be confirmed utilizing the various methods described in each section of this rule, HSD may request additional information. If information is provided and becomes questionable as defined at 8.100.130 NMAC, then additional documentation must be provided as described by 8.100.130 NMAC.
A. Income: Verification of income is mandatory for ACA related MAP and HSD will utilize electronic sources and documents provided by the applicant or recipient to verify his or her income. Examples of acceptable documentation can be found at 8.100.130 NMAC.
B. Residency: Self attestation is an acceptable form of verification of residency.
C. Age: Self attestation is an acceptable form of verification of age.
D. Enumeration: HSD will utilize electronic sources to verify an applicant or recipient’s enumeration.
E. Citizenship: HSD will utilize electronic sources to verify an applicant or recipient’s citizenship.
F. Immigration status: HSD will utilize electronic sources to verify an applicant or recipient’s immigration status.
G. Relationship: Self attestation is an acceptable form of verification of relationship.
H. Receipt of other benefits: HSD will utilize electronic sources to verify an applicant or recipient’s receipt of other benefits.
[8.291.410.21 - Rp, 8.291.410.20, 10/1/2017]
8.291.410.22 VERIFYING FINANCIAL INFORMATION (42 CFR 435.948):
A . HSD will request the following information relating to financial eligibility from other agencies in the state and other states and federal programs to the extent HSD determines such information is useful to verifying the financial eligibility of an individual.
(1) Information related to wages, net earnings from self-employment, unearned income and resources from the state wage information collection agency (SWICA), the internal revenue service (IRS), the social security administration (SSA), the agencies administering the state unemployment compensation laws, the state-administered supplementary payment programs under section 1616(a) of the Act, and any state program administered under a plan approved under Titles I, X, XIV, or XVI of the Act; and
(2) Information related to eligibility or enrollment from the supplemental nutrition assistance program (SNAP), the state program funded under Part A of Title IV of the Act, and other insurance affordability programs.
B. To the extent that the information identified in Subsection A of 8.291.410.22 NMAC is available through the electronic service established in accordance with 8.291.410.23 NMAC HSD will obtain the information through such service.
C. HSD will request the information by SSN, or if an SSN is not available, using other personally identifying information in the individual's account, if possible.
[8.291.410.22 NMAC - N, 10/1/2017]
8.291.410.23 VERIFICATION OF INFORMATION THROUGH AN ELECTRONIC SERVICE (42 CFR 435.949(a) and (b)): The federal government will establish an electronic service through which HSD may verify certain information with, or obtain such information from, federal agencies and other data sources, including SSA, the department of treasury, and the department of homeland security. To the extent that information related to eligibility for medicaid is available through the electronic service, HSD must obtain the information through such service.
[8.291.410.23 NMAC - N, 10/1/2017]
8.291.410.24 USE OF INFORMATION AND REQUESTS OF ADDITIONAL INFORMATION FROM INDIVIDUALS (42 CFR 435.952):
A . HSD will promptly evaluate information received or obtained by it in accordance with regulations per 42 CFR 435.940 through 435.960 to determine whether such information may affect the eligibility of an individual or the benefits to which he or she is entitled.
B . If information provided by or on behalf of an individual (on the application or renewal form or otherwise) is reasonably compatible with information obtained by HSD in accordance with 42. CFR 435.948, 435.949 or 435.956 HSD will determine or renew eligibility based on such information.
C. An individual must not be required to provide additional information or documentation unless information needed by the agency HSD in accordance with 42 CFR 435.948, 435.949 or 435.956 cannot be obtained electronically or the information obtained electronically is not reasonably compatible, as provided in the verification plan described in 8.291.410.24 NMAC with information provided by or on behalf of the individual.
(1) Income information obtained through an electronic data match shall be considered reasonably compatible with income information provided by or on behalf of an individual if both are either above or at or below the applicable income standard or other relevant income threshold.
(2) If information provided by or on behalf of an individual is not reasonably compatible with information obtained through an electronic data match, HSD must seek additional information from the individual including:
(a) A statement which reasonably explains the discrepancy; or
(b) Other information (which may include documentation), provided that documentation from the individual is permitted only to the extent electronic data are not available and establishing a data match would not be effective, considering such factors as the administrative costs associated with establishing and using the data match compared with the administrative costs associated with relying on paper documentation, and the impact on program integrity in terms of the potential for ineligible individuals to be approved as well as for eligible individuals to be denied coverage.
(c) HSD must provide the individual a reasonable period, defined as 10 calendar days, to furnish any additional information required under Subsection C of 8.291.410.24 NMAC.
(3) Exception for special circumstances. HSD must establish an exception to permit, on a case-by-case basis, self-attestation of individuals for all eligibility criteria when documentation does not exist at the time of application or renewal, or is not reasonably available, such as in the case of individuals who are homeless or have experienced domestic violence or a natural disaster. This exception does not apply if documentation is specifically required under title XI or XIX, such as requirements for verifying citizenship and immigration status.
D. HSD may not deny or terminate eligibility or reduce benefits for any individual on the basis of information received in accordance with regulations under 42 CFR 435.940 through 435.960 of this subpart unless HSD has sought additional information from the individual in accordance with Subsection C of 8.291.410.24 NMAC and provided proper notice and hearing rights to the individual.
[8.291.410.24 NMAC - N, 10/1/2017]
8.291.410.25 VERIFICATION PLAN: HSD has a verification plan describing the verification policies and procedures to implement the provisions set forth in 42 CFR 435.940 through 435.956 and 8.100.130 and 8.291.410 NMAC. The state verification plan is posted on the HSD website.
[8.291.410.25 NMAC - N, 10/1/2017]
8.291.410.26 TIMEFRAME FOR DISPOSITION: An applicant or recipient is given a timeframe to provide necessary verification in order for ISD to process an application within the timeframe set forth in this section. This requirement pertains to requests for verification for initial applications as well as for verification for ongoing eligibility. ISD shall make an eligibility decision within three working days of the receipt of all necessary verification.
A. The application disposition deadline for MAP is 45 days from the date of application.
(1) Day one: the date of application is the first day.
(2) No later than day 44, or by the preceding work day if day 44 falls on a weekend or holiday:
(a) if verification provided establishes eligibility or ineligibility; or
(b) if the day following day 44 is not a work day, then decision must be made earlier than day 44 to allow for mailing on or before the deadline.
(3) No later than day 45 by the next work day if day 45 falls on a weekend or holiday, if needed verification is not provided until day 42 - 44.
(4) Day 45 by the next work day if day 45 falls on a weekend or holiday, if needed verification is provided on day 45, or is not provided.
(5) After day 45:
(a) When an applicant or recipient requests one or more 10-calendar day extensions of time to provide needed verification. An applicant or recipient is entitled to receive up to three 10- calendar day extensions of time upon request.
(b) The eligibility decision must be made as soon as possible and within three working days of receipt of all necessary verification.
B. Tracking the application processing time limit: The application processing time limit begins on the day the signed application is received in the ISD county office.
C. Delayed determination: If an eligibility determination is not made within the required application processing time limit, the applicant or recipient shall be notified in writing of the reason for the delay and that the applicant or recipient has the right to request a HSD administrative hearing regarding ISD’s failure to act within the time limit.
D. Extensions of time: Up to three 10-calendar day extensions for providing verification shall be granted at the applicant or recipient's request. The extension begins at the end of the application processing time period or at the end of the previous extension.
E. Lack of verification: If verification needed to determine eligibility is not provided and no extension of time is requested, the application will be denied on the 45th day after the application date or by the next work day if 45th day falls on weekend or holiday.
F. Per 42 CFR 435.912(c)(3) the determination of eligibility for any medicaid applicant may not exceed:
(1) ninety days for applicants who apply for medicaid on the basis of disability; and
(2) forty-five days for all other medicaid applicants.
G . Per 42 CFR 435.912(g) HSD may not use the time standards cited at Subsection F of 8.291.410.26 NMAC:
(1) as a waiting period before determining eligibility; or
(2) as a reason for denying eligibility (because it has not determined eligibility within the time standards.
H . Case documentation (42 CFR 435.914).
(1) HSD includes in each applicant's case record facts to support the agency's decision on the application.
(2) HSD disposes of each application by a finding of eligibility or ineligibility, unless:
(a) there is an entry in the case record that the applicant voluntarily withdrew the application, and that HSD sent a notice confirming the decision;
(b) there is a supporting entry in the case record that the applicant has died; or
(c) there is a supporting entry in the case record that the applicant cannot be located.
[8.291.410.26 - Rp 8.291.410.21, 10/1/2017]
HISTORY OF 8.291.410 NMAC:
History of Repealed Material:
8.291.410 NMAC, General Recipient Requirements, filed 9/17/2013 - Duration expired 12/31/2013.
8.291.410 NMAC, General Recipient Requirements, filed 12/17/2013 – Repealed effective 10/1/2017.
NMAC History:
8.291.410 NMAC, General Recipient Requirements, filed 12/17/2013 was replaced by 8.291.410 NMAC, General Recipient Requirements effective 10/1/2017.
TITLE 8 SOCIAL SERVICES
CHAPTER 291 MEDICAID ELIGIBILITY - AFFORDABLE CARE
PART 420 RECIPIENT RIGHTS AND RESPONSIBILITIES
8.291.420.1 ISSUING AGENCY: New Mexico Health Care Authority .
[8.291.420.1 NMAC - Rp, 8.291.420.1 NMAC, 1/1/2014 ; A, 7/1/2024 ]
8.291.420.2 SCOPE: The rule applies to the general public .
[8.291.420.2 NMAC - Rp, 8.291.420.2 NMAC, 1/1/2014]
8.291.420.3 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 or by state statute. See Section 27-1-12 et seq . NMSA 1978. 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.
[8.291.420.3 NMAC - Rp , 8.291.420.3 NMAC, 1/1/ 2014 ; A, 7/1/2024 ]
8.291.420.4 DURATION: Permanent.
[8.291.420.4 NMAC - Rp, 8.291.420.4 NMAC, 1/1/2014]
8.291.420.5 EFFECTIVE DATE: January 1, 2014, unless a later date is cited at the end of a section.
[8.291.420.5 NMAC - Rp, 8.291.420.5 NMAC, 1/1/2014]
8.291.420.6 OBJECTIVE: The objective of this rule is to provide eligibility guidelines when determining eligibility for the medical assistance division (MAD) medicaid program and other health care programs it administers. Processes for establishing and maintaining this category of eligibility are found in the affordable care general provision chapter located at 8.291.400 NMAC through 8.291.430 NMAC.
[8.291.420.6 NMAC - Rp, 8.291.420.6 NMAC, 1/1/2014]
8.291.420.7 DEFINITIONS: Refer to 8.291.400.7 NMAC.
[8.291.420.7 NMAC - Rp, 8.291.420.7 NMAC, 1/1/2014]
8.291.420.8 RIGHT TO APPLY:
A. An individual has the right to apply for medicaid and other health care programs MAD administers regardless of whether it appears he or she may be eligible.
(1) The income support division (ISD) determines eligibility for medicaid , unless otherwise determined by another entity as stated in another NMAC rule. A decision shall be made promptly on applications in accordance with the timeliness standards set forth in 8.291.410 NMAC .
(2) Individuals who might be eligible for supplemental security income (SSI) are referred to the social security administration (SSA) office to apply.
B. Application: A signed electronic or paper application, as defined in 8.291.410 NMAC, is required from the applicant, an authorized representative, or, if the applicant is incompetent or incapacitated, someone acting responsibly for the applicant. The applicant may complete a joint application for all benefits that HSD administers. A recipient will not be required to submit an application if there is a need to switch from one medicaid benefit to another unless a redetermination is due in that month or the following month. Additional information may be requested if the new benefit requires additional information and verification of eligibility.
[8.291.420.8 NMAC - Rp, 8.291.420.8 NMAC, 1/1/2014]
8.291.420.9 FREEDOM OF CHOICE OF PROVIDER: Refer to 8.200.430.10 NMAC.
[8.291.420.9 NMAC - Rp, 8.291.420.9 NMAC, 1/1/2014]
8.291.420.10 RELEASE OF INFORMATION/CONFIDENTIALITY: Refer to 8.200.430.11 NMAC.
[8.291.420.10 NMAC - Rp, 8.291.420.10 NMAC, 1/1/2014]
8.291.420.11 RIGHT TO ADEQUATE NOTICE AND ADMINISTRATIVE HEARING: Refer to 8.200.430.12 NMAC.
[8.291.420.11 NMAC - Rp, 8.291.420.11 NMAC, 1/1/2014]
8.291.420.12 ASSIGNMENT OF MEDICAL SUPPORT RIGHTS: Refer to 8.200.430.13 NMAC.
[8.291.420.12 NMAC - Rp, 8.291.420.12 NMAC, 1/1/2014]
8.291.420.13 ELIGIBLE RECIPIENT RESPONSIBILITY TO COOPERATE WITH ASSIGNMENT OF SUPPORT RIGHTS: Refer to 8.200.430.14 NMAC.
[8.291.420.13 NMAC - Rp, 8.291.420.13 NMAC, 1/1/2014]
8.291.420.14 ELIGIBLE RECIPIENT RESPONSIBILITY TO GIVE PROVIDER PROPER IDENTIFICATION AND NOTICE OF ELIGIBILITY CHANGES: Refer to 8.200.430.15 NMAC.
[8.291.420.14 NMAC - Rp, 8.291.420.14 NMAC, 1/1/2014]
8.291.420.15 ELIGIBLE RECIPIENT FINANCIAL RESPONSIBILITIES: Refer to 8.200.430.16 NMAC.
[8.291.420.15 NMAC - Rp, 8.291.420.15 NMAC, 1/1/2014]
8.291.420.16 RESTITUTION: Refer to 8.200.430.17 NMAC.
[8.291.420.16 NMAC - Rp, 8.291.420.16 NMAC, 1/1/2014]
8.291.420.17 THIRD PARTY LIABILITY: Refer to 8.200.420.12 NMAC.
[8.291.420.17 NMAC - Rp, 8.291.420.17 NMAC, 1/1/2014]
8.291.420.18 MAD ESTATE RECOVERY: Refer to 8.200.420.13 NMAC.
[8.291.420.18 NMAC - Rp, 8.291.420.18 NMAC, 1/1/2014]
HISTORY OF 8.291.420 NMAC:
History of Repealed Material:
8.291.420 NMAC, Recipient Rights and Responsibilities, filed 9/17/2013 - Duration expired 12/31/2013.
TITLE 8 SOCIAL SERVICES
CHAPTER 291 MEDICAID ELIGIBILITY - AFFORDABLE CARE
PART 430 FINANCIAL RESPONSIBILITY REQUIREMENTS
8.291.430.1 ISSUING AGENCY: New Mexico Health Care Authority (HCA).
[8. 291.430.1 NMAC - Rp, 8.291.430.1 NMAC, 11/16/2015; A, 8/1/2024]
8.291.430.2 SCOPE: The rule applies to the general public .
[8. 291.430.2 NMAC - Rp, 8.291.430.2 NMAC, 11/16/2015]
8.291.430.3 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 Section 27-1-12 NMSA et seq.
