8.291.410 NMAC

(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.