Table of Contents State/Territory Name: New Mexico State Plan Amendment (SPA) #: 22-0016 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 601 E. 12th St., Room 355 Kansas City, Missouri 64106 Medicaid and CHIP Operations Group September 22, 2022 Ms. Nicole Comeaux Director Medical Assistance Division New Mexico Human Services Department 2025 South Pacheco Drive P.O. Box 2348 Santa Fe, New Mexico 87504-2348 Re: New Mexico State Plan Amendment (SPA) 22-0016

Dear Ms. Comeaux:

The Centers for Medicare & Medicaid Services (CMS) reviewed your Medicaid State Plan Amendment (SPA) submitted under transmittal number (TN) 22-0016. This amendment proposes to implement changes to state plan limits on amounts for necessary medical or remedial care to comply with 42 CFR 435.725(c)(4).

We conducted our review of your submittal according to statutory requirements in Title XIX of the Social Security Act and implementing regulations 42 CFR 435.725(c)(4). This letter is to inform you that New Mexico Medicaid SPA 22-0016 was approved on September 22, 2022, with an effective date of December 1, 2022.

If you have any questions, please contact Peter Banks at (415) 744-3782 or via email at Peter.Banks@cms.hhs.gov. Sincerely,

James G. Scott, Director Division of Program Operations cc: - Nicole Comeaux - Valerie Tapia - Donna Lopez

DEPARTMENT OF HEALTH ANDHUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB No. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES 1. TRANSMITTAL NUMBER 2. STATE 3. PROGRAM IDENTIFICATION: TITLE OF THE SOCIAL SECURITY ACT TO: CENTER DIRECTOR CENTERS FOR MEDICAID & CHIP SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES 4. PROPOSED EFFECTIVE DATE 5. FEDERAL STATUTE/REGULATION CITATION 6. FEDERAL BUDGET IMPACT (Amounts in WHOLE dollars) a. FFY $ b. FFY $ 7. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT GOVERNOR’S OFFICE REPORTED NO COMMENT OTHER, AS SPECIFIED: COMMENTS OF GOVERNOR’S OFFICE ENCLOSED NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 11. SIGNATURE OF STATE AGENCY OFFICIAL 15. RETURN TO 12. TYPED NAME 13. TITLE 14. DATE SUBMITTED FOR CMS USE ONLY 16. DATE RECEIVED 17. DATE APPROVED PLAN APPROVED - ONE COPY ATTACHED 18. EFFECTIVE DATE OF APPROVED MATERIAL 19. SIGN OVING OFFICIAL 20. TYPED NAME OF APPROVING OFFICIAL 21. TITLE OF APPROVING OFFICIAL 22. REMARKS FORM CMS-179 (09/24) Instructions on Back PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable) SUBJECT OF AMENDMENT GOVERNOR’S REVIEW (Check One)

SUPPLEMENT 3 to ATTACHMENT 2.6-A

Page 1 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: New Mexico REASONABLE LIMITS ON AMOUNTS FOR NECESSARY MEDICAL OR REMEDIAL CARE NOT COVERED UNDER MEDICAID

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. 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 “Professional Providers, Services, and Reimbursement”, even if such practitioner is not a Medicaid provider. 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 the New Mexico Administrative Code “Resource Standards” section (or a prorated amount of this figure, for unpaid nursing facility services that are for less than a full month). The deduction for medical and remedial care expenses that were incurred as the result of a transfer penalty period is limited to zero. 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. 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.

TN No. 22-0016

Approval Date: 9/22/2022 Supersedes TN No. 93-12 Effective Date: 12/1/2022

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 1301 Young Street, Room 833 Dallas, Texas 75202 CEN1ERSfbr MED/ CARE8A! ED/ CA / DSEN ICES Division of Medicaid & Children's Health, Region VI March 8, 2010 Our Reference: SPA-NM- 09-02 Ms. Carolyn Ingram, Director Medical Assistance Division State ofNew Mexico Post Office Box 2348 Santa Fe, New Mexico 87504-2348 Dear Ms. Ingram: We have reviewed the proposed amendment to your Medicaid State Plan submitted under Transmittal Number 09-02. The purpose of this amendment is for the State to implement the required Asset Verification System (AVS) for the purpose of determining eligibility for aged, blind, and disabled Medicaid applicants and recipients in accordance with 1940 ofthe Social Security Act. Transmittal Number 09-02 is approved with an effective July 1, 2009 as requested. A copy of the HCFA-179, Transmittal Number 09-02 dated March 31, 2009, is enclosed along with the approved plan pages. Ifyou have any questions, please contact Bobbie Sullivan at (214) 767-6391. Sincerely, ill Brooks Associate Regional Administrator Division of Medicaid and Children's Health Enclosures

DEPARTMENT O FlEAL.T4i AND HUA9AN SERVICES IiEALTH CARE FdAlANCWCr ADMIIdIS'I' RAT30Td S IVO'TICE FrPPROV O' S'd',' I' PL1ot T z:;l' i : , 1 = 1'' 41 : 1` i I ' nr a. s ,.. : 1 ,. t 1 i': 1 : : >: : 1; CI ; € 1l O: 1ZEC: IOIa., 11I TT' OR 4. I' OPOSEI GP i) T' HEAI.Tii CfRE FINANCING1, DM[ IMSTRfTTON Juiy 1, 2009 DEPAR O FiEt11.TH 1VD SERVIICS 5. 'I' SCPE OF Pf MAT ( Check One)a p xw sT ,rr p To oxs s rP 6. FTcDERAI, ST'aTU" I' UI, ATIOFd 5eiiot fl940( PrGE EFZ OF 'dE k'LAlV SETIOI OR .TTA N'T: Step9esnent 16 to Atcch en 2.6- A gs. &- 3 Y . S, TEC' O MEN'I': set /eraic ion ' Systex L r':' MENT' (5epcarate T1ntteral. or each amendmaa) 7. FIEDERAt. B[TI3t' iET IYe'ACT: FYY 2009 $ S(30, OQ0 b. FY 2010 1.5 RR 9. PAGE YdJIdIBEEt OF TiE SUPDID PLT OR A'YTAC ( I, f' Ap, pNcable): Nt p, C+ •!;, i' `. 1: !' 1 I';:.• Y . • . , , _ : : . , ih ., i' ,: , , , ,., ' : ;: , , ; ., lil'' , . , ; A; i r: a:. rr,: [ I3'a Ia r Dinecoor Ae dacel ssietasnce YD° avasion Iiuan ServicesI) epar9 eut P.O. ox 234 — ARtt Santa Fe, 1 7504234 tata, -s_' rno

Marks, Marsha L. (CMS/SC) From: Marks, Marsha L. (CMS/SC) Sent: Monday, March 15, 2010 6:26 AM To: CMS CMSO 508 SPA Cc: Sullivan, Bobbie L. (CMS/SC); Territo, Linda J. (CMS/SC); Cowan, Robert A. (CMS/SC); Seng, Suzette (CMS/SC); ' McGee, Paula, HSD' Subject: Approval Pkg for NM 09-02 Attachments: Final Approval Pkg for NM 09-02. pdf See attached. State: New Mexico Brief Description: The amendment allows the State to implement the required Asset Verification System (AVS) for determining eligibility for aged, blind, and disabled Medicaid applicants and recipients. Approval Date: 8 March, 2010 Effective Date: 1 July, 2009 1(ar tr 1Varks // Cept f Nith & Nurr Servics ; 7 Certers far Pdicar &icaic9 Srvic s t i( f fic 11 Divisicn f Nledicaid & Cildr€' s Fiealh ? i Dalls Texas 75202?12 4-i 7- 6280 fl Fx 21-7 7- 0322;' i marsha.marksancros hhs qov

STATE ,Cdl1_1 L ' Gr , DATE EC'C / ^ i DAT APPV'D $ - ! RATE EFF TCt. a HGA 179 D 4 Revision: rt SUPPLEMENT 16 TO ATTACHMENT 2.6- A Page 1 STATE PLAN iJNDER TITLE XDC OF THE SOCIAL SECURITY ACT State; New Mexico ASSET VERiFICATION SYSTEM 1940(a) 1. The agency will provide for the verification of assets for purposes of of the Act determining or redetermining Medicaid eligibility for aged, blind and disabled Medicaid applicants and recipients using an Asset Verification System (AVS) that meets the following minimum requirements. A. The request and response system must be electronic: 1) Verification inqwiries must be sent electionically via the internet or similar means from the agency to the financial institution (Fn. 2) The system cannot be based on mailing paper-based requests. 3) The system must have the capability to accept responses electronically. B. The system must be secure, based on a recognized industry standard of security (e.g., as defined by the U.S. Commerce DepartmenYs National Institute of Standards and Techriology, or I1IST. C. The system must establish and maintain a database of FIs that participate in the agency's AVS. D. Verification requests also must be sent to FIs other than those identified by applicants and recipients, based on some logic such as geographic proxitniiy to the applicant's home address, or other reasonable factors whenever the agency determines that such requests are needed to determine or redetermine the individual's eligibility. E. The verification requests must include a request for information on both open and closed accounts, going back up to S years as determined by the State. TN No. ' a py lat 3- Effective Date 7`! D 9' Supersedes TN Na - vtv 1VF

srA . CAfi AIPa/' f.... M.Qr' T FF-- l i, c a' H 179 ,..,,, ,_ 9 -Cb2 ...._ Revision: SUPPLEMENT 16 TO ATTACHMEIVT 2.6- A Page 2 STATE PLAN UNDER TITLE XIX OF TI SOCIAL SECURITY ACT State: New Mexico ASSET VERIFICATION SYSTEM 2. System Development A. The agency itselfwill develop an AVS. In 3 below, provide any additional information the agency wants to include. X B. The agency will hire a contractor to develop an AVS. In 3 below provide any additional information the agency wants to include. C. The agency will be joining a consortium to develop an AVS. In 3 below, identify the States participating in the consortium. Also, provide any other information the agency wants to include pertaining to how the consortium will implement the AVS requirements. D. The agency already has a system in place that meets the reqairements for an acceptable AVS. In 3 below, describe how the existing system meets the requirements in Section 1. E. Other alternative not included in A. — D. above. In 3 below, describe this alternative approach and how it will meet the requirements in Section 1. TN No. -- Approval Date 3-'S - ID Effective Date Zl- D 9' Supersedes TNNoUP RSEDES: NONE - NEUV PAGE