[8. 291.430.3 NMAC - Rp, 8.291.430.3 NMAC, 11/16/2015]
8.291.430.4 DURATION: Permanent.
[8. 291.430.4 NMAC - Rp, 8.291.430.4 NMAC, 11/16/2015]
8.291.430.5 EFFECTIVE DATE: November 16, 2015, unless a later date is cited at the end of a section.
[8. 291.430.5 NMAC - Rp, 8.291.430.5 NMAC, 11/16/2015]
8.291.430.6 OBJECTIVE: The objective of this rule is to provide specific instructions when determining eligibility for the medicaid program and other health care programs. Processes for establishing and maintaining a medical assistance programs (MAP) category of the affordable care eligibility are detailed in the 8.291.400 through 8.291.430 NMAC.
[8. 291.430.6 NMAC - Rp, 8.291.430.6 NMAC, 11/16/2015]
8.291.430.7 DEFINITIONS: Refer to 8.291.400 NMAC for detailed descriptions.
[8. 291.430.7 NMAC - Rp, 8.291.430.7 NMAC, 11/16/2015]
8.291.430.8 MISSION STATEMENT: We ensure that New Mexicans attain their highest level of health by providing whole-person, cost-effective, accessible, and high-quality health care and safety-net services.
[8. 291.430.8 NMAC - Rp, 8.291.430.8 NMAC, 11/16/2015; A/E, 4/1/2016; A, 12/1/2020; A, 8/1/2024]
8.291.430.9 GENERAL NEED DETERMINATION: To be eligible for a MAP category of eligibility, an applicant or a recipient must meet specific income standards.
[8. 291.430.9 NMAC - Rp, 8.291.430.9 NMAC, 11/16/2015]
8.291.430.10 FEDERAL POVERTY LEVEL (FPL): This part contains the monthly federal poverty level table for use in determining monthly income standards for MAP categories of eligibility outlined in 8.291.400.10 NMAC:
HOUSEHOLD SIZE 100% 133% 138% 190% 240% 250% 300% 1 $1,305 $1,735 $1,800 $2,478 $3,130 $3,261 $3,913 2 $1,763 $2,345 $2,433 $3,349 $4,230 $4,407 $5,288 3 $2,221 $2,954 $3,065 $4,220 $5,330 $5,553 $6,663 4 $2,680 $3,564 $3,698 $5,091 $6,430 $6,698 $8,038 5 $3,138 $4,173 $4,330 $5,962 $7,530 $7,844 $9,413 6 $3,596 $4,783 $4,963 $6,833 $8,630 $8,990 $10,788 7 $4,055 $5,393 $5,595 $7,703 $9,730 $10,136 $12,163 8 $4,513 $6,002 $6,228 $8,574 $10,830 $11,282 $13,538 +1 $458 $609 $633 $871 $1,100 $1,146 $1,375
[8.291.430.10 NMAC - Rp, 8.291.430.10 NMAC, 11/16/2015; A/E, 4/1/2016; A/E, 9/14/2017; A, 2/1/2018; A/E, 5/17/2018; A, 9/11/2018; A/E, 4/11/2019; A, 7/30/2019; A, 12/1/2020; A/E, 4/1/2021; A, 9/1/2021; A/E, 4/1/2022; A, 8/9/2022; A/E, 4/1/2023; A/E, 4/1/2024; A, 8/1/2024; A/E, 4/1/2025]
8.291.430.11 INCOME STANDARD FOR PREGNANT WOMEN AND PARENT CARETAKER ELIGIBILITY: This part contains the MAP category of pregnant women and parent caretaker eligibility’s fixed monthly standard for an applicant or recipient:
HOUSEHOLD SIZE MONTHLY INCOME LIMIT 1 $451 2 $608 3 $765 4 $923 5 $1,080 6 $1,238 7 $1,395 8 $1,553 +1 $158
[8. 291.430.11 NMAC - Rp, 8.291.430.11 NMAC, 11/16/2015]
8.291.430.12 INCOME DISREGARD: A disregard of five percent of 100 percent of the current FPL, according to the applicant’s or recipient’s budget group size, will be given according to the Affordable Care Act (ACA) related category of eligibility. This income disregard will be subtracted from the countable income.
[8. 291.430.12 NMAC - Rp, 8.291.430.12 NMAC, 11/16/2015]
8.291.430.13 LIVING ARRANGEMENT: All individuals listed on the MAP application are evaluated according to their living arrangement to determine if they can be included in an assistance group or budget group.
A. Extended living in the home: An individual physically absent from the home is a member of the assistance unit or budget group. Extended living in the home includes:
(1) attending college or boarding school;
(2) receiving treatment in a title XIX MAD enrolled facility (including institutionalized when meeting a nursing facility (NF) level of care (LOC) and intermediate care facilities for the mentally retarded (ICF-MRs);
(3) emergency absences: an applicant or recipient absent from the home due to an emergency, who is expected to return to the household, continues to be a member of the household;
(4) foster care placements: a minor applicant or minor recipient removed from the home by a child protective services agency (tribal, bureau of Indian affairs, or children, youth and families department) will be considered to be living in the home until the adjudicatory hearing; if the adjudicatory hearing results in custody being granted to some other entity, the minor applicant or minor recipient will be removed from the assistance unit and budget group;
(5) inmate of a public institution:
(a) see 8.200.410.15 NMAC for the definition of a public institution and an inmate of a public institution;
(b) an inmate of a public institution is included in the household with other mandatory household members if they are expected to file a tax return or be claimed as a tax dependent; see 8.291.430.14 NMAC;
(c) an inmate of a public institution is not included in the household if they neither file a tax return nor is claimed as a tax dependent which requires that mandatory household members be living together; see 8.291.430.14 NMAC.
B. Extended living in the home also includes:
(1) residential treatment centers;
(2) group homes; and
(3) free-standing psychiatric hospitals.
C. Living in the home with a parent caretaker: To be included in the assistance unit, a minor applicant or minor recipient must be living, or considered to be living, in the home of:
(1) a biological or adoptive or step parent (there is a presumption that a child born to a married woman is the child of the husband); or
(2) a specified relative who:
(a) is related within the fifth degree of relationship by blood, marriage or adoption, as determined by New Mexico statute Chapter 45 - Uniform Probate Code; a relationship based upon marriage, such as "in-law" or "step" relationships, continues to exist following the dissolution of the marriage by divorce or death; and
(b) assumes responsibility for the day-to-day care and control of the minor applicant or minor recipient; the determination of whether an individual functions as the specified relative shall be made by the specified relative unless other information known to the worker clearly indicates otherwise;
(3) a minor applicant or minor recipient considered to be living in the home: a minor applicant or minor recipient is considered to be part of the assistance unit and budget group as evidenced by the minor applicant’s or minor recipient’s customary physical presence in the home; if they are living in more than one household, the following applies:
(a) the custodial parent is the parent with whom the minor applicant or minor recipient lives the greater number of nights; or
(b) if the minor applicant or minor recipient spends equal amounts of time with each household, the minor applicant or minor recipient shall be considered to be living in the household of the parent with the higher modified adjusted gross income (MAGI).
D. For individuals for whom the state must complete a determination of income either based on MAGI or for MAGI-excepted groups:
(1) MAD recognizes same-sex couples as spouses, if they are legally married under the laws of the state, territory, or foreign jurisdiction in which the marriage was celebrated; and
(2) for an applicant or recipient whose MAP category of eligibility is based on the eligibility for any other HCA benefit program and for which income is not used in the eligibility determination, the applicant’s or recipient’s marital status will not be used in making the eligibility determination; the applicant’s or recipient’s MAP category of eligibility will continue to be based on the determination of eligibility of the other HCA applicable benefits.
[8. 291.430.13 NMAC - Rp, 8.291.430.13 NMAC, 11/16/2015; A, 8/1/2024]
8.291.430.14 BASIS FOR DEFINING THE ASSISTANCE UNIT AND BUDGET GROUPS: At the time of a MAP application, an applicant or recipient and ISD shall identify everyone who is to be considered for inclusion in an assistance unit and budget group. The composition of the assistance unit and budget group is based on the following factors:
A. Assistance group: the assistance unit includes an applicant or recipient who applies and who is determined to meet a MAP category of eligibility found in 8.291.430.10 NMAC.
B. Budget group: the budget group consists of the following types and will be established on an individual basis:
(1) tax filers and dependents: households that submit a MAP application where an applicant or a recipient intends to file for federal taxes or will be claimed as a dependent on federal income taxes for the current year:
(a) the budget group will consist of applicants or recipients who are listed on the MAP application as the taxpayer and tax dependents;
(b) if there are multiple taxpayers listed on a single MAP application, the budget group(s) will be established based on who the taxpayer intends to claim as a dependent (including the taxpayer); only the taxpayer and their child and tax dependent (dependent) listed on the MAP application will be considered as part of the budget group;
(c) in the case of an applicant or recipient married couple living together, each spouse will be included in the household of the other spouse, regardless of whether they expect to file a joint tax return, a separate tax return or whether one spouse expects to be claimed as a tax dependent by the other spouse;
(d) exceptions to tax filer rules: the following applicants or recipients will be treated as non-filers:
( i ) an applicant or a recipient other than a spouse or a biological, adopted, or step child who expect to be claimed as a tax dependent by another taxpayer outside of the household;
(ii) an applicant or a recipient under 19 who expect to be claimed by one parent as a tax dependent and are living with both parents but whose parents do not expect to file a joint tax return; and
(iii) an applicant or a recipient under 19 who expect to be claimed as a tax dependent by a non-custodial parent.
(2) individuals who neither file a tax return nor are claimed as a tax dependent: in the case of applicants or recipients who do not expect to file a federal tax return and do not expect to be claimed as a tax dependent for the taxable year in which a MAP category of eligibility is being made, or meet an exception to tax filer requirements in Paragraph (1) of Subsection B of 8.291.430.14 NMAC, the budget group consists of the applicant or recipient and, if living with the applicant or recipient:
(a) the applicant’s or recipient’s spouse;
(b) the applicant’s and recipient’s natural, adopted and step children under the age of 19; and
(c) in the case of applicants or recipients under the age of 19, the applicant’s or recipient’s natural , adopted and step parents and natural, adoptive and step siblings under the age of 19.
( 3) households may submit a MAP application that includes both filer and non-filers as defined in Subsections A and B of 8.291.430.14 NMAC; the budget group(s) will be organized using the filer and non-filer concepts, and eligibility will be established on an individual basis.
[8. 291.430.14 NMAC - Rp, 8.291.430.14 NMAC, 11/16/2015; A, 8/1/2024]
8.291.430.15 INCOME STANDARDS: Verification of income, both earned and unearned, is mandatory for all MAP categories of ACA related eligibility . Verification methods can be found at 8.291.410 NMAC.
A. All income will be calculated as defined by Section 36B of the Federal Tax Code to produce a MAGI. This amount is compared to the FPL for the appropriate MAP category of eligibility and household size.
B. MAGI is calculated using the methodologies defined in Section 36B(d)(2)(B) of the Federal Tax Code, with the following exceptions:
(1) an amount received as a lump sum is counted as income only in the month received except for qualified lottery and gambling winnings per Subsection D of 8.291.430.15 NMAC;
(2) scholarships, awards, or fellowship grants used for education purposes and not for living expenses are excluded from income;
(3) the following American Indian or Alaska native exceptions are excluded from income:
(a) distributions from Alaska native corporations and settlement trusts;
(b) distributions from any property held in trust, subject to federal restrictions, located within the most recent boundaries of a prior federal reservation, or otherwise under the supervision of the secretary of the interior;
(c) distributions and payments from rents, leases, rights of way, royalties, usage rights, or natural resource extraction and harvest from;
( i ) rights of ownership or possession in any lands described in Subsection B of 8.291.430.15 NMAC; or
(ii) federally protected rights regarding off-reservation hunting, fishing, gathering, or usage of natural resources;
(d) distributions resulting from real property ownership interests related to natural resources and improvements;
( i ) located on or near a reservation or within the most recent boundaries of a prior federal reservation; or
(ii) resulting from the exercise of federally-protected rights relating to such real property ownership interests.
(e) payments resulting from ownership interests in or usage rights to items that have unique religious, spiritual, traditional, or cultural significance or rights that support subsistence or a traditional lifestyle according to applicable tribal law or custom; and
(f) student financial assistance provided under the bureau of Indian affairs education programs.
C. Certain income of children and tax dependents: The following are not included in household income:
(1) The MAGI-based income of an applicant or recipient who is included in the household of their natural, adopted, or step parent and who is not expected to be required to file a tax return under Section 6012(a)(1) of the Internal Revenue Code for the taxable year in which a MAP category of eligibility is being determined, is not included in household income whether or not the applicant or recipient files a tax return.
(2) The MAGI-based income of an applicant’s or recipient’s dependent who is not expected to be required to file a tax return under Section 6012(a)(1) of the Internal Revenue Code for the taxable year in which a MAP category of eligibility is being determined is not included in the household income of the taxpayer whether or not such dependent files a tax return.
D. Qualified lottery and gambling winnings are included in MAGI-based income based on the following:
(1) Qualified lottery winnings are defined as winnings from sweepstakes, lottery, or pool described in section 4402 of the internal revenue code (which generally requires that these particular activities be conducted by a state agency or under the authority of state law), or winnings from a lottery operated by a multistate or multijurisdictional lottery association or tribe. Multijurisdictional lotteries include those that include multiple entities of government. Qualified lottery winnings apply to the single payout option. Lottery winnings paid out in installments are not considered qualified lottery winnings and are treated as recurring income that can be prorated over a twelve-month period to determine an average current monthly income for medicaid .
(2) Income that is received as a lump sum from monetary winnings from gambling is included in MAGI-based income. Gambling winnings include betting pools, wagers placed through bookmakers, slot machines, roulette wheels, dice tables, lotteries, bolita or number games, or the selling of chances therein including tribal winnings.
(3) Non-cash prizes, like a car or boat, are not counted as qualified lottery winnings or monetary winnings from gambling and are counted as lump sum income in the month received.
