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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.