Revision: SUPPLEMENT 16 TO ATTACHMENT 2.6- A Page 3 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: New Mexico ASSET VERIFICATIN SYSTEM 3. Provide the AVS implementation information requested for the implementation approach checked in Section 2, and any other information the agency may want to include. S" fAT ...,,._ oA cr_ 3/ / Y12 . 39 DATEAfPo/ D r / ,° t? Al' EF HC'A i79 _ O 9_ Do'l iw rruw ccww+.. r.. r a.e.. an. TN No. D Q Approval Date 3" g'/ Q Effective Date 1`' _' 09' Supersedes TN N ' .; jjQ _ NEW PAGE

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED HEALTH CARE FINANCRJG ADMiN[STRATION OMB NO. 0935-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF 1. TRANSMITTAL NUMBER: 2. STATE STATE PLAN MATERIAL NEW MEXICO 09-007 FOR: HEALTH CARE FINANCING ADMINISTRATION 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) TO: REGIONAL ADMINISTRATOR 4. PROPOSED EFFECTIVE DATE HEALTH CARE FINANCTNG ADMINISTRATION January 1, 2010 DEPARTIVIENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One): NEW STATE PLAN AMENDMENT TO BE CONSIDERED AS NEW PLAN AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT Se arate Transmittal or each amendment 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: Sections 1902(e)( 4) of the Social Security Act a. FFY 2010 $ 0 42 CFR 435.117 b. FFY 2011 $ 0 8. PAGE NUMBER OF THE PLAN SECTION OR A" TTACHMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (IjApplicable): ATTACHMENT 2.2- A Page 6 ATTACHMENT 2.2- A Page 6 10. SUBJECT OF AMENDMENT: Delete wording regarding Newborn eligibility per CHIPRA legislation. l l. GOVERNOR'S REVIEW (Check ne): GOVERNOR'S OFE'ICE REPORTED NO COMMENT OTHER, AS SPECIFIED: COMMENTS OF GOVERNOR'S OFFICE ENCI.OSED State Medicaid Director NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12. SIGN IAL: 16. RETURN TO: 13. TYPED NA . Carolyn Ingram, D'uector Caral In am NM Human Services Department — MAD 14. TITLE: Director Medicai Assistance Division p•O. Box 2348 Santa Fe, NM 87504-2348 15. DATE SUBMITTED: FOR!REGIONAL` OFFICE USE ONLY . 17. DATE RECENED; ' 18. DATE APPRO D: PLA APPRUVED - ONE COPY ATTACHED ' 19. EFFECTNE DATE `F APPR,., OVED MATERIAL; 20. SIGNA 21. TYPED NAME: 22. TITLE: r C roc' t <. 23. REMARKS: FORM HCFA-179 (07-92)

REVYSION: HCFA-PM- 92-1R (1VIB) ATTACffiKENT 2.Z- A MARCH 1992 PAGE 6 STATE PLAN UMDER 1TTLE XIX OF THE SOCIAL SECURITY ACT 1 v . 1 COVERAGE iND CONDITTONS OF ELIGIBILITY e cy " Ctadon /s) Grouos Covered IV-A 1902 (e) ( 4) of the Act 42 CFR.117 42 CFR 435.120 N-A A. Mandatory Covera¢e — Categorical Needv and Other Reauiied Special Grouns (continued) 12. A child born to a woman who is eligible far and receiving Medicaid es cabegorically nady on the date ofthe child's birth. The child ts deamed eligible for one year from birth as long as the mother remains eligible or would remain eligible ifstill pregnarn. 13. Aged, Blind and Disabled Individuals Receiving Cash Assistance X a. Individuals receiving SSI. itis includes beneficiaries' eligible spouses and persons receiving SSI benefits pending a final deterntinatian ofblindness or disability or pending disposal ofexcess resources under an agreement with the Social Security Adminisation; and beginning January I, 1981 petsons receiving SSI under scction 1619 (a) ofthe Act or considered to be receiving S3I under section 1619 (b) ofthe Act. C Agod X Blmd Disabled N Ivl SATE 3d t A pATE RE'! .' 1 b " CT "F' 1 0 — r p ;,. , aQ--O 1 A - . r as Agencv thatc( etcrmines eligibility for coveraee. TN No. i — fl•7 Approval Date / Effective Date 0 0 Supersedes TN No. 9- ol

Marks, Marsha L. (CMS/SC) From: Sent: To: Cc: Subject: Attachments: See Attached. State: New Mexico Marks, Marsha L. (CMS/SC) Thursday, January 21, 2010 12:22 PM CMS CMSO 508 SPA Sullivan, Bobbie L. (CMS/SC) Approval Pkg for NM 09-07 Final Approval Pkg for 09-07. pdf; NM- 0974Approval. doc Brief Description: The plan revises the Medicaid eligibility requirements for deemed newborns required by the Children's Health Insurance Program Reauthorization Act (CHIPRA) of 2009. Approval Date: 16 November, 2009 Effective Date: 1 January, 2010 Marsha Nlarks // Dept f Ne6th & Human Services 1/ Cenkers far edicare & Medicaid Srvices t1 Dlias Rgi nal Cffice /' Division Qf Medicaid & Children's Healkh fl C}allas Texas 75202 01214-76i- 628011 ax24- i67-3221 marsha.marksan,cros. hhs.qov

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 1301 Young Street, Room 833 Dallas, Texas 75202 c s G' MERS1brMED/ G4Rf MED/fNDSEIPY/ CFS Division of Medicaid & Children's Health, Region VI November 16, 2009 Our Reference: SPA-NM- 09-07 Ms. Carolyn Ingram, Director Medical Assistance Division State of New Mexico Post Office Box 2348 Santa Fe, New Mexico 87504-2348 Dear Ms. Ingram: We have reviewed the proposed amendment to your Medicaid State Plan submitted under Transmittal Number 09-07. The purpose of this amendment is to revise the Medicaid eligibility requirements for deemed newborns by the Children's Health Insurance Program Reauthorization Act (CHIPRA) of 2009. Transmittal Number 09-07 is approved with an effective date of July 1, 2009 as requested. A copy of the HCFA- 179, Transmittal Number 09-07 dated September 30, 2009, is enclosed along with the approved plan pages. Ifyou have any questions, please contact Bobbie Sullivan at (214) 767-6391. Sincerely, Bill Brooks Associate Regional Administrator Division of Medicaid and Children's Health Enclosures

Table of Contents

State/Territory Name: New Mexico State Plan Amendment (SPA) #: 13-0021 MM2 This file contains the following documents in the order listed: 1) Approval Letter 2) Additional Companion letter 3) CMS 179 Form/Summary Form 4) Superseding Pages Notice 5) Approved SPA Pages 6) Additional Attachments that are part of the state plan

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services

Dallas Regional Office

1301 Young Street, Room 714

Dallas, Texas 75202

CMS

(CENTERS FOR MEDICARE & MEDICAID SERVICES

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

February 12, 2014

Ms. Julie Weinberg, Director

Medical Assistance Division

New Mexico Department of Human Services P.O. Box 2348

Santa Fe, New Mexico 87504

Dear Ms. Weinberg:

Enclosed is an approved copy of New Mexico’s (NM) state plan amendment (SPA) NM 13- 0021-MM2, which was submitted to the Centers for Medicare & Medicaid Services (CMS) on December 13, 2013. SPA NM 13-0021—MM2 incorporates the MAGI-based eligibility process requirements, including the single streamlined application, into New Mexico’s Medicaid state plan in accordance with the Affordable Care Act. The effective date of this SPA is October 1, 2013.

The approval of SPA NM 13-0021-MM2 includes approval of the state’s alternative single streamlined paper application and the alternative paper application used to apply for multiple human service programs. The State is also using an interim alternative single streamlined online application and by December 31, 2014 will implement a revised alternative single streamlined online application that addresses CMS concerns outlined in the companion letter issued with this SPA approval.