(4) Formula for counting qualified lottery or gambling winnings: For qualified winnings from lotteries or gambling occurring on or after January 1, 2018, the following formula applies for counting income:
(a) winnings less than $80,000 are counted in the month received;
(b) winnings of $80,000 but less than $90,000 are counted as income over two months with an equal amount counted in each month;
(c) for every additional $10,000 one month is added to the period over which total winnings are divided, in equal installments, and counted as income;
(d) the maximum period of time over which winnings may be counted is 120 months, which would apply for winnings of $1,260,000 and above. HCA in the notice of case action (NOCA) notifies individuals of the date on which the lottery or gambling winnings no longer will be counted for the purposes of medicaid eligibility; and
(e) the formula for counting winnings is applied separately to each instance of winnings.
(5) Lottery or gambling winnings count as MAGI-based income over multiple months only for the individual receiving the winnings in the household. For other individuals in the household, the winnings count only in the month received in determining their MAGI-based income eligibility.
(6) Verification of lottery winnings: HCA requires verification of lottery winnings, but will first access electronic data sources, if available, before requesting documentation.
(7) Hardship exemption: HCA allows for an exemption of the counting of lottery winnings if the applicant or recipient with the lottery winnings can demonstrate an undue medical hardship such that the applicant or recipient’s health or life would be endangered. An applicant or recipient must submit a written request along with supporting documentation. A decision regarding a medical hardship exemption will be made within 30 calendar days of receipt of the written request. Notice of the exemption decision will be mailed to the applicant or recipient. If an exemption is approved, then an eligibility determination will be made without counting lottery winnings. If an exemption is denied, then the applicant or recipient can request an HCA administrative hearing pursuant to 8.352.2 NMAC. Hardship exemption request information is contained in the NOCA.
E. Parent mentor compensation: A parent mentor is a parent or guardian of a medicaid eligible child who is trained to assist families with children who have no health insurance coverage with respect to improving the social determinants of the health of such children. Section 3004 of the HEALTHY KIDS Act excludes certain parent mentor compensation from the MAGI calculation. The disregard of parent mentor income applies only in the case of parent mentors working with a grantee organization under section 2113 of the Social Security Act. Nominal amounts paid as a stipend, wages, or other compensation for participation as a parent mentor in a grant-funded program under section 2113 of the Act are excluded from income. A nominal amount is defined as $1,600 per month. Parent mentor income above $1,600 per month is counted in the MAGI calculation.
F. Discharged student loan debt: Student loan debt that is discharged, forgiven or cancelled is taxable income to the borrower, and the amount of discharged debt is included in the MAGI-based income. Discharged student loan debt is not included in income (and not counted in the MAGI-based income) of a borrower for tax years 2018 through 2025 if the debt is discharged on account of the death or the permanent and total disability of the student. The borrower and the student may or may not be the same person. Student loan debt discharged under these circumstances is not counted as income in determining household income for other members of the borrower’s household.
G. Alimony received: Alimony payments under separation or divorce agreements finalized after December 31, 2018, or pre-existing agreements modified after December 31, 2018, are not included in the income of the recipient. For individuals with alimony agreements finalized on or before December 31, 2018, alimony continues to be included in the income of the recipient for the duration of the agreement unless or until the agreement is modified. Self-attestation is accepted for the verification of the date of execution of separation or divorce agreements that include the provision for alimony.
H. Alimony paid: Alimony payments under separation or divorce agreements finalized after December 31, 2018, or pre-existing agreements modified after December 31, 2018, are not deductible by the payer. For individuals with alimony agreements finalized on or before December 31, 2018, alimony payments continue to be deductible. Self-attestation is accepted for the verification of the date of execution of separation or divorce agreements that include the provision for alimony.
I. Moving expenses, including expenses incurred by the individual as well as reimbursements from an employer, are not deductible in calculating MAGI for tax years 2018 through 2025. Moving expenses are deductible for active duty members of the military who are ordered to move or change duty station.
J. Tuition and fees deduction: Effective January 1, 2018 the payment of tuition and fees for qualified education expenses for postsecondary education is not an allowable deduction in calculating MAGI.
[8. 291.430.15 NMAC - Rp, 8.291.430.15 NMAC, 11/16/2015; A, 12/1/2020; A, 8/1/2024]
8.291.430.16 RESOURCE STANDARDS: Resources as defined in 8.100.130 NMAC are not a factor of eligibility for a MAP category of ACA eligibility.
[8. 291.430.16 NMAC - Rp, 8.291.430.16 NMAC, 11/16/2015]
HISTORY OF 8.291.430 NMAC:
History of Repealed Material:
8.291.430 NMAC, Financial Responsibility Requirements, filed 9/17/2013 - Duration expired 12/31/2013.
8.291.430 NMAC, Financial Responsibility Requirements, filed 12/17/2013 - Repealed effective 11/16/2015.
TITLE 8 SOCIAL SERVICES
CHAPTER 292 MEDICAID ELIGIBILITY - PARENT CARETAKER
PART 400 RECIPIENT REQUIREMENTS
8.292.400.1 ISSUING AGENCY: New Mexico Health Care Authority.
[8.292.400.1 NMAC - Rp, 8.292.400.1 NMAC, 1/1/2014 ; A, 7/1/2024 ]
8.292.400.2 SCOPE: The rule applies to the general public .
[8.292.400.2 NMAC - Rp, 8.292.400.2 NMAC, 1/1/2014]
8.292.400.3 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 or by state statute. See Section 27-1-12 et seq . NMSA 1978. 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.
[8.292.400.3 NMAC - Rp , 8.292.400.3 NMAC, 1/1/ 2014 ; A, 7/1/2024 ]
8.292.400.4 DURATION: Permanent.
[8.292.400.4 NMAC - Rp, 8.292.400.4 NMAC, 1/1/2014]
8.292.400.5 EFFECTIVE DATE: January 1, 2014, unless a later date is cited at the end of a section.
[8.292.400.5 NMAC - Rp, 8.292.400.5 NMAC, 1/1/2014]
8.292.400.6 OBJECTIVE: The objective of this rule is to provide eligibility guidelines when determining eligibility for the medical assistance division (MAD) medicaid program and other health care programs it administers. Processes for establishing and maintaining this category of eligibility are found in the affordable care general provision chapter located at 8.291.400 NMAC through 8.291.430 NMAC.
[8.292.400.6 NMAC - Rp, 8.292.400.6 NMAC, 1/1/2014]
8.292.400.7 DEFINITIONS: Refer to 8.291.400.7 NMAC.
[8.292.400.7 NMAC - Rp, 8.292.400.7 NMAC, 1/1/2014]
8.292.400.8 MISSION: To transform lives. Working with our partners, we design and deliver innovative, high quality health and human services that improve the security and promote independence for New Mexicans in their communities.
[8.292.400.8 NMAC - Rp, 8.292.400.8 NMAC, 1/1/2014; A, 7/1/2021]
8.292.400.9 WHO CAN BE A RECIPIENT: To be eligible, an individual must meet specific eligibility requirements:
A. In accordance with 42 Code of Federal Regulations (CFR) 435.4 an individual must be a parent or caretaker relative defined as a relative of a dependent child by blood, adoption, or marriage with whom the child is living, who assumes primary responsibility for the child's care (as may, but is not required to, be indicated by claiming the child as a tax dependent for federal income tax purposes), and who is within the fifth degree of relationship per Subsection C of 8.291.410.12 NMAC.
B. In accordance with 42 CFR 435.4 a dependent child is defined as one who meets both of the following criteria:
(1) is under the age of 18, or;
(2) is age 18 and a full-time student in secondary school (or equivalent vocational or technical training), if before attaining age 19 the child may reasonably be expected to complete such school or training.
C. An individual who meets the eligibility requirements pursuant to 8.291.400 through 8.291.430 NMAC.
D. Prior to the parent caretaker individual becoming an eligible recipient, all children listed on an application must meet the following:
(1) be evaluated for eligibility for a medicaid program if not already eligible; or
(2) if not medicaid eligible, have current health insurance coverage that meets criteria as a qualified health plan.
[8.292.400.9 NMAC - Rp, 8.292.400.9 NMAC, 1/1/2014; A, 7/1/2021]
8.292.400.10 PARENT CARETAKER ASSISTANCE UNIT AND BUDGET GROUP: To be considered in a parent caretaker assistance unit, an individual must apply and be determined eligible. Individuals living with the parent caretaker who meet criteria in 8.291.430 NMAC are included in the budget group.
[8.292.400.10 NMAC - Rp, 8.292.400.10 NMAC, 1/1/2014]
HISTORY OF 8.292.400 NMAC :
History of Repealed Material:
8.292.400 NMAC, Recipient Requirements, filed 9/17/2013 - Duration expired 12/31/2013.
TITLE 8 SOCIAL SERVICES
CHAPTER 292 MEDICAID ELIGIBILITY - PARENT CARETAKER
PART 500 INCOME AND RESOURCE STANDARDS
8.292.500.1 ISSUING AGENCY: New Mexico Health Care Authority.
[8.292.500.1 NMAC - Rp, 8.292.500.1 NMAC, 1/1/2014 ; A, 7/1/2024 ]
8.292.500.2 SCOPE: The rule applies to the general public .
[8.292.500.2 NMAC - Rp, 8.292.500.2 NMAC, 1/1/2014]
8.292.500.3 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 or by state statute. See , Section 27-1-12 et seq . NMSA 1978. 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.
[8.292.500.3 NMAC - Rp , 8.292.500.3 NMAC, 1/1/ 2014 ; A, 7/1/2024 ]
8.292.500.4 DURATION: Permanent.
[8.292.500.4 NMAC - Rp, 8.292.500.4 NMAC, 1/1/2014]
8.292.500.5 EFFECTIVE DATE: January 1, 2014, unless a later date is cited at the end of a section.
[8.292.500.5 NMAC - Rp, 8.292.500.5 NMAC, 1/1/2014]
8.292.500.6 OBJECTIVE: The objective of this rule is to provide eligibility guidelines when determining eligibility for the medical assistance division (MAD) medicaid program and other health care programs it administers. Processes for establishing and maintaining this category of eligibility are found in the affordable care general provision chapter located at 8.291.400 NMAC through 8.291.430 NMAC.
[8.292.500.6 NMAC - Rp, 8.292.500.6 NMAC, 1/1/2014]
8.292.500.7 DEFINITIONS: Refer to 8.291.400.7 NMAC.
[8.292.500.7 NMAC - Rp, 8.292.500.7 NMAC, 1/1/2014]
8.292.500.8 MISSION: To transform lives. Working with our partners, we design and deliver innovative, high quality health and human services that improve the security and promote independence for New Mexicans in their communities.
[8.292.500.8 NMAC - Rp, 8.292.500.8 NMAC, 1/1/2014; A, 1/1/2022]
8.292.500.9 RESOURCE STANDARDS: There are no resource standards for this category of eligibility.
[8.292.500.9 NMAC - Rp, 8.292.500.9 NMAC, 1/1/2014]
8.292.500.10 INCOME STANDARD:
A. Financial eligibility: An individual's financial eligibility is based on the rules in this chapter and 8.291.430.11 NMAC.
B. Income test: In order to become eligible for parent caretaker medicaid , the total countable income of the budget group must be less than the income standard for parent caretaker eligibility at 8.291.430 NMAC.
[8.292.500.10 NMAC - Rp, 8.292.500.10 NMAC, 1/1/2014]
8.292.500.11 AVAILABLE INCOME: Determination of eligibility for the assistance unit is made by considering income that is available to the assistance unit and budget group. The amount of countable income is determined pursuant to 8.291.430 NMAC .
[8.292.500.11 NMAC - Rp, 8.292.500.11 NMAC, 1/1/2014]
8.292.500.12 INCOME ELIGIBILITY: Income methodology is based on modified adjusted gross income (MAGI) in accordance with 42 Code of Federal Regulations (CFR) 435.603. Per 42 CFR 435.603(h)(2) HSD bases financial eligibility on current monthly household income and family size. Current monthly household income is defined as a 30-day period. If an amount of income is received less frequently than monthly, that amount is converted by dividing the total income by the number of months the income is intended to cover.
[8.292.500.12 NMAC - Rp, 8.292.500.12 NMAC, 1/1/2014; A, 1/1/2022]
8.292.500.13 DISREGARDS: Once a MAGI is calculated, no disregard will be given unless the individual is in receipt of medicare or has reached the age of 65, in which case the household will receive an income disregard in accordance with 8.291.430 NMAC.
[8.292.500.13 NMAC - Rp, 8.292.500.13 NMAC, 1/1/2014]
HISTORY OF 8.292.500 NMAC:
History of Repealed Material:
8.292.500 NMAC, Income and Resource Standards, filed 9/17/2013 - Duration expired 12/31/2013.
TITLE 8 SOCIAL SERVICES
CHAPTER 292 MEDICAID ELIGIBILITY - PARENT CARETAKER
PART 600 BENEFIT DESCRIPTION
8.292.600.1 ISSUING AGENCY: New Mexico Health Care Authority.
[8.292.600.1 NMAC - Rp, 8.292.600.1 NMAC, 1/1/2019 ; A, 7/1/2024 ]
8.292.600.2 SCOPE: The rule applies to the general public .
[8.292.600.2 NMAC - Rp, 8.292.600.2 NMAC, 1/1/2019]
8.292.600.3 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 or by state statute. See Section 27-1-12 et seq ., NMSA 1978. 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.
[8.292.600.3 NMAC - Rp, 8.292.600.3 NMAC, 1/1/2019; A, 7/1/2024]
8.292.600.4 DURATION: Permanent.
[8.292.600.4 NMAC - Rp, 8.292.600.4 NMAC, 1/1/2019]
8.292.600.5 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.
[8.292.600.5 NMAC - Rp, 8.292.600.5 NMAC, 1/1/2019]
8.292.600.6 OBJECTIVE: The objective of this rule is to provide eligibility guidelines when determining eligibility for the medical assistance division (MAD) medicaid program and other health care programs it administers. Processes for establishing and maintaining this category of eligibility are found in the affordable care general provision chapter located at 8.291.400 NMAC through 8.291.430 NMAC.
[8.292.600.6 NMAC - Rp, 8.292.600.6 NMAC, 1/1/2019]
8.292.600.7 DEFINITIONS: Refer to 8.291.400.7 NMAC.
[8.292.600.7 NMAC - Rp, 8.292.600.7 NMAC, 1/1/2019]
8.292.600.8 [ RESERVED ]
[8.292.600.8 NMAC - Rp, 8.292.600.8 NMAC, 1/1/2019]
8.292.600.9 BENEFIT DESCRIPTION: This medicaid category provides the full range of medicaid -covered services for individuals considered a parent caretaker.
[8.292.600.9 NMAC - Rp, 8.292.600.9 NMAC, 1/1/2019]
8.292.600.10 BENEFIT DETERMINATION: The HSD income support division (ISD) determines initial and ongoing eligibility. Refer to affordable care general provision chapters located at 8.291.400 through 8.291.430 NMAC for eligibility requirements. Retroactive medicaid coverage is provided in accordance with 8.200.400.14 NMAC.
[8.292.600.10 NMAC - Rp, 8.292.600.10 NMAC, 1/1/2019]
8.292.600.11 PERIODIC REDETERMINATIONS OF ELIGIBILITY:
A. A redetermination of eligibility is conducted in accordance with 8.291.410 NMAC.
B. All changes that may affect eligibility must be reported within 10 calendar days of the date of the change as detailed in 8.291.400 NMAC.
[8.292.600.11 NMAC - Rp, 8.292.600.11 NMAC, 1/1/2019]
HISTORY OF 8.292.600 NMAC:
History of Repealed Material:
8.292.600 NMAC, Benefit Description, filed 9/17/2013 - Duration expired 12/31/2013.
8.292.600 NMAC, Benefit Description, filed 12/17/2013 – Repeal effective 1/1/2019.
TITLE 8 SOCIAL SERVICES
CHAPTER 293 MEDICAID ELIGIBILITY - PREGNANT WOMEN
PART 400 RECIPIENT REQUIREMENTS
8.293.400.1 ISSUING AGENCY: New Mexico Health Care Authority.
[8.293.400.1 NMAC - Rp, 8.293.400.1 NMAC, 1/1/2014 ; A, 7/1/2024 ]
8.293.400.2 SCOPE: The rule applies to the general public .
[8.293.400.2 NMAC - Rp, 8.293.400.2 NMAC, 1/1/2014]
8.293.400.3 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 or by state statute. See , Section 27-1-12 et seq . NMSA 1978. 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.
[8.293.400.3 NMAC - Rp , 8.293.400.3 NMAC, 1/1/ 2014 ; A, 7/1/2024 ]
8.293.400.4 DURATION: Permanent.
[8.293.400.4 NMAC - Rp, 8.293.400.4 NMAC, 1/1/2014]
8.293.400.5 EFFECTIVE DATE: January 1, 2014, unless a later date is cited at the end of a section.
[8.293.400.5 NMAC - Rp, 8.293.400.5 NMAC, 1/1/2014]
8.293.400.6 OBJECTIVE: The objective of this rule is to provide eligibility guidelines when determining eligibility for the medical assistance division (MAD) medicaid program and other health care programs it administers. Processes for establishing and maintaining this category of eligibility are found in the affordable care general provision chapter located at 8.291.400 NMAC through 8.291.430 NMAC.
[8.293.400.6 NMAC - Rp, 8.293.400.6 NMAC, 1/1/2014]
8.293.400.7 DEFINITIONS: Refer to 8.291.400.7 NMAC.
[8.293.400.7 NMAC - Rp, 8.293.400.7 NMAC, 1/1/2014]
8.293.400.8 [RESERVED]
[8.293.400.8 NMAC - Rp, 8.293.400.8 NMAC, 1/1/2014; A, 10/1/2017]
8.293.400.9 WHO CAN BE A RECIPIENT: To be eligible, a woman must meet the following eligibility requirements:
A. Per 42 CFR 435.956(e) HSD accepts self-attestation of pregnancy unless HSD has reason to believe the information is questionable as defined in 8.100.130.12 NMAC.
B. a woman who meets all ACA eligibility requirements pursuant to 8.291.400 through 8.291.430 NMAC; and
C. the existence of creditable health insurance is not a disqualifying factor.
[8.293.400.9 NMAC - Rp, 8.293.400.9 NMAC, 1/1/2014; A, 10/1/2017]
8.293.400.10 BASIS FOR DEFINING THE ASSISTANCE UNIT AND BUDGET GROUP: At the time of application, an applicant or recipient and the department shall identify everyone who is to be considered for inclusion in the assistance unit and budget group as defined in 8.291.430 NMAC. Each member of the assistance unit and budget group, including any unborn child(ren), is counted as one in the household size.
[8.293.400.10 NMAC - Rp, 8.293.400.10 NMAC, 1/1/2014]
8.293.400.11 PREGNANCY ASSISTANCE UNIT: The assistance unit is the pregnant woman who applies for medicaid and for whom an eligibility determination is made.
[8.293.400.11 NMAC - Rp, 8.293.400.11 NMAC, 1/1/2014]
8.293.400.12 BUDGET GROUP: The budget group is established in accordance with 8.291.430 NMAC .
[8.293.400.12 NMAC - Rp, 8.293.400.12 NMAC, 1/1/2014]
HISTORY OF 8.293.400 NMAC :
History of Repealed Material:
8.293.400 NMAC, Recipient Requirements, filed 9/17/2013 - Duration expired 12/31/2013.
TITLE 8 SOCIAL SERVICES
CHAPTER 293 MEDICAID ELIGIBILITY - PREGNANT WOMEN
PART 500 INCOME AND RESOURCE STANDARDS
8.293.500.1 ISSUING AGENCY: New Mexico Health Care Authority.
[8.293.500.1 NMAC - Rp, 8.293.500.1 NMAC, 1/1/2014 ; A, 7/1/2024 ]
8.293.500.2 SCOPE: The rule applies to the general public .
[8.293.500.2 NMAC - Rp, 8.293.500.2 NMAC, 1/1/2014]
8.293.500.3 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 or by state statute. See Section 27-1-12 et seq . NMSA 1978. 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.
[8.293.500.3 NMAC - Rp , 8.293.500.3 NMAC, 1/1/ 2014 ; A, 7/1/2024 ]
8.293.500.4 DURATION: Permanent.
[8.293.500.4 NMAC - Rp, 8.293.500.4 NMAC, 1/1/2014]
8.293.500.5 EFFECTIVE DATE: January 1, 2014, unless a later date is cited at the end of a section.
[8.293.500.5 NMAC - Rp, 8.293.500.5 NMAC, 1/1/2014]
8.293.500.6 OBJECTIVE: The objective of this rule is to provide eligibility guidelines when determining eligibility for the medical assistance division (MAD) medicaid program and other health care programs it administers. Processes for establishing and maintaining this category of eligibility are found in the affordable care general provision chapter located at 8.291.400 NMAC through 8.291.430 NMAC.
[8.293.500.6 NMAC - Rp, 8.293.500.6 NMAC, 1/1/2014]
8.293.500.7 DEFINITIONS: Refer to 8.291.400.7 NMAC.
[8.293.500.7 NMAC - Rp, 8.293.500.7 NMAC, 1/1/2014]
8.293.500.8 MISSION: To transform lives. Working with our partners, we design and deliver innovative, high quality health and human services that improve the security and promote independence for New Mexicans in their communities.
[8.293.500.8 NMAC - Rp, 8.293.500.8 NMAC, 1/1/2014; A, 1/1/2022]
8.293.500.9 RESOURCE STANDARDS: Resources are not an eligibility factor for this category of eligibility.
[8.293.500.9 NMAC - Rp, 8.293.500.9 NMAC, 1/1/2014]
8.293.500.10 INCOME STANDARD:
A. Financial eligibility: An applicant’s financial eligibility is based on the rules in this chapter and 8.291.430 NMAC.
B. Income test: In order to become eligible for pregnant women medicaid , the total countable income of the budget group must be less than the income standard for pregnant woman eligibility found in 8.291.430 NMAC .
[8.293.500.10 NMAC - Rp, 8.293.500.10 NMAC, 1/1/2014; A, 7/1/2014; A, 5/1/2015]
8.293.500.11 AVAILABLE INCOME: Determination of eligibility for the assistance unit is made by considering income that is available to the assistance unit and budget group. The amount of countable income is determined pursuant to 8.291.430 NMAC .
[8.293.500.11 NMAC - Rp, 8.293.500.11 NMAC, 1/1/2014]
8.293.500.12 INCOME ELIGIBILITY: Income methodology is based on modified adjusted gross income (MAGI) in accordance with 42 Code of Federal Regulations (CFR) 435.603. Per 42 CFR 435.603(h)(2) HSD bases financial eligibility on current monthly household income and family size. Current monthly household income is defined as a 30-day period. If an amount of income is received less frequently than monthly, that amount is converted by dividing the total income by the number of months the income is intended to cover.
[8.293.500.12 NMAC - Rp, 8.293.500.12 NMAC, 1/1/2014; A, 1/1/2022]
8.293.500.13 DISREGARDS: An income disregard according to 8.291.430 NMAC will be given only to an applicant whose countable modified adjusted gross income (MAGI) income is at or above the income standard for a pregnant for the size of the budget group.
[8.293.500.13 NMAC - Rp, 8.293.500.13 NMAC, 1/1/2014; A, 7/1/2014; A, 5/1/2015]
HISTORY OF 8.293.500 NMAC:
History of Repealed Material:
8.293.500 NMAC, Income and Resource Standards, filed 9/7/2013 - Duration expired 12/31/2013.
TITLE 8 SOCIAL SERVICES
CHAPTER 293 MEDICAID ELIGIBILITY - PREGNANT WOMEN
PART 600 BENEFIT DESCRIPTION
8.293.600.1 ISSUING AGENCY: New Mexico Health Care Authority.
[8.293.600.1 NMAC - Rp, 8.293.600.1 NMAC, 1/1/2019 ; A, 7/1/2024 ]
8.293.600.2 SCOPE: The rule applies to the general public .
[8.293.600.2 NMAC - Rp, 8.293.600.2 NMAC, 1/1/2019 ]
8.293.600.3 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 or by state statute. See Section 27-1-12 et seq ., NMSA 1978. 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.
[8.293.600.3 NMAC - Rp, 8.293.600.3 NMAC, 1/1/2019; A, 7/1/2024 ]
8.293.600.4 DURATION: Permanent.
[8.293.600.4 NMAC - Rp, 8.293.600.4 NMAC, 1/1/2019 ]
8.293.600.5 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.
[8.293.600.5 NMAC - Rp, 8.293.600.5 NMAC, 1/1/2019 ]
8.293.600.6 OBJECTIVE: The objective of this rule is to provide eligibility guidelines when determining eligibility for the medical assistance division (MAD) medicaid program and other health care programs it administers. Processes for establishing and maintaining this category of eligibility are found in the affordable care general provision chapter located at 8.291.400 NMAC through 8.291.430 NMAC.
[8.293.600.6 NMAC - Rp, 8.293.600.6 NMAC, 1/1/2019 ]
8.293.600.7 DEFINITIONS: Refer to 8.291.400.7 NMAC.
[8.293.600.7 NMAC - Rp, 8.293.600.7 NMAC, 1/1/2019 ]
8.293.600.8 MISSION: To transform lives. Working with our partners, we design and deliver innovative, high quality health and human services that improve the security and promote independence for New Mexicans in their communities.
[8.293.600.8 NMAC - Rp, 8.293.600.8 NMAC, 1/1/2019; A, 4/5/2022 ]
8.293.600.9 BENEFIT DESCRIPTION: This category provides the full range of medicaid coverage for the duration of the pregnancy and for the 12-month postpartum period.
[8.293.600.9 NMAC - Rp, 8.293.600.9 NMAC, 1/1/2019; A, 4/5/2022 ]
8.293.600.10 BENEFIT DETERMINATION: The HSD income support division (ISD) determines initial and ongoing eligibility. Refer to affordable care general provision chapters located at 8.291.400 through 8.291.430 NMAC for eligibility requirements. An individual eligible for pregnant women medicaid remains eligible throughout the pregnancy and for a 12-month postpartum period in accordance with 8.291.400.14 NMAC. Retroactive medicaid coverage is provided in accordance with 8.200.400.14 NMAC.
[8.293.600.10 NMAC - Rp, 8.293.600.10 NMAC, 1/1/2019; A, 4/5/2022 ]
8.293.600.11 REPORTING REQUIREMENTS: All changes that may affect eligibility must be reported within 10 calendar days of the date of the change as detailed in 8.291.400 NMAC.
[8.293.600.11 NMAC - Rp, 8.293.600.11 NMAC, 1/1/2019 ]
HISTORY OF 8.293.600 NMAC:
History of Repealed Material:
8.293.600 NMAC, Benefit Description, filed 9/17/2013 - Duration expired 12/31/2013.
8.293.600 NMAC, Benefit Description, filed 12/17/2013 - Repealed effective 1/1/2019.
TITLE 8 SOCIAL SERVICES
CHAPTER 294 MEDICAID ELIGIBILITY - PREGNANCY-RELATED SERVICES
PART 400 RECIPIENT REQUIREMENTS
8.294.400.1 ISSUING AGENCY: New Mexico Health Care Authority.
[8.294.400.1 NMAC - Rp, 8.294.400.1 NMAC, 1/1/2014 ; A, 7/1/2024 ]
8.294.400.2 SCOPE: The rule applies to the general public .
[8.294.400.2 NMAC - Rp, 8.294.400.2 NMAC, 1/1/2014]
8.294.400.3 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 or by state statute. See, Section 27-1-12 et seq. NMSA 1978. 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.
[8.294.400.3 NMAC - Rp , 8.294.400.3 NMAC, 1/1/ 2014 ; A, 7/1/2024 ]
8.294.400.4 DURATION: Permanent.
[8.294.400.4 NMAC - Rp, 8.294.400.4 NMAC, 1/1/2014]
8.294.400.5 EFFECTIVE DATE: January 1, 2014, unless a later date is cited at the end of a section.
[8.294.400.5 NMAC - Rp, 8.294.400.5 NMAC, 1/1/2014]
8.294.400.6 OBJECTIVE: The objective of this rule is to provide eligibility guidelines when determining eligibility for the medical assistance division (MAD) medicaid program and other health care programs it administers. Processes for establishing and maintaining this category of eligibility are found in the affordable care general provision chapter located at 8.291.400 NMAC through 8.291.430 NMAC.
[8.294.400.6 NMAC - Rp, 8.294.400.6 NMAC, 1/1/2014]
8.294.400.7 DEFINITIONS: Refer to 8.291.400.7 NMAC.
[8.294.400.7 NMAC - Rp, 8.294.400.7 NMAC, 1/1/2014]
8.294.400.8 [RESERVED]
[8.294.400.8 NMAC - Rp, 8.294.400.8 NMAC, 1/1/2014; A, 10/1/2017]
8.294.400.9 WHO CAN BE A RECIPIENT: To be eligible, a woman must meet the following eligibility requirements:
A. Per 42 CFR 435.956(e) HSD accepts self-attestation of pregnancy unless HSD has reason to believe the information is questionable as defined in 8.100.130.12 NMAC.