Enclosed is a copy of the following S94 state plan pages and attachments to be incorporated within a separate section at the end of New Mexico’s approved state plan:

S94, pages $94-1, S94-2 Attachment | - New Mexico Single Streamlined Application - Medical Assistance Only (Alternative Paper application)

e Attachment 2 - New Mexico Single Streamlined Application - All Programs (Alterative application used to apply for multiple human service programs)

e Attachment 3 — Statement of use with respect to the alternative single streamlined online application

In addition, enclosed is a summary of state plan pages which are superseded by NM SPA 13- 0021-MM2, which should also be incorporated into a separate section in the front of the state plan.

e Superseding Pages of State Plan Material, 13-002 1-MM2

CMS appreciates the significant amount of work your staff dedicated to preparing this State Plan amendment. For technical assistance with your online application, please contact Dena Greenblum at (410) 786-8684 or dena.greenblum@cms.hhs.gov. If you have any questions concerning this SPA, please contact Stacey Shuman at 214 767-6479 or by email at Stacey.Shuman@cms.hhs.gov.

Sincerely,

Bill Brooks Associate Regional Administrator Division of Medicaid & Children’s Health Operations

Enclosures

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services

Dallas Regional Office

1301 Young Street, Room 714

Dallas, Texas 75202

CMS

(CENTERS FOR MEDICARE & MEDICAID SERVICES

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

February 12, 2014

Ms. Julie Weinberg, Director

Medical Assistance Division

New Mexico Department of Human Services P.O. Box 2348

Santa Fe, New Mexico 87504

Dear Ms. Weinberg:

This letter is being sent as a companion to Centers for Medicare & Medicaid Services (CMS) approval of state plan amendment (SPA) 13-0021-MM2, which was submitted to CMS on December 13, 2013. Our review of this submission included the review of New Mexico’s alternative single streamlined online application.

Until December 31, 2014 the state is using an interim alternative single streamlined online application. This interim online application will need to be revised to reflect the following changes.

Date by which changes

Necessary changes: will be completed:

Questions about tax filing status will refer to whether the | December 31, 2014 applicant plans to file taxes, not whether the applicant has filed taxes in the past.

The following questions will not appear for household | December 31, 2014 members not seeking any benefits:

Questions regarding citizenship

Questions regarding residency

Questions regarding immigration status Questions regarding disability and blindness

Questions regarding student status will only be asked when | December 31, 2014 relevant to eligibility.

Applicants who do not appear eligible for Medicaid and CHIP | December 31, 2014 based on income attestation will be asked whether they are offered health insurance from a job, and if so, will be asked additional details about that insurance offer.

Applicants will have the opportunity to identify themselves as | December 31, 2014 American Indians and Alaska Natives for purposes of cost- sharing protections, and identify American Indian and Alaska Native income not countable for Medicaid and CHIP income determinations.

Please submit the revised alternative single streamlined online application to CMS for review no later than November 31, 2014 to ensure approval by December 31, 2014. We continue to be available to provide technical assistance. If you have any questions about your application, please contact Dena Greenblum at Dena.Greenblum@cms.hhs.gov or (410) 786-8684. If you have any other questions or require further assistance, please contact Stacey Shuman of my staff at either 214 767-6479 or by email at Stacey. Shuman@cms.hhs.gov.

Sincerely,

Bill Brooks

Associate Regional Administrator Division of Medicaid & Children’s Health Operations

Enclosures

NM.0603.R00.00 - Oct 01, 2013 Page | of |

Medicaid State Plan Eligibility: Summary Page (CMS 179)

State/Territory name: New Mexico

Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered.

NM-13-0021

Proposed Effective Date 40/01/2013

Federal Statute/Regulation Citation 42 CFR 435, Subpart J and Subpart M

Federal Budget Impact

Federal Fiscal Year Amount First Year 2014 $0.00 Second Year 2015 $0.00

Subject of Amendment $94: General Eligibility Requirements: Eligibility Process

Governor's Office Review Governor's office reported no comment

Comments of Governor's office received Describe:

No reply received within 45 days of submittal Other, as specified

Deserib Authority Delegated to the Medicaid Director

Signature of State Agency Official

Submitted By: Caitlin Kuennen Breen Last Revision Date: Jan 15, 2014 Submit Date: Dec 13, 2013

Date Received: 12/13/13

Date Approved: 2/12/14 Pe

Signature of Regional Official:

PRINTED NAME and Title: Bill Brooks, Associate Regional Administrator Division of Medicaid and Children's Health

SUPERSEDING PAGES OF STATE PLAN MATERIAL

TRANSMITTAL NUMBER:

13-0021-MM2 STATE:

New Mexico

PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

S94 – Eligibility Process PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable):

Section 2, Page 10, section 2.1(a), TN [06-01] Effective date:[07-01-2006], approved: [06-09-2006] Section 2, Page 11a, section 2.1(d), TN [91-19] Effective date: [10-01-1991], approved: [01-15-1992]

State: New Mexico Date Received: 12/13/13 Date Approved: 2/12/14 Date Effective: 10/1/13 Transmittal Number: 13-21 ___________________________________________________________________________ TN No: 13-21

APPROVAL DATE: 2/12/14

EFFECTIVE DATE: 10/1/13 STATE: New Mexico

PAGE: Superseding Document Page 1

State: New Mexico Date Received: 12/13/13 Date Approved: 2/12/14 Date Effective: 10/1/13 Transmittal Number: 13-21 ___________________________________________________________________________ TN No: 13-21

APPROVAL DATE: 2/12/14

EFFECTIVE DATE: 10/1/13 STATE: New Mexico

PAGE: S94 Page 1 of 2

State: New Mexico Date Received: 12/13/13 Date Approved: 2/12/14 Date Effective: 10/1/13 Transmittal Number: 13-21 ___________________________________________________________________________ TN No: 13-21

APPROVAL DATE: 2/12/14

EFFECTIVE DATE: 10/1/13 STATE: New Mexico

PAGE: S94 Page 2 of 2

USE OF THE ALTERNATIVE SINGLE STREAMLINED APPLICATION

 Paper Application  Online Application

TRANSMITTAL NUMBER:

13-0021-MM

STATE:

New Mexico

Through December 31, 2014, the state is using an interim online alternative single streamlined application. After December 31, 2014, the state will use a revised online alternative single streamlined application, which will address the issues outlined in the CMS letter concerning the state’s application. The revised application will be incorporated by reference into the state plan.

___________________________________________________________________________ TN No: 13-21

APPROVAL DATE: 2/12/14

EFFECTIVE DATE: 10/1/13 STATE: New Mexico PAGE: Attachment Page 1 State: New Mexico Date Received: 12/13/13 Date Approved: 2/12/14 Date Effective: 10/1/13 Transmittal Number: 13-21

State: New Mexico Date Received: 12/13/13 Date Approved: 2/12/14 Date Effective: 10/1/13 Transmittal Number: 13-21 NM 13-21 Page 2

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State: New Mexico Date Received: 12/13/13 Date Approved: 2/12/14 Date Effective: 10/1/13 Transmittal Number: 13-21

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State: New Mexico Date Received: 12/13/13 Date Approved: 2/12/14 Date Effective: 10/1/13 Transmittal Number: 13-21

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State: New Mexico Date Received: 12/13/13 Date Approved: 2/12/14 Date Effective: 10/1/13 Transmittal Number: 13-21

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State: New Mexico Date Received: 12/13/13 Date Approved: 2/12/14 Date Effective: 10/1/13 Transmittal Number: 13-21

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State: New Mexico Date Received: 12/13/13 Date Approved: 2/12/14 Date Effective: 10/1/13 Transmittal Number: 13-21

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State: New Mexico Date Received: 12/13/13 Date Approved: 2/12/14 Date Effective: 10/1/13 Transmittal Number: 13-21

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State: New Mexico Date Received: 12/13/13 Date Approved: 2/12/14 Date Effective: 10/1/13 Transmittal Number: 13-21

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State: New Mexico Date Received: 12/13/13 Date Approved: 2/12/14 Date Effective: 10/1/13 Transmittal Number: 13-21

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State: New Mexico Date Received: 12/13/13 Date Approved: 2/12/14 Date Effective: 10/1/13 Transmittal Number: 13-21

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State: New Mexico Date Received: 12/13/13 Date Approved: 2/12/14 Date Effective: 10/1/13 Transmittal Number: 13-21

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State: New Mexico Date Received: 12/13/13 Date Approved: 2/12/14 Date Effective: 10/1/13 Transmittal Number: 13-21

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State: New Mexico Date Received: 12/13/13 Date Approved: 2/12/14 Date Effective: 10/1/13 Transmittal Number: 13-21

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State: New Mexico Date Received: 12/13/13 Date Approved: 2/12/14 Date Effective: 10/1/13 Transmittal Number: 13-21

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State: New Mexico Date Received: 12/13/13 Date Approved: 2/12/14 Date Effective: 10/1/13 Transmittal Number: 13-21

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State: New Mexico Date Received: 12/13/13 Date Approved: 2/12/14 Date Effective: 10/1/13 Transmittal Number: 13-21

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State: New Mexico Date Received: 12/13/13 Date Approved: 2/12/14 Date Effective: 10/1/13 Transmittal Number: 13-21

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State: New Mexico Date Received: 12/13/13 Date Approved: 2/12/14 Date Effective: 10/1/13 Transmittal Number: 13-21

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State: New Mexico Date Received: 12/13/13 Date Approved: 2/12/14 Date Effective: 10/1/13 Transmittal Number: 13-21

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State: New Mexico Date Received: 12/13/13 Date Approved: 2/12/14 Date Effective: 10/1/13 Transmittal Number: 13-21

NM 13-21 Page 25

State: New Mexico Date Received: 12/13/13 Date Approved: 2/12/14 Date Effective: 10/1/13 Transmittal Number: 13-21