B. a woman who meets all affordable care act (ACA) eligibility requirements pursuant to 8.291.400 through 8.291.430 NMAC; and
C. the existence of creditable health insurance is not a disqualifying factor.
[8.294.400.9 NMAC - Rp, 8.294.400.9 NMAC, 1/1/2014; A, 10/1/2017]
8.294.400.10 BASIS FOR DEFINING THE ASSISTANCE UNIT AND BUDGET GROUP: At time of application, an applicant or recipient and the department shall identify everyone who is to be considered for inclusion in the assistance unit and budget group as defined in 8.291.430 NMAC. Each member of the assistance unit and budget group, including any unborn child(ren), is counted as one in the household size.
[8.294.400.10 NMAC - Rp, 8.294.400.10 NMAC, 1/1/2014]
8.294.400.11 PREGNANCY ASSISTANCE UNIT: The assistance unit is the pregnant woman who applies for medicaid and for whom an eligibility determination is made.
[8.294.400.11 NMAC - Rp, 8.294.400.11 NMAC, 1/1/2014]
8.294.400.12 BUDGET GROUP: The budget group is established in accordance with 8.291.430 NMAC.
[8.294.400.12 NMAC - Rp, 8.294.400.12 NMAC, 1/1/2014]
HISTORY OF 8.294.400 NMAC :
History of Repealed Material:
8.294.400 NMAC, Recipient Requirements, filed 9/17/2013 - Duration expired 12/31/2013.
TITLE 8 SOCIAL SERVICES
CHAPTER 294 MEDICAID ELIGIBILITY - PREGNANCY-RELATED SERVICES
PART 500 INCOME AND RESOURCE STANDARDS
8.294.500.1 ISSUING AGENCY: New Mexico Health Care Authority.
[8.294.500.1 NMAC - Rp, 8.294.500.1 NMAC, 1/1/2014 ; A, 7/1/2024 ]
8.294.500.2 SCOPE: The rule applies to the general public .
[8.294.500.2 NMAC - Rp, 8.294.500.2 NMAC, 1/1/2014]
8.294.500.3 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 or by state statute. See , Section 27-1-12 et seq . NMSA 1978. 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.
[8.294.500.3 NMAC - Rp , 8.294.500.3 NMAC, 1/1/2014 ; A, 7/1/2024 ]
8.294.500.4 DURATION: Permanent.
[8.294.500.4 NMAC - Rp, 8.294.500.4 NMAC, 1/1/2014]
8.294.500.5 EFFECTIVE DATE: January 1, 2014, unless a later date is cited at the end of a section.
[8.294.500.5 NMAC - Rp, 8.294.500.5 NMAC, 1/1/2014]
8.294.500.6 OBJECTIVE: The objective of this rule is to provide eligibility guidelines when determining eligibility for the medical assistance division (MAD) medicaid program and other health care programs it administers. Processes for establishing and maintaining this category of eligibility are found in the affordable care general provision chapter located at 8.291.400 NMAC through 8.291.430 NMAC.
[8.294.500.6 NMAC - Rp, 8.294.500.6 NMAC, 1/1/2014]
8.294.500.7 DEFINITIONS: Refer to 8.291.400.7 NMAC.
[8.294.500.7 NMAC - Rp, 8.294.500.7 NMAC, 1/1/2014]
8.294.500.8 MISSION: To transform lives. Working with our partners, we design and deliver innovative, high quality health and human services that improve the security and promote independence for New Mexicans in their communities.
[8.294.500.8 NMAC - Rp, 8.294.500.8 NMAC, 1/1/2014; A, 1/1/2022]
8.294.500.9 RESOURCE STANDARDS: Resources are not an eligibility factor for this category of eligibility.
[8.294.500.9 NMAC - Rp, 8.294.500.9 NMAC, 1/1/2014]
8.294.500.10 INCOME STANDARD :
A. Financial eligibility: An individual's financial eligibility is based on the rules in this chapter and 8.291.430 NMAC.
B. Income test: In order to become eligible for pregnancy medicaid , the total countable income of the budget group must be less than two hundred and fifty percent of the federal poverty guidelines found at 8.291.430 NMAC .
[8.294.500.10 NMAC - Rp, 8.294.500.10 NMAC, 1/1/2014; A, 1/1/2022]
8.294.500.11 AVAILABLE INCOME: Determination of eligibility for the assistance unit is made by considering income that is available to the assistance unit and budget group. The amount of countable income is determined pursuant to 8.291.430 NMAC .
[8.294.500.11 NMAC - Rp, 8.294.500.11 NMAC, 1/1/2014]
8.294.500.12 INCOME ELIGIBILITY: Income methodology is based on modified adjusted gross income (MAGI) in accordance with 42 Code of Federal Regulations (CFR) 435.603. Per 42 CFR 435.603(h)(2) HSD bases financial eligibility on current monthly household income and family size. Current monthly household income is defined as a 30-day period. If an amount of income is received less frequently than monthly, that amount is converted by dividing the total income by the number of months the income is intended to cover.
[8.294.500.12 NMAC - Rp, 8.294.500.12 NMAC, 1/1/2014; A, 1/1/2022]
8.294.500.13 DISREGARDS: An income disregard according to 8.291.430 NMAC will be given only to individuals whose countable MAGI income is at or above two hundred and fifty percent of the federal poverty level for the size of the budget group.
[8.294.500.13 NMAC - Rp, 8.294.500.13 NMAC, 1/1/2014; A, 1/1/2022]
HISTORY OF 8.294.500 NMAC:
History of Repealed Material:
8.294.500 NMAC, Income and Resource Standards, filed 9/17/2013 - Duration expired 12/31/2013.
TITLE 8 SOCIAL SERVICES
CHAPTER 294 MEDICAID ELIGIBILITY - PREGNANCY-RELATED SERVICES
PART 600 BENEFIT DESCRIPTION
8.294.600.1 ISSUING AGENCY: New Mexico Health Care Authority.
[8.294.600.1 NMAC - Rp, 8.294.600.1 NMAC, 1/1/2019 ; A, 7/1/2024 ]
8.294.600.2 SCOPE: The rule applies to the general public .
[8.294.600.2 NMAC - Rp, 8.294.600.2 NMAC, 1/1/2019]
8.294.600.3 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 or by state statute. See Section 27-1-12 et seq ., NMSA 1978. 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.
[8.294.600.3 NMAC - Rp, 8.294.600.3 NMAC, 1/1/2019; A, 7/1/2024]
8.294.600.4 DURATION: Permanent.
[8.294.600.4 NMAC - Rp, 8.294.600.4 NMAC, 1/1/2019]
8.294.600.5 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.
[8.294.600.5 NMAC - Rp, 8.294.600.5 NMAC, 1/1/2019]
8.294.600.6 OBJECTIVE: The objective of this rule is to provide eligibility guidelines when determining eligibility for the medical assistance division (MAD) medicaid program and other health care programs it administers. Processes for establishing and maintaining this category of eligibility are found in the affordable care general provision chapter located at 8.291.400 NMAC through 8.291.430 NMAC.
[8.294.600.6 NMAC - Rp, 8.294.600.6 NMAC, 1/1/2019]
8.294.600.7 DEFINITIONS: Refer to 8.291.400.7 NMAC.
[8.294.600.7 NMAC - Rp, 8.294.600.7 NMAC, 1/1/2019]
8.294.600.8 MISSION : To transform lives. Working with our partners, we design and deliver innovative, high quality health and human services that improve the security and promote independence for New Mexicans in their communities.
[8.294.600.8 NMAC - Rp, 8.294.600.8 NMAC, 1/1/2019; A, 4/5/2022]
8.294.600.9 BENEFIT DESCRIPTION: This category provides the full range of Medicaid coverage for the duration of the pregnancy and for the 12-month postpartum period.
[8.294.600.9 NMAC - Rp, 8.294.600.9 NMAC, 1/1/2019; A, 4/5/2022]
8.294.600.10 BENEFIT DETERMINATION: The HSD income support division (ISD) determines initial and ongoing eligibility. Refer to affordable care general provision chapters located at 8.291.400 through 8.291.430 NMAC for eligibility requirements. An individual eligible for pregnancy-related services medicaid remains eligible throughout the pregnancy and for a 12-month postpartum period in accordance with 8.291.400.14 NMAC. Retroactive medicaid coverage is provided in accordance with 8.200.400.14 NMAC.
[8.294.600.10 NMAC - Rp, 8.294.600.10 NMAC, 1/1/2019; A, 4/5/2022]
8.294.600.11 REPORTING REQUIREMENTS: All changes that may affect eligibility must be reported within 10 calendar days of the date of the change as detailed in 8.291.400 NMAC.
[8.292.600.11 NMAC - Rp, 8.294.600.11 NMAC, 1/1/2019]
HISTORY OF 8.294.600 NMAC:
History of Repealed Material:
8.294.600 NMAC, Benefit Description, filed 9/17/2013 - Duration expired 12/31/2013.
8.294.600 NMAC, Benefit Description, filed 12/17/2013 – Repealed effective 1/1/2019.
TITLE 8 SOCIAL SERVICES
CHAPTER 295 MEDICAID ELIGIBILITY - CHILDREN UNDER 19
PART 400 RECIPIENT REQUIREMENTS
8.295.400 .1 ISSUING AGENCY: New Mexico Health Care Authority.
[8.295.400.1 NMAC - Rp, 8.295.400.1 NMAC, 1/1/2014 ; A,7/1/2024 ]
8.295.400 .2 SCOPE: The rule applies to the general public .
[8.295.400.2 NMAC - Rp, 8.295.400.2 NMAC, 1/1/2014]
8.295.400 .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 and XXI of the Social Security Act as amended or by state statute. See Section 27-1-12 et seq . NMSA 1978. 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.
[8.295.400.3 NMAC - Rp , 8.295.400.3 NMAC, 1/1/ 2014 ; A,7/1/2024 ]
8.295.400 .4 DURATION: Permanent.
[8.295.400.4 NMAC - Rp, 8.295.400.4 NMAC, 1/1/2014]
8.295.400 .5 EFFECTIVE DATE: January 1, 2014, unless a later date is cited at the end of a section.
[8.295.400.5 NMAC - Rp, 8.295.400.5 NMAC, 1/1/2014]
8.295.400 .6 OBJECTIVE: The objective of this rule is to provide eligibility guidelines when determining eligibility for the medical assistance division (MAD) medicaid program and other health care programs it administers. Processes for establishing and maintaining this category of eligibility are found in the affordable care general provision chapter located at 8.291.400 NMAC through 8.291.430 NMAC.
[8.295.400.6 NMAC - Rp, 8.295.400.6 NMAC, 1/1/2014]
8.295.400 .7 DEFINITIONS: Refer to 8.291.400.7 NMAC.
[8.295.400.7 NMAC - Rp, 8.295.400.7 NMAC, 1/1/2014]
8.295.400 .8 MISSION: 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.
[8.295.400.8 NMAC - Rp, 8.295.400.8 NMAC, 1/1/2014]
8.295.400.9 WHO CAN BE A RECIPIENT: To be eligible, an applicant must meet specific medical assistance programs (MAP) requirements:
A. an individual under 19 years of age; and
B. an individual who meets Affordable Care Act (ACA) eligibility requirements pursuant to 8.291.400 through 2.291.430 NMAC.
[8.295.400.9 NMAC - Rp, 8.295.400.9 NMAC, 1/1/2014; A, 5/1/2015]
8.295.400.10 BASIS FOR DEFINING THE ASSISTANCE UNIT AND BUDGET GROUP: To be considered in a child assistance unit, an individual must apply and be determined eligible. Individuals living with the applicant who meet criteria in 8.291.430 NMAC are included in the budget group.
[8.295.400.10 NMAC - Rp, 8.295.400.10 NMAC, 1/1/2014; A, 5/1/2015]
8.295.400.11 CHILDRENS HEALTH INSURANCE PROGRAM (CHIP):
A. A budget group that includes the applicant and has countable income between the following federal income poverty limits (FPL) is considered to be eligible for the CHIP:
(1) if the applicant in the assistance unit is under the age of six and the assistance unit and budget group’s countable income is between two hundred-forty and three hundred percent of FPL for the countable household size; or
(2) if the assistance unit consists of the applicant age six or over and the assistance unit’s and budget group’s countable income is between one hundred-ninety and two hundred-forty percent of FPL for the countable household size.
B. In order to be eligible for CHIP, the applicant in the assistance unit cannot have other qualified health plan (QHP) coverage. Individuals who have voluntarily dropped a QHP will be eligible for inclusion in the assistance unit in the month the individual no longer has a QHP.
[8.295.400.11 NMAC - Rp, 8.295.400.11 NMAC, 1/1/2014; A, 5/1/2015]
HISTORY OF 8.295.400 NMAC :
History of Repealed Material:
8.295.400 NMAC, Recipient Requirements, filed 9/17/2013 - Duration expired 12/31/2013.
TITLE 8 SOCIAL SERVICES
CHAPTER 295 MEDICAID ELIGIBILITY - CHILDREN UNDER 19
PART 500 INCOME AND RESOURCE STANDARDS
8.295.500.1 ISSUING AGENCY: New Mexico Health Care Authority.
[8.295.500.1 NMAC - Rp, 8.295.500.1 NMAC, 1/1/2019 ; A, 7/1/2024 ]
8.295.500.2 SCOPE: The rule applies to the general public .
[8.295.500.2 NMAC - Rp, 8.295.500.2 NMAC, 1/1/2014]
8.295.500.3 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 and XXI of the Social Security Act as amended or by state statute. See Section 27-1-12 et seq ., NMSA 1978. 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.
[8.295.500.3 NMAC - Rp, 8.295.500.3 NMAC, 1/1/2019; A, 7/1/2024]
8.295.500.4 DURATION: Permanent.
[8.295.500.4 NMAC - Rp, 8.295.500.4 NMAC, 1/1/2014]
8.295.500.5 EFFECTIVE DATE: January 1, 2014, unless a later date is cited at the end of a section.
[8.295.500.5 NMAC - Rp, 8.295.500.5 NMAC, 1/1/2014]
8.295.500.6 OBJECTIVE: The objective of this rule is to provide eligibility guidelines when determining eligibility for the medical assistance division (MAD) medicaid program and other health care programs it administers. Processes for establishing and maintaining this category of eligibility are found in the affordable care general provision chapter located at 8.291.400 NMAC through 8.291.430 NMAC.
[8.295.500.6 NMAC - Rp, 8.295.500.6 NMAC, 1/1/2014]
8.295.500.7 DEFINITIONS: Refer to 8.291.400.7 NMAC.
[8.295.500.7 NMAC - Rp, 8.295.500.7 NMAC, 1/1/2014]
8.295.500.8 MISSION: To transform lives. Working with our partners, we design and deliver innovative, high quality health and human services that improve the security and promote independence for New Mexicans in their communities.