NM 13-21 Page 26

State: New Mexico Date Received: 12/13/13 Date Approved: 2/12/14 Date Effective: 10/1/13 Transmittal Number: 13-21

NM 13-21 Page 27

State: New Mexico Date Received: 12/13/13 Date Approved: 2/12/14 Date Effective: 10/1/13 Transmittal Number: 13-21

NM 13-21 Page 28

State: New Mexico Date Received: 12/13/13 Date Approved: 2/12/14 Date Effective: 10/1/13 Transmittal Number: 13-21

NM 13-21 Page 29

State: New Mexico Date Received: 12/13/13 Date Approved: 2/12/14 Date Effective: 10/1/13 Transmittal Number: 13-21

NM 13-21 Page 30

State: New Mexico Date Received: 12/13/13 Date Approved: 2/12/14 Date Effective: 10/1/13 Transmittal Number: 13-21

NM 13-21 Page 31

State: New Mexico Date Received: 12/13/13 Date Approved: 2/12/14 Date Effective: 10/1/13 Transmittal Number: 13-21

NM 13-21 Page 32

State: New Mexico Date Received: 12/13/13 Date Approved: 2/12/14 Date Effective: 10/1/13 Transmittal Number: 13-21

NM 13-21 Page 33

State: New Mexico Date Received: 12/13/13 Date Approved: 2/12/14 Date Effective: 10/1/13 Transmittal Number: 13-21

NM 13-21 Page 34

State: New Mexico Date Received: 12/13/13 Date Approved: 2/12/14 Date Effective: 10/1/13 Transmittal Number: 13-21

Table of Contents

State/Territory Name: New Mexico State Plan Amendment (SPA) #: NM 13-0022 MM1 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Superseding Page List 4) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services

Dallas Regional Office

1301 Young Street, Suite 833

Dallas, Texas 75202

CMS

CENTERS FOR MEDICARE & MEDICAID SERVICES CONSORTIUM FOR MEDICAID & CHILDREN’S HEALTH OPERATIONS

DIVISION OF MEDICAID & CHILDREN’S HEALTH _- REGION VI

April 11, 2014

Ms. Julie Weinberg, Director

Medical Assistance Division

New Mexico Department of Human Services P.O. Box 2348

Santa Fe, New Mexico 87504

Dear Ms. Weinberg:

We have reviewed the proposed amendment to your Medicaid State Plan submitted under Transmittal Number (TN) 13-22. With the approval of TN 13-22, Centers for Medicare and Medicaid Services (CMS) has reviewed and approved eligibility standards for the State’s Medicaid mandatory and optional eligibility groups under the authority of the Social Security Act Section 1902(e)(14) and 42 Code of Federal Regulations (CFR) 435.603, and according to the new provisions of the Affordable Care Act

(ACA).

Transmittal Number 13-22 is approved with an effective date of January 1, 2014, as requested. A signed and dated copy of the Transmittal No. 13-22 summary is enclosed, along with the approved plan pages

and their attachments.

If you have any questions, please contact Stacey Shuman at (214) 767-6479.

Enclosures

Sincerely,

Bill Brooks

Associate Regional Administrator Division of Medicaid & Children’s Health Operations

1/14/14 4/11/14

NM.0735.R00.00 - Jan 01, 2014

Signature of State Agency Official

Submitted E Caitlin Kuennen Breen Last Revision Date: Apr 10, 2014

Submit Date: Jan 13, 2014

Page 2 of 2

1

SUPERSEDING PAGES OF STATE PLAN MATERIAL

TRANSMITTAL NUMBER:

13-0022-MM1

STATE:

New Mexico

Pages or sections of pages being superseded by S25, S28, S30, S51, S52, S53, S54, S57,S59 and S14 and related pages or sections of pages being deleted as obsolete

State Plan Section

Complete Pages Removed

Partial Pages Removed Attachment 2.2-A

Page 1 Page 3 Page 3a Page 4 Page 4a Page 12 Page 13 Page 13a Page 14 Page 14a Page 17a Page 23 Page 23b Page 23f Page 23G Page 23H

Page 2, A.2.b Page 2, A.2.c Page 2a, A.3 Page 5, A.10 Page 9c, B.1 for “Caretaker relatives” and “Pregnant women” Page 17b (1st paragraph Page 17c, #15 Page 20, B.14 Page 23c, B.20 Page 23c, B.22 Page 25, C.4

Supplement 1 to Attachment 2.2-A

Page 1

Attachment 2.6-A

Page 3b Page 11a Page 19 Page 19a Page 19b Page 21

Page 1, A.2.a(i) and (iii) Page 6 related to AFDC recipients, pregnant women, infants, and children Page 7, 1.a(1) and (2) Page 12, C.1.e(2) Page 18, C.5.e Page 21a, C.6.e Page 25, C.11.a(3) Supplement 1 to Attachment 2.6-A Pages 1, 1a, 2, and 3

Supplement 2 to Attachment 2.6-A

Pages 1-5

State: New Mexico Date Received: 1/14/14 Date Approved: 1/17/14 Effective Date: 1/1/14 Transmittal Number: NM 13-22 MM1

2

Supplement 8a to Attachment 2.6-A Page 3

Page 3a, #4,7, 8, 9 Page 3b for pregnant women and children

Supplement 8b to Attachment 2.6-A

Page 1 for children only. Page 2 for pregnant women and children only.

Supplement 12 to Attachment 2.6-A Pages 1, 2, 2a, 3

State: New Mexico Date Received: 1/14/14 Date Approved: 1/17/14 Effective Date: 1/1/14 Transmittal Number: NM 13-22 MM1

TN: NM 13-22 MM1 Date Effective: 1 Jan, 2014

State: New Mexico Date Received: 1/13/14 Date Approved: 4/11/14 Date Effective: 1/1/14 Transmittal Number: NM 13-22 MM1 Approved: 4/11/14

TN: NM 13-22 MM1 Date Effective: 1 Jan, 2014

State: New Mexico Date Received: 1/13/14 Date Approved: 4/11/14 Date Effective: 1/1/14 Transmittal Number: NM 13-22 MM1 Approved: 4/11/14

TN: NM 13-22 MM1 Date Effective: 1 Jan, 2014

State: New Mexico Date Received: 1/13/14 Date Approved: 4/11/14 Date Effective: 1/1/14 Transmittal Number: NM 13-22 MM1 Approved: 4/11/14

TN: NM 13-22 MM1 Date Effective: 1 Jan, 2014

State: New Mexico Date Received: 1/13/14 Date Approved: 4/11/14 Date Effective: 1/1/14 Transmittal Number: NM 13-22 MM1 Approved: 4/11/14

TN: NM 13-22 MM1 Date Effective: 1 Jan, 2014

State: New Mexico Date Received: 1/13/14 Date Approved: 4/11/14 Date Effective: 1/1/14 Transmittal Number: NM 13-22 MM1 Approved: 4/11/14

TN: NM 13-22 MM1 Date Effective: 1 Jan, 2014

State: New Mexico Date Received: 1/13/14 Date Approved: 4/11/14 Date Effective: 1/1/14 Transmittal Number: NM 13-22 MM1 Approved: 4/11/14

TN: NM 13-22 MM1 Date Effective: 1 Jan, 2014

State: New Mexico Date Received: 1/13/14 Date Approved: 4/11/14 Date Effective: 1/1/14 Transmittal Number: NM 13-22 MM1 Approved: 4/11/14

TN: NM 13-22 MM1 Date Effective: 1 Jan, 2014

State: New Mexico Date Received: 1/13/14 Date Approved: 4/11/14 Date Effective: 1/1/14 Transmittal Number: NM 13-22 MM1 Approved: 4/11/14

TN: NM 13-22 MM1 Date Effective: 1 Jan, 2014

State: New Mexico Date Received: 1/13/14 Date Approved: 4/11/14 Date Effective: 1/1/14 Transmittal Number: NM 13-22 MM1 Approved: 4/11/14

TN: NM 13-22 MM1 Date Effective: 1 Jan, 2014

State: New Mexico Date Received: 1/13/14 Date Approved: 4/11/14 Date Effective: 1/1/14 Transmittal Number: NM 13-22 MM1 Approved: 4/11/14

TN: NM 13-22 MM1 Date Effective: 1 Jan, 2014

State: New Mexico Date Received: 1/13/14 Date Approved: 4/11/14 Date Effective: 1/1/14 Transmittal Number: NM 13-22 MM1 Approved: 4/11/14

TN: NM 13-22 MM1 Date Effective: 1 Jan, 2014

State: New Mexico Date Received: 1/13/14 Date Approved: 4/11/14 Date Effective: 1/1/14 Transmittal Number: NM13-22 MM1 Approved: 4/11/14

TN: NM 13-22 MM1 Date Effective: 1 Jan, 2014

State: New Mexico Date Received: 1/13/14 Date Approved: 4/11/14 Date Effective: 1/1/14 Transmittal Number: NM 13-22 MM1 Approved: 4/11/14

TN: NM 13-22 MM1 Date Effective: 1 Jan, 2014

State: New Mexico Date Received: 1/13/14 Date Approved: 4/11/14 Date Effective: 1/1/14 Transmittal Number: NM 13-22 MM1 Approved: 4/11/14