[8.295.500.8 NMAC - Rp, 8.295.500.8 NMAC, 1/1/2014; A, 1/1/2022]
8.295.500.9 RESOURCE STANDARDS: Resources are not an eligibility factor for this category of eligibility.
[8.295.500.9 NMAC - Rp, 8.295.500.9 NMAC, 1/1/2014]
8.295.500.10 INCOME STANDARD:
A. Financial eligibility: An individual's financial eligibility is based on the rules in this chapter and 8.291.430 NMAC.
B. Income test: In order to become eligible for children’s medicaid , the total countable income of the budget group must be less than the income standard for eligibility found at 8.291.430 NMAC.
(1) If the assistance unit consists of a child under the age of six, the assistance unit and budget group’s countable income must be less than three hundred percent of FPL for the countable household size.
(2) If the assistance unit consists of a child age six to age 19, the assistance unit and budget group’s countable income must be less than two hundred and forty percent of FPL for the countable household size.
[8.295.500.10 NMAC - Rp, 8.295.500.10 NMAC, 1/1/2014; A, 1/1/2022 ]
8.295.500.11 INCOME ELIGIBILITY: Income methodology is based on modified adjusted gross income (MAGI) in accordance with 42 Code of Federal Regulations (CFR) 435.603. Per 42 CFR 435.603(h)(2) HSD bases financial eligibility on current monthly household income and family size. Current monthly household income is defined as a 30-day period. If an amount of income is received less frequently than monthly, that amount is converted by dividing the total income by the number of months the income is intended to cover.
[8.295.500.11 NMAC - Rp, 8.295.500.11 NMAC, 1/1/2014; A, 1/1/2022 ]
8.295.500.12 DISREGARDS: An income disregard according to 8.291.430 NMAC, will be given only to the following:
A. individuals whose budget group’s countable MAGI income is at or above one hundred and ninety percent of the FPL if the assistance unit consists of a child age six to age 19, or two hundred and forty percent of the FPL if the assistance unit consists of a child under the age of six; when a child has a QHP, an income disregard will be given when the existence of the QHP makes the individual ineligible due to CHIP requirements found at 8.295.400 NMAC; or
B. individuals whose budget group’s countable MAGI income is at or above two hundred and forty percent of the FPL if the assistance unit consists of a child age six to age 19, or three hundred percent of the FPL if the assistance unit consists of a child under the age of six.
[8.295.500.12 NMAC - Rp, 8.295.500.12 NMAC, 1/1/2014; A, 1/1/2022]
HISTORY OF 8.295.500 NMAC:
History of Repealed Material:
8.295.500 NMAC, Income and Resource Standards, filed 9/17/2013 - Duration expired 12/31/2013.
TITLE 8 SOCIAL SERVICES
CHAPTER 295 MEDICAID ELIGIBILITY - CHILDREN UNDER 19
PART 600 BENEFIT DESCRIPTION
8.295.600.1 ISSUING AGENCY : New Mexico Health Care Authority.
[8.295.600.1 NMAC - Rp, 8.295.600.1 NMAC, 1/1/2019 ; A,7/1/2024 ]
8.295.600.2 SCOPE: The rule applies to the general public .
[8.295.600.2 NMAC - Rp, 8.295.600.2 NMAC, 1/1/2019]
8.295.600.3 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 and XXI of the Social Security Act as amended or by state statute. See Section 27-1-12 et seq ., NMSA 1978. 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.
[8.295.600.3 NMAC - Rp, 8.295.600.3 NMAC, 1/1/2019; A,7/1/2024]
8.295.600.4 DURATION: Permanent.
[8.295.600.4 NMAC - Rp, 8.295.600.4 NMAC, 1/1/2019
8.295.600.5 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.
[8.295.600.5 NMAC - Rp, 8.295.600.5 NMAC, 1/1/2019]
8.295.600.6 OBJECTIVE: The objective of this rule is to provide eligibility guidelines when determining eligibility for the medical assistance division (MAD) medicaid program and other health care programs it administers. Processes for establishing and maintaining this category of eligibility are found in the affordable care general provision chapter located at 8.291.400 NMAC through 8.291.430 NMAC.
[8.295.600.6 NMAC - Rp, 8.295.600.6 NMAC, 1/1/2019]
8.295.600.7 DEFINITIONS: Refer to 8.291.400.7 NMAC.
[8.295.600.7 NMAC - Rp, 8.295.600.7 NMAC, 1/1/2019]
8.295.600.8 [RESERVED]
[8.295.600.8 NMAC - Rp, 8.295.600.8 NMAC, 1/1/2019]
8.295.600.9 BENEFIT DESCRIPTION: This category provides full range of medicaid -covered services for eligible children.
A. An eligible child age five and under, whose budget group’s countable income is less than two hundred forty percent of the federal poverty level (FPL) guidelines, receives the full range of medicaid services.
B. An eligible child age six through 18, whose budget group’s countable income is less than one hundred ninety percent of the FPL guidelines, receives the full range of medicaid services.
C. An eligible child age five and under, whose budget group’s countable income is greater than two hundred forty percent but less than three hundred percent of the FPL guidelines receives the full range of medicaid services.
D. An eligible recipient child age six through 18, whose budget group’s countable income is greater than one hundred ninety percent but less than two hundred forty percent of the FPL guidelines, receives the full range of medicaid services.
[8.295.600.9 NMAC - Rp, 8.295.600.9 NMAC, 1/1/2019]
8.295.600.10 BENEFIT DETERMINATION: The HSD income support division determines initial and ongoing eligibility. Refer to affordable care general provision chapters located at 8.291.400 through 8.291.430 NMAC for eligibility requirements. Retroactive medicaid coverage is provided in accordance with 8.200.400.14 NMAC.
[8.295.600.10 NMAC - Rp, 8.295.600.10 NMAC, 1/1/2019]
8.295.600.11 PERIODIC REDETERMINATIONS OF ELIGIBILITY:
A. A redetermination of eligibility is made in accordance with 8.291.410 NMAC.
B. Continuous eligibility is applicable for medicaid eligible children. Refer to 8.291.400 NMAC.
C. All changes that may affect eligibility must be reported within 10 calendar days of the date of the change as detailed in 8.291.400 NMAC.
[8.295.600.11 NMAC - Rp, 8.295.600.11 NMAC, 1/1/2019]
HISTORY OF 8.295.600 NMAC:
History of Repealed Material:
8.295.600 NMAC, Benefit Description, filed 9/17/2013 - Duration expired 12/31/2013.
8.295.600 NMAC, Benefit Description, filed 12/17/2013 – Repealed effective 1/1/2019.
TITLE 8 SOCIAL SERVICES
CHAPTER 296 MEDICAID ELIGIBILITY - OTHER ADULTS
PART 400 RECIPIENT REQUIREMENTS
8.296.400.1 ISSUING AGENCY: New Mexico Health Care Authority.
[8.296.400.1 NMAC - Rp, 8.296.400.1 NMAC, 1/1/2019 ; A, 7/1/2024 ]
8.296.400.2 SCOPE: The rule applies to the general public .
[8.296.400.2 NMAC - Rp, 8.296.400.2 NMAC, 1/1/2019]
8.296.400.3 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 or by state statute. See Section 27-1-12 et seq ., NMSA 1978. 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.
[8.296.400.3 NMAC - Rp, 8.296.400.3 NMAC, 1/1/2019; A, 7/1/2024]
8.296.400.4 DURATION: Permanent.
[8.296.400.4 NMAC - Rp, 8.296.400.4 NMAC, 1/1/2019]
8.296.400.5 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.
[8.296.400.5 NMAC - Rp, 8.296.400.5 NMAC, 1/1/2019]
8.296.400.6 OBJECTIVE: The objective of this rule is to provide eligibility guidelines when determining eligibility for the medical assistance division (MAD) medicaid program and other health care programs it administers. Processes for establishing and maintaining this category of eligibility are found in the affordable care general provision chapter located at 8.291.400 NMAC through 8.291.430 NMAC.
[8.296.400.6 NMAC - Rp, 8.296.400.6 NMAC, 1/1/2019]
8.296.400.7 DEFINITIONS: Refer to 8.291.400.7 NMAC.
[8.296.400.7 NMAC - Rp, 8.296.400.7 NMAC, 1/1/2019]
8.296.400.8 [RESERVED]
[8.296.400.8 NMAC - Rp, 8.296.400.8 NMAC, 1/1/2019]
8.296.400.9 WHO CAN BE A RECIPIENT: To be eligible, an individual must meet specific eligibility requirements:
A. is age 19 or older and under age 65;
B. is not pregnant;
C. are not entitled to or enrolled in part A or B medicare benefits;
D. meets ACA eligibility requirements pursuant to 8.291.400 through 8.291.430 NMAC; and
E. has household income that is at or below one hundred thirty-three percent of the federal poverty level (FPL) for the applicable family size.
[8.296.400.9 NMAC - Rp, 8.296.400.9 NMAC, 1/1/2019; A, 2/1/2020]
8.296.400.10 OTHER ADULT ASSISTANCE UNIT AND BUDGET GROUP: To be considered in the other adult assistance unit, an individual must apply and be determined eligible. Individuals living with the other adult who meet criteria in 8.291.430 NMAC are included in the budget group.
[8.296.400.10 NMAC - Rp, 8.296.400.10 NMAC, 1/1/2019]
HISTORY OF 8.296.400 NMAC :
History of Repealed Material:
8.296.400 NMAC, Recipient Requirements, filed 9/17/2013 - Duration expired 12/31/2013.
8.296.400 NMAC, Recipient Requirements, filed 12/17/2013 - Repealed 1/1/2019.
TITLE 8 SOCIAL SERVICES
CHAPTER 296 MEDICAID ELIGIBILITY - OTHER ADULTS
PART 500 INCOME AND RESOURCE STANDARDS
8.296.500.1 ISSUING AGENCY: New Mexico Health Care Authority.
[8.296.500.1 NMAC - Rp, 8.296.500.1 NMAC, 1/1/2014 ; A, 7/1/2024 ]
8.296.500.2 SCOPE: The rule applies to the general public .
[8.296.500.2 NMAC - Rp, 8.296.500.2 NMAC, 1/1/2014 ]
8.296.500.3 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 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.
[8.296.500.3 NMAC - Rp, 8.296.500.3 NMAC, 1/1/2014; A, 7/1/2024 ]
8.296.500.4 DURATION: Permanent.
[8.296.500.4 NMAC - Rp, 8.296.500.4 NMAC, 1/1/2014 ]
8.296.500.5 EFFECTIVE DATE: January 1, 2014, unless a later date is cited at the end of a section.
[8.296.500.5 NMAC - Rp, 8.296.500.5 NMAC, 1/1/2014 ]
8.296.500.6 OBJECTIVE: The objective of this rule is to provide eligibility guidelines when determining eligibility for the medical assistance division (MAD) medicaid program and other health care programs it administers. Processes for establishing and maintaining this category of eligibility are found in the affordable care general provision chapter located at 8.291.400 NMAC through 8.291.430 NMAC.
[8.296.500.6 NMAC - Rp, 8.296.500.6 NMAC, 1/1/2014 ]
8.296.500.7 DEFINITIONS: Refer to 8.291.400.7 NMAC.
[8.296.500.7 NMAC - Rp, 8.296.500.7 NMAC, 1/1/2014 ]
8.296.500.8 MISSION: To transform lives. Working with our partners we design and deliver innovative, high quality health and human services that improve the security and promote independence for New Mexicans in their communities.
[8.296.500.8 NMAC - Rp, 8.296.500.8 NMAC, 1/1/2014; A, 1/1/2022 ]
8.296.500.9 RESOURCE STANDARDS: There are no resource standards for this category of eligibility.
[8.296.500.9 NMAC - Rp, 8.296.500.9 NMAC, 1/1/2014 ]
8.296.500.10 INCOME STANDARD:
A. Financial eligibility: An individual's financial eligibility is based on the rules in this chapter and 8.291.430 NMAC.
B. Income test: In order to become eligible for other adult medicaid , the total countable income of the budget group must be less than one hundred and thirty-three percent of the federal poverty guidelines found at 8.291.430 NMAC .
[8.296.500.10 NMAC - Rp, 8.296.500.10 NMAC, 1/1/2014; A, 1/1/2022 ]
8.296.500.11 INCOME ELIGIBILITY: Income methodology is based on modified adjusted gross income (MAGI) in accordance with 42 Code of Federal Regulations (CFR) 435.603. Per 42 CFR 435.603(h)(2) HSD bases financial eligibility on current monthly household income and family size. Current monthly household income is defined as a 30-day period. If an amount of income is received less frequently than monthly, that amount is converted by dividing the total income by the number of months the income is intended to cover.
[8.296.500.11 NMAC - Rp, 8.296.500.11 NMAC, 1/1/2014; A, 1/1/2022 ]
8.296.500.12 DISREGARD: An income disregard according to 8.291.430 NMAC will be given only to individuals whose countable MAGI income is at or above one hundred and thirty-three percent of federal poverty level for the size of the budget group.
[8.296.500.12 NMAC - Rp, 8.296.500.12 NMAC, 1/1/2014; A, 1/1/2022]
HISTORY OF 8.296.500 NMAC:
History of Repealed Material:
8.296.500 NMAC, Income and Resource Standards, filed 9/17/2013 - Duration expired 12/31/2013.
TITLE 8 SOCIAL SERVICES
CHAPTER 296 MEDICAID ELIGIBILITY - OTHER ADULTS
PART 600 BENEFIT DESCRIPTION
8.296.600.1 ISSUING AGENCY: New Mexico Health Care Authority.
[8.296.600.1 NMAC - Rp, 8.296.600.1 NMAC, 1/1/2019 ; A, 7/1/2024 ]
8.296.600.2 SCOPE: The rule applies to the general public .
[8.296.600.2 NMAC - Rp, 8.296.600.2 NMAC, 1/1/2019]
8.296.600.3 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 or by state statute. See Section 27-1-12 et seq ., NMSA 1978. 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.
[8.296.600.3 NMAC - Rp, 8.296.600.3 NMAC, 1/1/2019; A, 7/1/2024]
8.296.600.4 DURATION: Permanent.
[8.296.600.4 NMAC - Rp, 8.296.600.4 NMAC, 1/1/2019]
8.296.600.5 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.