TN: NM 13-22 MM1 Date Effective: 1 Jan, 2014

State: New Mexico Date Received: 1/13/14 Date Approved: 4/11/14 Date Effective: 1/1/14 Transmittal Number: NM 13-22 MM1 Approved: 4/11/14

TN: NM 13-22 MM1 Date Effective: 1 Jan, 2014

State: New Mexico Date Received: 1/13/14 Date Approved: 4/11/14 Date Effective: 1/1/14 Transmittal Number: NM 13-22 MM1 Approved: 4/11/14

TN: NM 13-22 MM1 Date Effective: 1 Jan, 2014

State: New Mexico Date Received: 1/13/14 Date Approved: 4/11/14 Date Effective: 1/1/14 Transmittal Number: NM 13-22 MM1 Approved: 4/11/14

TN: NM 13-22 MM1 Date Effective: 1 Jan, 2014

State: New Mexico Date Received: 1/13/14 Date Approved: 4/11/14 Date Effective: 1/1/14 Transmittal Number: NM 13-22 MM1 Approved: 4/11/14

TN: NM 13-22 MM1 Date Effective: 1 Jan, 2014

State: New Mexico Date Received: 1/13/14 Date Approved: 4/11/14 Date Effective: 1/1/14 Transmittal Number: NM 13-22 MM1 Approved: 4/11/14

TN: NM 13-22 MM1 Date Effective: 1 Jan, 2014

State: New Mexico Date Received: 1/13/14 Date Approved: 4/11/14 Date Effective: 1/1/14 Transmittal Number: NM 13-22 MM1 Approved: 4/11/14

TN: NM 13-22 MM1 Date Effective: 1 Jan, 2014

State: New Mexico Date Received: 1/13/14 Date Approved: 4/11/14 Date Effective: 1/1/14 Transmittal Number: NM 13-22 MM1 Approved: 4/11/14

TN: NM 13-22 MM1 Date Effective: 1 Jan, 2014

State: New Mexico Date Received: 1/13/14 Date Approved: 4/11/14 Date Effective: 1/1/14 Transmittal Number: NM 13-22 MM1 Approved: 4/11/14

TN: NM 13-22 MM1 Date Effective: 1 Jan, 2014

State: New Mexico Date Received: 1/13/14 Date Approved: 4/11/14 Date Effective: 1/1/14 Transmittal Number: NM 13-22 MM1 Approved: 4/11/14

TN: NM 13-22 MM1 Date Effective: 1 Jan, 2014

State: New Mexico Date Received: 1/13/14 Date Approved: 4/11/14 Date Effective: 1/1/14 Transmittal Number: NM 13-22 MM1 Approved: 4/11/14

TN: NM 13-22 MM1 Date Effective: 1 Jan, 2014

State: New Mexico Date Received: 1/13/14 Date Approved: 4/11/14 Date Effective: 1/1/14 Transmittal Number: NM 13-22 MM1 Approved: 4/11/14

TN: NM 13-22 MM1 Date Effective: 1 Jan, 2014

State: New Mexico Date Received: 1/13/14 Date Approved: 4/11/14 Date Effective: 1/1/14 Transmittal Number: NM 13-22 MM1 Approved: 4/11/14

TN: NM 13-22 MM1 Date Effective: 1 Jan, 2014

State: New Mexico Date Received: 1/13/14 Date Approved: 4/11/14 Date Effective: 1/1/14 Transmittal Number: NM 13-22 MM1 Approved: 4/11/14

TN: NM 13-22 MM1 Date Effective: 1 Jan, 2014

State: New Mexico Date Received: 1/13/14 Date Approved: 4/11/14 Date Effective: 1/1/14 Transmittal Number: NM 13-22 MM1 Approved: 4/11/14

TN: NM 13-22 MM1 Date Effective: 1 Jan, 2014

State: New Mexico Date Received: 1/13/14 Date Approved: 4/11/14 Date Effective: 1/1/14 Transmittal Number: NM 13-22 MM1 Approved: 4/11/14

TN: NM 13-22 MM1 Date Effective: 1 Jan, 2014

State: New Mexico Date Received: 1/13/14 Date Approved: 4/11/14 Date Effective: 1/1/14 Transmittal Number: NM 13-22 MM1 Approved: 4/11/14

TN: NM 13-22 MM1 Date Effective: 1 Jan, 2014

State: New Mexico Date Received: 1/13/14 Date Approved: 4/11/14 Date Effective: 1/1/14 Transmittal Number: NM 13-22 MM1 Approved: 4/11/14

TN: NM 13-22 MM1 Date Effective: 1 Jan, 2014

State: New Mexico Date Received: 1/13/14 Date Approved: 4/11/14 Date Effective: 1/1/14 Transmittal Number: NM 13-22 MM1 Approved: 4/11/14

TN: NM 13-22 MM1 Date Effective: 1 Jan, 2014

State: New Mexico Date Received: 1/13/14 Date Approved: 4/11/14 Date Effective: 1/1/14 Transmittal Number: NM 13-22 MM1 Approved: 4/11/14

TN: NM 13-22 MM1 Date Effective: 1 Jan, 2014

State: New Mexico Date Received: 1/13/14 Date Approved: 4/11/14 Date Effective: 1/1/14 Transmittal Number: NM 13-22 MM1 Approved: 4/11/14

TN: NM 13-22 MM1 Date Effective: 1 Jan, 2014

State: New Mexico Date Received: 1/13/14 Date Approved: 4/11/14 Date Effective: 1/1/14 Transmittal Number: NM 13-22 MM1 Approved: 4/11/14

Final TN: NM 13-22 MM1 Date Effective: 1 Jan, 2014

State: New Mexico Date Received: 1/13/14 Date Approved: 4/11/14 Date Effective: 1/1/14 Transmittal Number: NM 13-22 MM1 Approved: 4/11/14

TN: NM 13-22 MM1 Date Effective: 1 Jan, 2014

State: New Mexico Date Received: 1/13/14 Date Approved: 4/11/14 Date Effective: 1/1/14 Transmittal Number: NM 13-22 MM1 Approved: 4/11/14

TN: NM 13-22 MM1 Date Effective: 1 Jan, 2014

State: New Mexico Date Received: 1/13/14 Date Approved: 4/11/14 Date Effective: 1/1/14 Transmittal Number: NM 13-22 MM1 Approved: 4/11/14

TN: NM 13-22 MM1 Date Effective: 1 Jan, 2014

State: New Mexico Date Received: 1/13/14 Date Approved: 4/11/14 Date Effective: 1/1/14 Transmittal Number: NM 13-22 MM1 Approved: 4/11/14

TN: NM 13-22 MM1 Date Effective: 1 Jan, 2014

State: New Mexico Date Received: 1/13/14 Date Approved: 4/11/14 Date Effective: 1/1/14 Transmittal Number: NM 13-22 MM1 Approved: 4/11/14

TN: NM 13-22 MM1 Date Effective: 1 Jan, 2014

State: New Mexico Date Received: 1/13/14 Date Approved: 4/11/14 Date Effective: 1/1/14 Transmittal Number: NM 13-22 MM1 Approved: 4/11/14

TN: NM 13-22 MM1 Date Effective: 1 Jan, 2014

State: New Mexico Date Received: 1/13/14 Date Approved: 4/11/14 Date Effective: 1/1/14 Transmittal Number: NM 13-22 MM1 Approved: 4/11/14

TN: NM 13-22 MM1 Date Effective: 1 Jan, 2014

State: New Mexico Date Received: 1/13/14 Date Approved: 4/11/14 Date Effective: 1/1/14 Transmittal Number: NM 13-22 MM1 Approved: 4/11/14

TN: NM 13-22 MM1 Date Effective: 1 Jan, 2014

State: New Mexico Date Received: 1/13/14 Date Approved: 4/11/14 Date Effective: 1/1/14 Transmittal Number: NM 13-22 MM1 Approved: 4/11/14

Table of Contents

State/Territory Name: New Mexico State Plan Amendment (SPA) #: NM 13-0024 MM5 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Superseding Page List 4) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services

Dallas Regional Office

1301 Young Street, Suite 833

Dallas, Texas 75202

CENTERS FOR MEDICARE & MEDI CONSORTIUM FOR MI & CHILDREN’S HEALTH OPERATIONS

DIVISION OF MEDICAID & CHILDREN’S HEALTH _- REGION VI

April 11, 2014

Ms. Julie Weinberg, Director

Medical Assistance Division

New Mexico Department of Human Services P.O. Box 2348

Santa Fe, New Mexico 87504

Dear Ms. Weinberg:

We have reviewed the proposed amendment to your Medicaid State Plan submitted under Transmittal Number (TN) 13-24. With the approval of TN 13-24, Centers for Medicare and Medicaid Services (CMS) has reviewed and approved the State’s residency regulations, and policies regarding interstate agreements and temporary absence in regards to 42 Code of Federal Regulations (CFR) 435.603, and according to the requirements of the Social Security Act 1902(e)(14) and the Affordable Care Act

(ACA).

TN 13-24 is approved with an effective date of January 1, 2014, as requested. A signed and dated copy of the TN 13-24 summary is enclosed, along with the approved plan pages and their attachments.

If you have any questions, please contact Stacey Shuman at (214) 767-6479.

Enclosures

Sincerely,

Bill Brooks

Associate Regional Administrator Division of Medicaid & Children’s Health Operations

NM.0736.R00.00 - Jan 01, 2014 Page | of 2

Medicaid State Plan Eligibility: Summary Page (CMS 179)

State/Territory name: New Mexico

Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered.

NM-13-0024

Proposed Effective Date 01/01/2014

Federal Statute/Regulation Citation 42 CFR 435.403 and 1902(b) of the Act

Federal Budget Impact Federal Fiscal Year Amount

First Year 2014 $0.00

Second Year 2015 $0.00

Subject of Amendment S88 Non-Financial Eligibility - Updates State Residency criteria used for Section 42 CFR 435.403 1902(b) of the Act

Governor's Office Review Gov

Comments of Governor's office received Describe:

or's office reported no comment

No reply r Other, as specified

Describe:

Authority Delegated to the Medicaid Director

ved within 45 days of submittal

Signature of State Agency Official

Submitted By: Caitlin Kuennen Breen Last Revision Date: Apr 8, 2014 Submit Date: Jan 13, 2014

Date Received: 1/13/14

Date Approved: 4/11/14

Signature of Regional Official:

Printed Name and Title: Bill Brooks, Associate Regional Administrator, Division of Medicaid and Children's Health

SUPERSEDING PAGES OF STATE PLAN MATERIAL

TRANSMITTAL NUMBER:

NM-13-0024 STATE:

New Mexico

PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

S88 Non-Financial Eligibility- State Residency

PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable):

Section 2, Page 13, Item 2.3, TN 87-12 Attachment 2.6-A: Page 3, TN 09-08

State: New Mexico Date Received: 1/13/14 Date Approved: 4/11/14 Date Effective: 1/1/14 Transmittal Number: NM 13-24

Page 1 of 4 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Non-Financial Eligibility State Residency S88 42 CFR 435.403 State Residency The state provides Medicaid to otherwise eligible residents of the state, including residents who are absent from the state under certain conditions. ✔ Individuals are considered to be residents of the state under the following conditions: Non-institutionalized individuals age 21 and over, or under age 21, capable of indicating intent and who are emancipated or married, if the individual is living in the state and: ■ Intends to reside in the state, including without a fixed address, or ■ Entered the state with a job commitment or seeking employment, whether or not currently employed. ■ Individuals age 21 and over, not living in an institution, who are not capable of indicating intent, are residents of the state in which they live. ■ Non-institutionalized individuals under 21 not described above and non IV-E beneficiary children: ■ Residing in the state, with or without a fixed address, or ■ The state of residency of the parent or caretaker, in accordance with 42 CFR 435.403(h)(1), with whom the individual resides. ■ Individuals living in institutions, as defined in 42 CFR 435.1010, including foster care homes, who became incapable of indicating intent before age 21 and individuals under age 21 who are not emancipated or married: ■ Regardless of which state the individual resides, if the parent or guardian applying for Medicaid on the individual's behalf resides in the state, or ■ Regardless of which state the individual resides, if the parent or guardian resides in the state at the time of the individual's placement, or ■ If the individual applying for Medicaid on the individual's behalf resides in the state and the parental rights of the institutionalized individual's parent(s) were terminated and no guardian has been appointed and the individual is institutionalized in the state. ■ Individuals living in institutions who became incapable of indicating intent at or after age 21, if physically present in the state, unless another state made the placement. ■ Individuals who have been placed in an out-of-state institution, including foster care homes, by an agency of the state. ■ Any other institutionalized individual age 21 or over when living in the state with the intent to reside there, and not placed in the institution by another state. ■ IV-E eligible children living in the state, or ■ State: New Mexico Date Received: 1/13/14 Date Approved: 4/11/14 Date Effective: 1/1/14 Transmittal Number: NM 13-24 _______________________________________________________________________________________________ TN: NM 13-24

Date Approved: 4/11/14

Date Effective: 1/1/14

Page 2 of 4 Medicaid Eligibility Otherwise meet the requirements of 42 CFR 435.403. ■ State: New Mexico Date Received: 1/13/14 Date Approved: 4/11/14 Date Effective: 1/1/14 Transmittal Number: NM 13-24 _______________________________________________________________________________________________ TN: NM 13-24

Date Approved: 4/11/14

Date Effective: 1/1/14

Page 3 of 4 Medicaid Eligibility Meet the criteria specified in an interstate agreement. Yes No The state has interstate agreements with the following selected states: ■ Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming The interstate agreement contains a procedure for providing Medicaid to individuals pending resolution of their residency status and criteria for resolving disputed residency of individuals who (select all that apply): ■ Are IV-E eligible Are in the state only for the purpose of attending school Are out of the state only for the purpose of attending school Retain addresses in both states Other type of individual The state has a policy related to individuals in the state only to attend school. Yes No Otherwise meet the criteria of resident, but who may be temporarily absent from the state. ■ The state has a definition of temporary absence, including treatment of individuals who attend school in another state. Yes No State: New Mexico Date Received: 1/13/14 Date Approved: 4/11/14 Date Effective: 1/1/14 Transmittal Number: NM 13-24 _______________________________________________________________________________________________ TN: NM 13-24

Date Approved: 4/11/14

Date Effective: 1/1/14

Page 4 of 4 Medicaid Eligibility Provide a description of the definition:

Residence is not abandoned by temporary absences. Temporary absences occur when recipients leave New Mexico for specific purposes with time-limited goals. An individual may be temporarily absent from the State if the person intends to return when the purpose of the absence has been accomplished, unless another State has determined the individual is a resident there for purposes of Medicaid. PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938‐1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4‐26‐05, Baltimore, Maryland 21244‐1850. State: New Mexico Date Received: 1/13/14 Date Approved: 4/11/14 Date Effective: 1/1/14 Transmittal Number: NM 13-24 _______________________________________________________________________________________________ TN: NM 13-24

Date Approved: 4/11/14

Date Effective: 1/1/14

Table of Contents

State/Territory Name: New Mexico State Plan Amendment (SPA) #: NM 13-0025 MM6 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Superseding Page Listing 4) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services

Dallas Regional Office Rd 1301 Young Street, Room 714

Dallas, Texas 75202 CENTERS FOR MEDICARE & MEDICAID SERVICES

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

March 19, 2014

Ms. Julie Weinberg, Director

Medical Assistance Division

New Mexico Department of Human Services P.O. Box 2348

Santa Fe, New Mexico 87504

Dear Ms. Weinberg:

We have reviewed the proposed amendment to your Medicaid State Plan submitted under Transmittal Number (TN) 13-25. With the approval of TN 13-25, CMS has reviewed and approved updates to Citizenship and Non-Citizen Eligibility under Section 1903(v)(4) of the Act, and in accordance with provisions as outlined in the Affordable Care Act (ACA).

Transmittal Number 13-25 is approved with an effective date of January |, 2014, as requested. A signed and dated copy of the Transmittal No. 13-25 summary is enclosed, along with the

approved plan pages and their attachments.

If you have any questions, please contact Stacey Shuman at (214) 767-6479.

Sincerely,

Bill Brooks Associate Regional Administrator Division of Medicaid & Children’s Health Operations

Enclosures

NM.0734.R00.00 - Jan 01, 2014 -

Medicaid State Plan Eligibility: Summary Page (CMS 179)

State/Territory name: New Mexico

Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered.

NM-13-0025

Proposed Effective Date 01/01/2014

Federal Statute/Regulation Citation 42 CFR 435.406, 42 CFR 435.956, 42 CFR 435.4,1902(a)(46)(B), 8 U.S.C. 1611, 1612, 1613, and 1641, and 19

Federal Budget Impact

Federal Fiscal Year Amount First Year 2014 $0.00 Second Year 2015 $0.00

Subject of Amendment $89 Non-Financial Eligibility : Updates Citizenship and Non-Citizen Eligibility under Section 1903(v)(4) of the Act.

Governor's Office Review Governor's office reported no comment

Comments of Governor's office received Describe:

No reply received within 45 days of submittal Other, as specified

Describe:

Authority Delegated to Medicaid Director

Signature of State Agency Official

Submitted By: Caitlin Kuennen Breen Last Revision Date: Mar 4, 2014 Submit Date: Jan 13, 2014

Date Received: 1/13/14

Date Approved: 3/19/14 pF

Signature of Regional Official:

PRINTED NAME and Title: Bill Brooks, Associate Regional Administrator Division of Medicaid and Children's Health

SUPERSEDING PAGES OF STATE PLAN MATERIAL

TRANSMITTAL NUMBER:

NM 13-25

STATE:

New Mexico

PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

S89 Non-Financial Eligibility- Citizenship and Non-Citizen Eligibility

PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable):

Attachment 2.6-A: Page 2a, TN 09-08 Attachment 2.6-A: Page 2b, TN 09-08 Attachment 2.6-A, Page 2c, TN 09-08

State: New Mexico Date Received: 1/13/14 Date Approved: 3/19/14 Effective Date: 1/1/4 Transmittal Number: 13-25 ___________________________________________________________________________ TN No: 13-25

APPROVAL DATE: 3/19/14

EFFECTIVE DATE: 1/1/14 STATE: NEW MEXICO

SUPERSEDING DOCUMENT

Page 1 of 3 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Non-Financial Eligibility Citizenship and Non-Citizen Eligibility S89 1902(a)(46)(B) 8 U.S.C. 1611, 1612, 1613, and 1641 1903(v)(2),(3) and (4) 42 CFR 435.4 42 CFR 435.406 42 CFR 435.956 Citizenship and Non-Citizen Eligibility The state provides Medicaid to citizens and nationals of the United States and certain non-citizens consistent with requirements of 42 CFR 435.406, including during a reasonable opportunity period pending verification of their citizenship, national status or satisfactory immigration status. ✔ The state provides Medicaid eligibility to otherwise eligible individuals: ■ Who are citizens or nationals of the United States; and

■ Who are qualified non-citizens as defined in section 431 of the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) (8 U.S.C. §1641), or whose eligibility is required by section 402(b) of PRWORA (8 U.S.C. §1612(b)) and is not prohibited by section 403 of PRWORA (8 U.S.C. §1613); and ■ Who have declared themselves to be citizens or nationals of the United States, or an individual having satisfactory immigration status, during a reasonable opportunity period pending verification of their citizenship, nationality or satisfactory immigration status consistent with requirements of 1903(x), 1137(d), 1902(ee) of the SSA and 42 CFR 435.406, and 956.