[8.296.600.5 NMAC - Rp, 8.296.600.5 NMAC, 1/1/2019]
8.296.600.6 OBJECTIVE: The objective of this rule is to provide eligibility guidelines when determining eligibility for the medical assistance division (MAD) medicaid program and other health care programs it administers. Processes for establishing and maintaining this category of eligibility are found in the affordable care general provision chapter located at 8.291.400 NMAC through 8.291.430 NMAC.
[8.296.600.6 NMAC - Rp, 8.296.600.6 NMAC, 1/1/2019]
8.296.600.7 DEFINITIONS: Refer to 8.291.400.7 NMAC.
[8.296.600.7 NMAC - Rp, 8.296.600.7 NMAC, 1/1/2019]
8.296.600.8 [RESERVED]
[8.296.600.8 NMAC - Rp, 8.296.600.8 NMAC, 1/1/2019]
8.296.600.9 BENEFIT DESCRIPTION: This medicaid category provides alternative benefit plan services for individuals who meet other adult eligibility requirements. Refer to 8.309 NMAC.
[8.296.600.9 NMAC - Rp, 8.296.600.9 NMAC, 1/1/2019]
8.296.600.10 BENEFIT DETERMINATION: The HSD income support division (ISD) determines initial and ongoing eligibility. Refer to affordable care general provision chapters located at 8.291.400 through 8.291.430 NMAC for eligibility requirements. Retroactive medicaid coverage is provided in accordance with 8.200.400.14 NMAC.
[8.296.600.10 NMAC - Rp, 8.296.600.10 NMAC, 1/1/2019]
8.296.600.11 PERIODIC REDETERMINATIONS OF ELIGIBILITY:
A. A redetermination of eligibility is conducted in accordance with 8.291.410 NMAC.
B. All changes that may affect eligibility must be reported within 10 calendar days of the date of the change as detailed in 8.291.400 NMAC.
[8.292.600.11 NMAC - Rp, 8.296.600.11 NMAC, 1/1/2019]
HISTORY OF 8.296.600 NMAC:
History of Repealed Material:
8.296.600 NMAC, Benefit Description, filed 9/17/2013 - Duration expired 12/31/2013.
8.296.600 NMAC, Benefit Description, filed 12/17/2013 - Repealed effective 1/1/2019.
TITLE 8 SOCIAL SERVICES
CHAPTER 297 MEDICAID ELIGIBILITY - LOSS OF PARENT CARETAKER MEDICAID DUE TO SPOUSAL SUPPORT
PART 400 RECIPIENT REQUIREMENTS
8.297.400.1 ISSUING AGENCY: New Mexico Health Care Authority.
[8.297.400.1 NMAC - Rp, 8.297.400.1 NMAC, 1/1/2019 ; A, 7/1/2024 ]
8.297.400.2 SCOPE: The rule applies to the general public .
[8.297.400.2 NMAC - Rp, 8.297.400.2 NMAC, 1/1/2019]
8.297.400.3 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 or by state statute. See Section 27-1-12 et seq., NMSA 1978. 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.
[8.297.400.3 NMAC - Rp, 8.297.400.3 NMAC, 1/1/2019; A, 7/1/2024]
8.297.400.4 DURATION: Permanent.
[8.297.400.4 NMAC - Rp, 8.297.400.4 NMAC, 1/1/2019]
8.297.400.5 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.
[8.297.400.5 NMAC - Rp, 8.297.400.5 NMAC, 1/1/2019]
8.297.400.6 OBJECTIVE: The objective of this rule is to provide eligibility guidelines when determining eligibility for the medical assistance division (MAD) medicaid program and other health care programs it administers. Processes for establishing and maintaining this category of eligibility are found in the affordable care general provision chapter located at 8.291.400 NMAC through 8.291.430 NMAC.
[8.297.400.6 NMAC - Rp, 8.297.400.6 NMAC, 1/1/2019]
8.297.400.7 DEFINITIONS: Refer to 8.291.400.7 NMAC.
[8.297.400.7 NMAC - Rp, 8.297.400.7 NMAC, 1/1/2019]
8.297.400.8 [RESERVED]
[8.297.400.8 NMAC - Rp, 8.297.400.8 NMAC, 1/1/2019]
8.297.400.9 WHO CAN BE AN ELIGIBLE RECIPIENT: A four month transitional medical assistance (TMA) period is established following the loss of parent caretaker eligibility due to new or increased spousal support. TMA is the full medicaid coverage of last resort. A parent or caretaker is evaluated for other full medicaid coverage, including other adults, before being placed on the TMA category of eligibility. A parent or caretaker losing full medicaid coverage during any month(s) of his or her four month TMA period is automatically placed on the TMA category. Coverage under the TMA category ends after the four month TMA period expires. Only parent(s) and guardian(s) are placed on the TMA category. The medicaid eligibility of dependent children living in the home is extended to at least match the TMA period of parent(s) and guardian(s).
A. To be a medicaid eligible recipient, the assistance unit must have:
(1) received parent caretaker medicaid in at least one month of the six months prior to ineligibility for parent caretaker medicaid ;
(2) lost parent caretaker medicaid wholly or in part due to new or increased spousal support;
(3) at least one medicaid eligible dependent child living in the home; and
(4) met the medicaid eligibility requirements pursuant to 8.291.400 through 8.291.430 NMAC.
B. An individual with a new TMA period beginning on or after July 1, 2019, is subject to a premium for eligibility months the individual is on TMA category 027. Native Americans are exempt from the premium requirement.
C. An applicant or an eligible recipient may have a qualified health plan.
[8.297.400.9 NMAC - Rp, 8.297.400.9 NMAC, 1/1/2019]
HISTORY OF 8.297.400 NMAC:
History of Repealed Material:
8.297.400 NMAC, Recipient Requirements, filed 9/17/2013 - Duration expired 12/31/2013.
8.297.400 NMAC, Recipient Requirements, filed 12/17/2013 - Repealed effective 1/1/2019.
TITLE 8 SOCIAL SERVICES
CHAPTER 297 MEDICAID ELIGIBILITY - LOSS OF PARENT CARETAKER MEDICAID DUE TO SPOUSAL SUPPORT
PART 500 INCOME AND RESOURCE STANDARDS
8.297.500.1 ISSUING AGENCY: New Mexico Health Care Authority.
[8.297.500.1 NMAC - Rp, 8.297.500.1 NMAC, 1/1/2014 ; A, 7/1/2024 ]
8.297.500.2 SCOPE: The rule applies to the general public .
[8.297.500.2 NMAC - Rp, 8.297.500.2 NMAC, 1/1/2014]
8.297.500.3 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 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.
[8.297.500.3 NMAC - Rp, 8.297.500.3 NMAC, 1/1/2014 ; A, 7/1/2024 ]
8.297.500.4 DURATION: Permanent.
[ 8.297.500.4 NMAC - Rp, 8.297.500.4 NMAC, 1/1/2014]
8.297.500.5 EFFECTIVE DATE: January 1, 2014, unless a later date is cited at the end of a section.
[8.297.500.5 NMAC - Rp, 8.297.500.5 NMAC, 1/1/2014]
8.297.500.6 OBJECTIVE: The objective of this rule is to provide eligibility guidelines when determining eligibility for the medical assistance division (MAD) medicaid program and other health care programs it administers. Processes for establishing and maintaining this category of eligibility are found in the affordable care general provision chapter located at 8.291.400 NMAC through 8.291.430 NMAC.
[ 8.297.500.6 NMAC - Rp, 8.297.500.6 NMAC, 1/1/2014]
8.297.500.7 DEFINITIONS: Refer to 8.291.400.7 NMAC.
[8.297.500.7 NMAC - Rp, 8.297.500.7 NMAC, 1/1/2014]
8.297.500.8 MISSION: 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.
[8.297.500.8 NMAC - Rp, 8.297.500.8 NMAC, 1/1/2014]
8.297.500.9 RESOURCE STANDARDS: There are no resource standards for this category of eligibility.
[8.297.500.9 NMAC - Rp, 8.297.500.9 NMAC, 1/1/2014]
8.297.500.10 INCOME STANDARDS: There are no income standards for this category of eligibility.
[8.297.500.10 NMAC - Rp, 8.297.500.10 NMAC, 1/1/2014]
HISTORY OF 8.297.500 NMAC:
History of Repealed Material:
8.297.500 NMAC, Income and Resource Standards, filed 9/17/2013 - Duration expired 12/31/2013.
TITLE 8 SOCIAL SERVICES
CHAPTER 297 MEDICAID ELIGIBILITY - LOSS OF PARENT CARETAKER MEDICAID DUE TO SPOUSAL SUPPORT
PART 600 BENEFIT DESCRIPTION
8.297.600.1 ISSUING AGENCY: New Mexico Health Care Authority.
[8.297.600.1 NMAC - Rp, 8.297.600.1 NMAC, 1/1/2019 ; A, 7/1/2024 ]
8.297.600.2 SCOPE: The rule applies to the general public .
[8.297.600.2 NMAC - Rp, 8.297.600.2 NMAC, 1/1/2019]
8.297.600.3 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 or by state statute. See Section 27-1-12 et seq ., NMSA 1978. 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.
[8.297.600.3 NMAC - Rp, 8.297.600.3 NMAC, 1/1/2019 ; A, 7/1/2024 ]
8.297.600.4 DURATION: Permanent.
[8.297.600.4 NMAC - Rp, 8.297.600.4 NMAC, 1/1/2019]
8.297.600.5 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.
[8.297.600.5 NMAC - Rp, 8.297.600.5 NMAC, 1/1/2019]
8.297.600.6 OBJECTIVE: The objective of this rule is to provide eligibility guidelines when determining eligibility for the medical assistance division (MAD) medicaid program and other health care programs it administers. Processes for establishing and maintaining this category of eligibility are found in the affordable care general provision chapter located at 8.291.400 NMAC through 8.291.430 NMAC.
[8.297.600.6 NMAC - Rp, 8.297.600.6 NMAC, 1/1/2019]
8.297.600.7 DEFINITIONS: Refer to 8.291.400.7 NMAC.
[8.297.600.7 NMAC - Rp, 8.297.600.7 NMAC, 1/1/2019]
8.297.600.8 [RESERVED]
[8.297.600.8 NMAC - Rp, 8.297.600.8 NMAC, 1/1/2019]
8.297.600.9 BENEFIT DESCRIPTION: A medicaid eligible recipient under this category is eligible to receive the full range of medicaid covered services.
[8.297.600.9 NMAC - Rp, 8.297.600.9 NMAC, 1/1/2019]
8.297.600.10 BENEFIT DETERMINATION: The HSD income support division (ISD) determines initial and ongoing eligibility.
[8.297.600.10 NMAC - Rp, 8.297.600.10 NMAC, 1/1/2019]
8.297.600.11 PERIODIC REDETERMINATIONS OF ELIGIBILITY :
A. A four month period of eligibility following parent caretaker medicaid is established without a new application. At the end of the four month period of eligibility a beneficiary is evaluated for other medicaid coverage in accordance with 8.291.410.19 NMAC. Retroactive medicaid coverage is not provided in accordance with 8.200.400.14 NMAC.
B. All changes that may affect eligibility must be reported within 10 calendar days of the date of the change as detailed in 8.291.400 NMAC.
[8.297.600.11 NMAC - Rp, 8.297.600.11 NMAC, 1/1/2019]
HISTORY OF 8.297.600 NMAC:
History of Repealed Material:
8.297.600 NMAC, Benefit Description, filed 9/17/2013 - Duration expired 12/31/2013.
8.297.600 NMAC, Benefit Description, filed 12/17/2013 - Repealed effective 12/17/2013.
TITLE 8 SOCIAL SERVICES
CHAPTER 298 MEDICAID ELIGIBILITY - LOSS OF PARENT CARETAKER MEDICAID DUE TO EARNINGS FROM EMPLOYMENT
PART 400 RECIPIENT REQUIREMENTS
8.298.400.1 ISSUING AGENCY: New Mexico Health Care Authority.
[8.298.400.1 NMAC - Rp, 8.298.400.1 NMAC, 1/1/2019 ; A, 7/1/2024 ]
8.298.400.2 SCOPE: The rule applies to the general public .
[8.298.400.2 NMAC - Rp, 8.298.400.2 NMAC, 1/1/2019]
8.298.400.3 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 or by state statute. See Section 27-1-12 et seq ., NMSA 1978. 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.
[8.298.400.3 NMAC - Rp, 8.298.400.3 NMAC, 1/1/2019; A, 7/1/2024]
8.298.400.4 DURATION: Permanent.
[8.298.400.4 NMAC - Rp, 8.298.400.4 NMAC, 1/1/2019]
8.298.400.5 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.
[8.298.400.5 NMAC - Rp, 8.298.400.5 NMAC, 1/1/2019]
8.298.400.6 OBJECTIVE: The objective of this rule is to provide eligibility guidelines when determining eligibility for the medical assistance division (MAD) medicaid program and other health care programs it administers. Processes for establishing and maintaining this category of eligibility are found in the affordable care general provision chapter located at 8.291.400 NMAC through 8.291.430 NMAC.
[8.298.400.6 NMAC - Rp, 8.298.400.6 NMAC, 1/1/2019]
8.298.400.7 DEFINITIONS: Refer to 8.291.400.7 NMAC.
[8.298.400.7 NMAC - Rp, 8.298.400.7 NMAC, 1/1/2019]
8.298.400.8 [RESERVED]
[8.298.400.8 NMAC - Rp, 8.298.400.8 NMAC, 1/1/2019]
8.298.400.9 WHO CAN BE AN ELIGIBLE RECIPIENT: A 12 month transitional medical assistance (TMA) period is established following the loss of parent caretaker eligibility due to new or increased earnings. TMA is the full medicaid coverage of last resort. A parent or caretaker is evaluated for other full medicaid coverage, including other adults, before being placed on the TMA category of eligibility. A parent or caretaker losing full medicaid coverage during any month(s) of his or her 12 month TMA period is automatically placed on the TMA category. Coverage under the TMA category ends after the 12 month TMA period expires. Only parent(s) and guardian(s) are placed on the TMA category. The medicaid eligibility of dependent children living in the home is extended to at least match the TMA period of parent(s) and guardian(s).
A. To be a medicaid eligible recipient, the assistance unit must have:
(1) received parent caretaker medicaid in at least one month of the six months prior to ineligibility for parent caretaker medicaid ;
(2) lost parent caretaker medicaid wholly or in part due to new or increased earnings;
(3) at least one medicaid eligible dependent child living in the home; and
(4) met the medicaid eligibility requirements pursuant to 8.291.400 through 8.291.430 NMAC.
B. An individual with a new TMA period beginning on or after July 1, 2019, is subject to a premium for eligibility months the individual is on TMA category 028. Native Americans are exempt from the premium requirement.
C. An applicant or an eligible recipient may have a qualified health plan.
[8.298.400.9 NMAC - Rp, 8.298.400.9 NMAC, 1/1/2019]
HISTORY OF 8.298.400 NMAC:
History of Repealed Material:
8.298.400 NMAC, Recipient Requirements, filed 9/17/2013 - Duration expired 12/31/2013.
8.298.400 NMAC, Recipient Requirements, filed 12/17/2013 - Repealed effective 1/1/2019.
TITLE 8 SOCIAL SERVICES
CHAPTER 298 MEDICAID ELIGIBILITY - LOSS OF PARENT CARETAKER MEDICAID DUE TO EARNINGS FROM EMPLOYMENT
PART 500 INCOME AND RESOURCE STANDARDS
8.298.500.1 ISSUING AGENCY: New Mexico Health Care Authority.
[8.298.500.1 NMAC - Rp, 8.298.500.1 NMAC, 1/1/2014 ; A, 7/1/2024 ]
8.298.500.2 SCOPE: The rule applies to the general public .
[8.298.500.2 NMAC - Rp, 8.298.500.2 NMAC, 1/1/2014]
8.298.500.3 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 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.
[8.298.500.3 NMAC - Rp, 8.298.500.3 NMAC, 1/1/2014 ; A, 7/1/2024 ]
8.298.500.4 DURATION: Permanent.
[8.298.500.4 NMAC - Rp, 8.298.500.4 NMAC, 1/1/2014]
8.298.500.5 EFFECTIVE DATE: January 1, 2014, unless a later date is cited at the end of a section.
[8.298.500.5 NMAC - Rp, 8.298.500.5 NMAC, 1/1/2014]
8.298.500.6 OBJECTIVE: The objective of this rule is to provide eligibility guidelines when determining eligibility for the medical assistance division (MAD) medicaid program and other health care programs it administers. Processes for establishing and maintaining this category of eligibility are found in the affordable care general provision chapter located at 8.291.400 NMAC through 8.291.430 NMAC.
[8.298.500.6 NMAC - Rp, 8.298.500.6 NMAC, 1/1/2014]
8.298.500.7 DEFINITIONS: Refer to 8.291.400.7 NMAC.
[8.298.500.7 NMAC - Rp, 8.298.500.7 NMAC, 1/1/2014]
8.298.500.8 MISSION: 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.
[8.298.500.8 NMAC - Rp, 8.298.500.8 NMAC, 1/1/2014]
8.298.500.9 RESOURCE STANDARDS: There are no resource standards for this category of eligibility.
[8.298.500.9 NMAC - Rp, 8.298.500.9 NMAC, 1/1/2014]
8.298.500.10 INCOME STANDARDS: There are no income standards for this category of eligibility.
[8.298.500.10 NMAC - Rp, 8.298.500.10 NMAC, 1/1/2014]
HISTORY OF 8.298.500 NMAC:
History of Repealed Material:
8.298.500 NMAC, Income and Resource Standards, filed 9/17/2013 - Duration expired 12/31/2013.
TITLE 8 SOCIAL SERVICES
CHAPTER 298 MEDICAID ELIGIBILITY - LOSS OF PARENT CARETAKER MEDICAID DUE TO EARNINGS FROM EMPLOYMENT
PART 600 BENEFIT DESCRIPTION
8.298.600.1 ISSUING AGENCY: New Mexico Health Care Authority.
[8.298.600.1 NMAC - Rp, 8.298.600.1 NMAC, 1/1/2019 ; A, 7/1/2024 ]
8.298.600.2 SCOPE: The rule applies to the general public .
[8.298.600.2 NMAC - Rp, 8.298.600.2 NMAC, 1/1/2019]
8.298.600.3 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 or by state statute. See Section 27-1-12 et seq ., NMSA 1978. 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.
[8.298.600.3 NMAC - Rp, 8.298.600.3 NMAC, 1/1/2019 ; A, 7/1/2024 ]
8.298.600.4 DURATION: Permanent.
[8.298.600.4 NMAC - Rp, 8.298.600.4 NMAC, 1/1/2019]
8.298.600.5 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.
[8.298.600.5 NMAC - Rp, 8.298.600.5 NMAC, 1/1/2019]
8.298.600.6 OBJECTIVE: The objective of this rule is to provide eligibility guidelines when determining eligibility for the medical assistance division (MAD) medicaid program and other health care programs it administers. Processes for establishing and maintaining this category of eligibility are found in the affordable care general provision chapter located at 8.291.400 NMAC through 8.291.430 NMAC.
[8.298.600.6 NMAC - Rp, 8.298.600.6 NMAC, 1/1/2019]
8.298.600.7 DEFINITIONS: Refer to 8.291.400.7 NMAC.
[8.298.600.7 NMAC - Rp, 8.298.600.7 NMAC, 1/1/2019]
8.298.600.8 [RESERVED]
[8.298.600.8 NMAC - Rp, 8.298.600.8 NMAC, 1/1/2019]
8.298.600.9 BENEFIT DESCRIPTION: A medicaid eligible recipient under this category is eligible to receive the full range of medicaid covered services.
[8.298.600.9 NMAC - Rp, 8.298.600.9 NMAC, 1/1/2019]
8.298.600.10 BENEFIT DETERMINATION: The HSD income support division (ISD) determines initial and ongoing eligibility.
[8.298.600.10 NMAC - Rp, 8.298.600.10 NMAC, 1/1/2019]
8.298.600.11 PERIODIC REDETERMINATIONS OF ELIGIBILITY :
A. A 12 month period of eligibility following parent caretaker medicaid is established without a new application. At the end of the 12 month period of eligibility a beneficiary is evaluated for other medicaid coverage in accordance with 8.291.410.19 NMAC. Retroactive medicaid coverage is not provided in accordance with 8.200.400.14 NMAC.
B. All changes that may affect eligibility must be reported within 10 calendar days from the date of the change as detailed in 8.291.400 NMAC.
[8.298.600.11 NMAC - Rp, 8.298.600.11 NMAC, 1/1/2019]
HISTORY OF 8.298.600 NMAC:
History of Repealed Material:
8.298.600 NMAC, Benefit Description, filed 9/17/2013 - Duration expired 12/31/2013.
8.298.600 NMAC, Benefit Description, filed 12/17/2013 - Repealed effective 1/1/2019.
TITLE 8 SOCIAL SERVICES
CHAPTER 299 MEDICAID ELIGIBILITY - FAMILY PLANNING SERVICES
PART 400 RECIPIENT REQUIREMENTS
8.299.400.1 ISSUING AGENCY: New Mexico Health Care Authority.
[8.299.400.1 NMAC - Rp, 8.299.400.1 NMAC, 1/1/2019 ; A, 7/1/2024 ]
8.299.400.2 SCOPE: The rule applies to the general public .
[8.299.400.2 NMAC - Rp, 8.299.400.2 NMAC, 1/1/2019]
8.299.400.3 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 Section 27-1-12 et seq ., NMSA 1978. 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.
[8.299.400.3 NMAC - Rp, 8.299.400.3 NMAC, 1/1/2019; A, 7/1/2024]
8.299.400.4 DURATION: Permanent.
[8.299.400.4 NMAC - Rp, 8.299.400.4 NMAC, 1/1/2019]
8.299.400.5 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.
[8.299.400.5 NMAC - Rp, 8.299.400.5 NMAC, 1/1/2019]
8.299.400.6 OBJECTIVE: The objective of this rule is to provide specific instructions when determining eligibility for the medicaid program and other health care programs. Processes for establishing and maintaining this category of eligibility are found in the affordable care general provision chapter located at 8.291.400 NMAC through 8.291.430 NMAC.
[8.299.400.6 NMAC - Rp, 8.299.400.6 NMAC, 1/1/2019]
8.299.400.7 DEFINITIONS: [RESERVED]
8.299.400.8 [RESERVED]
[8.299.400.7 NMAC - Rp, 8.299.400.8 NMAC, 1/1/2019]
8.299.400.9 WHO CAN BE A RECIPIENT (42 CFR 435.214):
HSD provides medicaid limited to family planning and family planning related services to individuals (of any gender) who:
A. are under the age of 51 and do not have other health insurance; or
B. who are under the age of 65 who have only medicare coverage and no other health insurance; and
C. who are not pregnant; and
D. meet the general recipient requirements found at 8.291.410 NMAC; and
E. meet the income eligibility requirements found at Subsection B of 8.299.500.10 NMAC.
[8.299.400.9 NMAC - Rp, 8.299.400.9 NMAC, 1/1/2019]
8.299.400.10 BASIS FOR DEFINING THE GROUP: At time of application, an applicant or recipient and the department shall identify everyone who is to be considered for inclusion in the assistance unit and budget group as defined in 8.291.430 NMAC.
[8.299.400.10 NMAC - Rp, 8.299.400.10 NMAC, 1/1/2019]
HISTORY OF 8.299.400 NMAC: [RESERVED]
History of Repealed Material:
8.299.400 NMAC - Recipient Requirements, filed 9/14/2017 - Repealed effective 1/1/2019.
TITLE 8 SOCIAL SERVICES
CHAPTER 299 MEDICAID ELIGIBILITY - FAMILY PLANNING SERVICES
PART 500 INCOME AND RESOURCE STANDARDS
8.299.500.1 ISSUING AGENCY: New Mexico Health Care Authority.
[8.299.500.1 NMAC - N, 10/1/2017 ; A, 7/1/2024 ]
8.299.500.2 SCOPE: The rule applies to the general public .
[8.299.500.2 NMAC - N, 10/1/2017]
8.299.500.3 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 or by state statute. See Section 27-1-12 et seq, NMSA 1978. 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.
[8.299.500.3 NMAC - N, 10/1/2017; A, 7/1/2024]
8.299.500.4 DURATION: Permanent.
[8.299.500.4 NMAC - N, 10/1/2017]
8.299.500.5 EFFECTIVE DATE: October 1, 2017, unless a later date is cited at the end of a section.
[8.299.500.5 NMAC - N, 10/1/2017]
8.299.500.6 OBJECTIVE: The objective of this rule is to provide specific instructions when determining eligibility for the medicaid program and other health care programs. Processes for establishing and maintaining this category of eligibility are found in the affordable care general provision chapter located at 8.291.400 NMAC through 8.291.430 NMAC.
[8.299.500.6 NMAC - N, 10/1/2017]
8.299.500.7 DEFINITIONS: [RESERVED]
8.299.500.8 MISSION: To transform lives. Working with our partners, we design and deliver innovative, high quality health and human services that improve the security and promote independence for New Mexicans in their communities.
[8.299.500.8 NMAC - N, 10/1/2017; A, 1/1/2022]
8.299.500.9 RESOURCE STANDARDS: Resources are not an eligibility factor for this category of eligibility.
[8.299.500.9 NMAC - N, 10/1/2017]
8.299.500.10 INCOME STANDARD: In order to become eligible for family planning medicaid , the total countable income of the budget group must be less than two hundred fifty percent of the federal poverty guidelines found at 8.291.430 NMAC.
[8.299.500.10 NMAC - N, 10/1/2017]
8.299.500.11 INCOME ELIGIBILITY: Income methodology is based on modified adjusted gross income (MAGI) in accordance with 42 Code of Federal Regulations (CFR) 435.603. Per 42 CFR 435.603(h)(2) HSD bases financial eligibility on current monthly household income and family size. Current monthly household income is defined as a 30-day period. If an amount of income is received less frequently than monthly, that amount is converted by dividing the total income by the number of months the income is intended to cover.
[8.299.500.10 NMAC - N, 10/1/2017; A, 1/1/2022]
8.299.500.12 DISREGARD: An income disregard according to 8.291.430 NMAC will be given only to individuals whose countable modified adjusted gross income (MAGI) is at or above two hundred fifty percent of the federal poverty level for the size of the budget group.
[8.299.500.10 NMAC - N, 10/1/2017]
HISTORY OF 8.299.500 NMAC: [RESERVED]
TITLE 8 SOCIAL SERVICES
CHAPTER 299 MEDICAID ELIGIBILITY - FAMILY PLANNING SERVICES
PART 600 BENEFIT DESCRIPTION
8.299.600.1 ISSUING AGENCY: New Mexico Health Care Authority.
[8.299.600.1 NMAC – Rp, 8.299.600.1 NMAC, 1/1/2019 ; A, 7/1/2024 ]
8.299.600.2 SCOPE: The rule applies to the general public .
[8.299.600.2 NMAC - Rp, 8.299.600.2 NMAC, 1/1/2019]
8.299.600.3 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 Section 27-1-12 et seq ., NMSA 1978. 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.
[8.299.600.3 NMAC - Rp, 8.299.600.3 NMAC, 1/1/2019; A, 7/1/2024]
8.299.600.4 DURATION: Permanent.
[8.299.600.4 NMAC - Rp, 8.299.600.4 NMAC, 1/1/2019]
8.299.600.5 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.
[8.299.600.5 NMAC - Rp, 8.299.600.5 NMAC, 1/1/2019]
8.299.600.6 OBJECTIVE: The objective of this rule is to provide specific instructions when determining eligibility for the medicaid program and other health care programs. Processes for establishing and maintaining this category of eligibility are found in the affordable care general provision chapter located at 8.291.400 NMAC through 8.291.430 NMAC.
[8.299.600.6 NMAC - Rp, 8.299.600.6 NMAC, 1/1/2019]
8.299.600.7 DEFINITIONS: [RESERVED]
8.299.600.8 [RESERVED]
8.299.600.9 BENEFIT DESCRIPTION: This category provides a limited range of medicaid -covered services for family planning and family planning-related services for both men and women.
[8.299.600.9 NMAC - Rp, 8.299.600.9 NMAC, 1/1/2019]
8.299.600.10 BENEFIT DETERMINATION: The HSD income support division (ISD) determines initial and ongoing eligibility. Refer to affordable care general provision chapters located at 8.291.400 through 8.291.430 NMAC for eligibility requirements. Retroactive medicaid coverage is provided in accordance with 8.200.400.14 NMAC.
[8.299.600.10 NMAC - Rp, 8.299.600.10 NMAC, 1/1/2019]
8.299.600.11 PERIODIC REDETERMINATIONS OF ELIGIBILITY:
A. A redetermination of eligibility is conducted in accordance with 8.291.410 NMAC.
B. All changes that may affect eligibility must be reported within 10 calendar days of the date of the change as detailed in 8.291.400 NMAC.
[8.299.600.11 NMAC - Rp, 8.299.600.11 NMAC, 1/1/2019]
HISTORY OF 8.299.600 NMAC: [RESERVED]
History of Repealed Material:
8.299.600 NMAC - Benefit Description, filed 9/14/2017 - Repealed effective 1/1/2019.