■ The reasonable opportunity period begins on and extends 90 days from the date the notice of reasonable opportunity is received by the individual. The agency provides for an extension of the reasonable opportunity period if the individual is making a good faith effort to resolve any inconsistencies or obtain any necessary documentation, or the agency needs more time to complete the verification process. Yes No The agency begins to furnish benefits to otherwise eligible individuals during the reasonable opportunity period on a date earlier than the date the notice is received by the individual. Yes No The date benefits are furnished is: The date of application containing the declaration of citizenship or immigration status. The date the reasonable opportunity notice is sent. Other date, as described: State: New Mexico Date Received: 1/13/14 Date Approved: 3/19/14 Effective Date: 1/1/4 Transmittal Number: 13-25 ___________________________________________________________________________ TN No: 13-25

APPROVAL DATE: 3/19/14

EFFECTIVE DATE: 1/1/14 STATE: NEW MEXICO

SUPERSEDES: NEW PAGE

Page 2 of 3 Medicaid Eligibility The state provides Medicaid coverage to all Qualified Non-Citizens whose eligibility is not prohibited by section 403 of PRWORA (8 U.S.C. §1613). Yes No The state elects the option to provide Medicaid coverage to otherwise eligible individuals under 21 and pregnant women, lawfully residing in the United States, as provided in section 1903(v)(4) of the Act. Yes No Pregnant women Individuals under age 21: Individuals under age 21 Individuals under age 20 Individuals under age 19 An individual is considered to be lawfully residing in the United States if he or she is lawfully present and otherwise meets the eligibility requirements in the state plan. ■ An individual is considered to be lawfully present in the United States if he or she: ■ 1. Is a qualified non-citizen as defined in 8 U.S.C. 1641(b) and (c); 2. Is a non-citizen in a valid nonimmigrant status, as defined in 8 U.S.C. 1101(a)(15) or otherwise under the immigration laws (as defined in 8 U.S.C. 1101(a)(17)); 3. Is a non-citizen who has been paroled into the United States in accordance with 8 U.S.C. 1182(d)(5) for less than 1 year, except for an individual paroled for prosecution, for deferred inspection or pending removal proceedings; 4. Is a non-citizen who belongs to one of the following classes: Granted temporary resident status in accordance with 8 U.S.C. 1160 or 1255a, respectively; ■ Granted Temporary Protected Status (TPS) in accordance with 8 U.S.C. §1254a, and individuals with pending applications for TPS who have been granted employment authorization; ■ Granted employment authorization under 8 CFR 274a.12(c); ■ Family Unity beneficiaries in accordance with section 301 of Pub. L. 101-649, as amended; ■ Under Deferred Enforced Departure (DED) in accordance with a decision made by the President; ■ Granted Deferred Action status; ■ Granted an administrative stay of removal under 8 CFR 241; ■ Beneficiary of approved visa petition who has a pending application for adjustment of status; ■ 5. Is an individual with a pending application for asylum under 8 U.S.C. 1158, or for withholding of removal under 8 U.S.C.1231, or under the Convention Against Torture who - Has been granted employment authorization; or ■ Is under the age of 14 and has had an application pending for at least 180 days; ■ State: New Mexico Date Received: 1/13/14 Date Approved: 3/19/14 Effective Date: 1/1/4 Transmittal Number: 13-25 ___________________________________________________________________________ TN No: 13-25

APPROVAL DATE: 3/19/14

EFFECTIVE DATE: 1/1/14 STATE: NEW MEXICO

SUPERSEDES:NEW PAGE

Page 3 of 3 Medicaid Eligibility 6. Has been granted withholding of removal under the Convention Against Torture; 7. Is a child who has a pending application for Special Immigrant Juvenile status as described in 8 U.S.C. 1101(a)(27)(J); 8. Is lawfully present in American Samoa under the immigration laws of American Samoa; or 9. Is a victim of severe trafficking in persons, in accordance with the Victims of Trafficking and Violence Protection Act of 2000, Pub. L. 106-386, as amended (22 U.S.C. 7105(b)); 10. Exception: An individual with deferred action under the Department of Homeland Security's deferred action for the childhood arrivals process, as described in the Secretary of Homeland Security's June 15, 2012 memorandum, shall not be considered to be lawfully present with respect to any of the above categories in paragraphs (1) through (9) of this definition. Other 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 SSA 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 and/or present an SSN: ✔ Qualified non-citizens subject to the 5 year waiting period described in 8 U.S.C. 1613; ■ Non-qualified non-citizens, unless covered as a lawfully residing child or pregnant woman by the state under the option in accordance with 1903(v)(4) and implemented at 435.406(b). ■ PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. State: New Mexico Date Received: 1/13/14 Date Approved: 3/19/14 Effective Date: 1/1/4 Transmittal Number: 13-25 ___________________________________________________________________________ TN No: 13-25

APPROVAL DATE: 3/19/14

EFFECTIVE DATE: 1/1/14 STATE: NEW MEXICO

SUPERSEDES: NEW PAGE

_____________________________________________________________________________

Table of Contents State/Territory Name: New Mexico State Plan Amendment (SPA) #: 13-26 MM7 This file contains the following documents in the order listed: 1) Approval Letter 2) Companion Letter 3) CMS 179 Form/Summary Form 4) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services

Dallas Regional Office < Rv Ses 1301 Young Street, Room 714 Dallas, Texas 75202 CENTERS FOR MEDICARE & MEDICAID SERVICES

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

June 13, 2014

Ms. Julie Weinberg, Director

Medical Assistance Division

New Mexico Department of Human Services P.O. Box 2348

Santa Fe, New Mexico 87504

RE: Transmittal Number NM 13-026

Dear Ms. Weinberg:

We have reviewed the proposed amendment to your Medicaid State Plan submitted under Transmittal Number (TN) 13-26, dated March 26, 2014. With the approval of TN 13-26, the State is clarifying its options for Medicaid presumptive eligibility performed by hospitals.

Transmittal Number 13-26 is approved with an effective date of January 1, 2014, as requested. A signed and dated copy of the Transmittal No. 13-26 summary is enclosed, along with the approved plan pages and their attachments.

If you have any questions concerning this SPA, please contact Stacey Shuman at 214 767-6479 or by email at Stacey.Shuman@cms.hhs.gov.

Sincerely,

Bill Brooks Associate Regional Administrator Division of Medicaid & Children’s Health Operations

Enclosures

NM.0827.R00.00 - Jan 01, 2014 Page | of 2

Medicaid State Plan Eligibility: Summary Page (CMS 179)

State/Territory name: New Mexico

Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-Y¥-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered.

NM-13-0026

Proposed Effective Date 01/01/2014

Federal Statute/Regulation Citation 42 CFR 435.1110

Federal Budget Impact

Federal Fiscal Year Amount First Year = 2014 $ 17500000.00 Second Year 2015 $89300000.00

Subject of Amendment New Mexico Presumptive Eligibility by Hospitals (S21)

Governor's Office Re Governor's office reported no comment

Comments of Governor's office received Describe:

No reply received within 45 days of submittal » Other, as specified

Describe:

Authority Delegated to Medicaid Director

Signature of State Agency Official

Submitted By: Caitlin Kuennen Breen Last Revision Date: Mar 26, 2014 Submit Date: Mar 26, 2014

Date Received: March 26, 2014 Date Approved: June 13, 2014 Signature of Regional Official: Fe Printed Name and Title: Bill Brooks, Associate Regional Administrator, Division of Medicaid and Children's Health https://wms-mmdl.cdsvde.com/MMDL/faces/protected/mac/c01/print/PrintSelector.jsp 06/17/2014

USE OF THE ALTERNATIVE SINGLE STREAMLINED APPLICATION ( )Paper Application ( X ) Online A pplication TRANSMITTAL NUMBER: NM 13-26 MM7 STATE: New Mexico The plan amends the Connect Care under the authority of section 1932(a)(1)(A) of the Social Security Act (the Act). Under this authority, a state can amend its Medicaid state plan to require certain categories of Medicaid beneficiaries to enroll in managed care entities without being out of compliance.

State: New Mexico Date Received: 3/26/14 Date Approved: 6/13/14 Effective Date: 1/1/14 Transmittal Number: NM 13-26

Page 1 of 3 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Presumptive Eligibility by Hospitals S21 42 CFR 435.1110 One or more qualified hospitals are determining presumptive eligibility under 42 CFR 435.1110, and the state is providing Medicaid coverage for individuals determined presumptively eligible under this provision. Yes No The state attests that presumptive eligibility by hospitals is administered in accordance with the following provisions: ✔ A qualified hospital is a hospital that: ■ Participates as a provider under the Medicaid state plan or a Medicaid 1115 Demonstration, notifies the Medicaid agency of its election to make presumptive eligibility determinations and agrees to make presumptive eligibility determinations consistent with state policies and procedures. ■ Has not been disqualified by the Medicaid agency for failure to make presumptive eligibility 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. ■ Assists individuals in completing and submitting the full application and understanding any documentation requirements. Yes No The eligibility groups or populations for which hospitals determine eligibility presumptively are: ■ Pregnant Women ■ Infants and Children under Age 19 ■ Parents and Other Caretaker Relatives ■ Adult Group, if covered by the state ■ Individuals above 133% FPL under Age 65, if covered by the state ■ Individuals Eligible for Family Planning Services, if covered by the state ■ Former Foster Care Children ■ Certain Individuals Needing Treatment for Breast or Cervical Cancer, if covered by the state ■ Other Family/Adult groups: Eligibility groups for individuals age 65 and over Eligibility groups for individuals who are blind Eligibility groups for individuals with disabilities Other Medicaid state plan eligibility groups Demonstration populations covered under section 1115 The state establishes standards for qualified hospitals making presumptive eligibility determinations. TN: NM 13-26 Approval Date: 06/13/14 Effective Date: 01/01/14 State: New Mexico Date Received: 3/26/14 Date Approved: 6/13/14 Effective Date: 1/1/14 Transmittal Number: NM 13-26

Page 2 of 3 Medicaid Eligibility Yes No Select one or both: The state has standards that relate to the proportion of individuals determined presumptively eligible who submit a regular application, as described at 42 CFR 435.907, before the end of the presumptive eligibility period. Description of standards: 90% of PE should result in a submission of a Medicaid application. The state has standards that relate to the proportion of individuals who are determined eligible for Medicaid based on the submission of an application before the end of the presumptive eligibility period. Description of standards: 90% of Medicaid applications that are submitted with a PE determination should result in Medicaid eligibility. The presumptive period begins on the date the determination is made. ■ The end date of the presumptive period is the earlier of: ■ The date the eligibility determination for regular Medicaid is made, if an application for Medicaid is filed by the last day of the month following the month in which the determination of presumptive eligibility is made; or The last day of the month following the month in which the determination of presumptive eligibility is made, if no application for Medicaid is filed by that date. Periods of presumptive eligibility are limited as follows: ■ No more than one period within a calendar year. No more than one period within two calendar years. No more than one period within a twelve-month period, starting with the effective date of the initial presumptive eligibility period. Other reasonable limitation: The state requires that a written application be signed by the applicant, parent or representative, as appropriate. Yes No The state uses a single application form for Medicaid and presumptive eligibility, approved by CMS. The state uses a separate application form for presumptive eligibility, approved by CMS. A copy of the application form is included. An attachment is submitted. TN: NM 13-26 Approval Date: 06/13/14 Effective Date: 01/01/14 State: New Mexico Date Received: 3/26/14 Date Approved: 6/13/14 Effective Date: 1/1/14 Transmittal Number: NM 13-26

Page 3 of 3 Medicaid Eligibility The presumptive eligibility determination is based on the following factors: ■ The individual’s categorical or non-financial eligibility for the group for which the individual’s presumptive eligibility is being determined (e.g., based on age, pregnancy status, status as a parent/caretaker relative, disability, or other requirements specified in the Medicaid state plan or a Medicaid 1115 demonstration for that group) ■ Household income must not exceed the applicable income standard for the group for which the individual's presumptive eligibility is being determined, if an income standard is applicable for this group. ■ State residency Citizenship, status as a national, or satisfactory immigration status The state assures that it has communicated the requirements for qualified hospitals, and has provided adequate training to the hospitals. A copy of the training materials has been included. ✔ An attachment is submitted. PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN: NM 13-26 Approval Date: 06/13/14 Effective Date: 01/01/14 State: New Mexico Date Received: 3/26/14 Date Approved: 6/13/14 Effective Date: 1/1/14 Transmittal Number: NM 13-26

_____________________________________________________________________________

Table of Contents State/Territory Name: New Mexico State Plan Amendment (SPA) #: 13-26 MM7 This file contains the following documents in the order listed: 1) Approval Letter 2) Companion Letter 3) CMS 179 Form/Summary Form 4) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services

Dallas Regional Office < Rv Ses 1301 Young Street, Room 714 Dallas, Texas 75202 CENTERS FOR MEDICARE & MEDICAID SERVICES

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

June 13, 2014

Ms. Julie Weinberg, Director

Medical Assistance Division

New Mexico Department of Human Services P.O. Box 2348

Santa Fe, New Mexico 87504

RE: Transmittal Number NM 13-026

Dear Ms. Weinberg:

We have reviewed the proposed amendment to your Medicaid State Plan submitted under Transmittal Number (TN) 13-26, dated March 26, 2014. With the approval of TN 13-26, the State is clarifying its options for Medicaid presumptive eligibility performed by hospitals.

Transmittal Number 13-26 is approved with an effective date of January 1, 2014, as requested. A signed and dated copy of the Transmittal No. 13-26 summary is enclosed, along with the approved plan pages and their attachments.

If you have any questions concerning this SPA, please contact Stacey Shuman at 214 767-6479 or by email at Stacey.Shuman@cms.hhs.gov.

Sincerely,

Bill Brooks Associate Regional Administrator Division of Medicaid & Children’s Health Operations

Enclosures

NM.0827.R00.00 - Jan 01, 2014 Page | of 2

Medicaid State Plan Eligibility: Summary Page (CMS 179)

State/Territory name: New Mexico

Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-Y¥-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered.

NM-13-0026

Proposed Effective Date 01/01/2014

Federal Statute/Regulation Citation 42 CFR 435.1110

Federal Budget Impact

Federal Fiscal Year Amount First Year = 2014 $ 17500000.00 Second Year 2015 $89300000.00

Subject of Amendment New Mexico Presumptive Eligibility by Hospitals (S21)

Governor's Office Re Governor's office reported no comment

Comments of Governor's office received Describe:

No reply received within 45 days of submittal » Other, as specified

Describe:

Authority Delegated to Medicaid Director

Signature of State Agency Official

Submitted By: Caitlin Kuennen Breen Last Revision Date: Mar 26, 2014 Submit Date: Mar 26, 2014

Date Received: March 26, 2014 Date Approved: June 13, 2014 Signature of Regional Official: Fe Printed Name and Title: Bill Brooks, Associate Regional Administrator, Division of Medicaid and Children's Health https://wms-mmdl.cdsvde.com/MMDL/faces/protected/mac/c01/print/PrintSelector.jsp 06/17/2014

USE OF THE ALTERNATIVE SINGLE STREAMLINED APPLICATION ( )Paper Application ( X ) Online A pplication TRANSMITTAL NUMBER: NM 13-26 MM7 STATE: New Mexico The plan amends the Connect Care under the authority of section 1932(a)(1)(A) of the Social Security Act (the Act). Under this authority, a state can amend its Medicaid state plan to require certain categories of Medicaid beneficiaries to enroll in managed care entities without being out of compliance.

State: New Mexico Date Received: 3/26/14 Date Approved: 6/13/14 Effective Date: 1/1/14 Transmittal Number: NM 13-26

Page 1 of 3 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Presumptive Eligibility by Hospitals S21 42 CFR 435.1110 One or more qualified hospitals are determining presumptive eligibility under 42 CFR 435.1110, and the state is providing Medicaid coverage for individuals determined presumptively eligible under this provision. Yes No The state attests that presumptive eligibility by hospitals is administered in accordance with the following provisions: ✔ A qualified hospital is a hospital that: ■ Participates as a provider under the Medicaid state plan or a Medicaid 1115 Demonstration, notifies the Medicaid agency of its election to make presumptive eligibility determinations and agrees to make presumptive eligibility determinations consistent with state policies and procedures. ■ Has not been disqualified by the Medicaid agency for failure to make presumptive eligibility 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. ■ Assists individuals in completing and submitting the full application and understanding any documentation requirements. Yes No The eligibility groups or populations for which hospitals determine eligibility presumptively are: ■ Pregnant Women ■ Infants and Children under Age 19 ■ Parents and Other Caretaker Relatives ■ Adult Group, if covered by the state ■ Individuals above 133% FPL under Age 65, if covered by the state ■ Individuals Eligible for Family Planning Services, if covered by the state ■ Former Foster Care Children ■ Certain Individuals Needing Treatment for Breast or Cervical Cancer, if covered by the state ■ Other Family/Adult groups: Eligibility groups for individuals age 65 and over Eligibility groups for individuals who are blind Eligibility groups for individuals with disabilities Other Medicaid state plan eligibility groups Demonstration populations covered under section 1115 The state establishes standards for qualified hospitals making presumptive eligibility determinations. TN: NM 13-26 Approval Date: 06/13/14 Effective Date: 01/01/14 State: New Mexico Date Received: 3/26/14 Date Approved: 6/13/14 Effective Date: 1/1/14 Transmittal Number: NM 13-26

Page 2 of 3 Medicaid Eligibility Yes No Select one or both: The state has standards that relate to the proportion of individuals determined presumptively eligible who submit a regular application, as described at 42 CFR 435.907, before the end of the presumptive eligibility period. Description of standards: 90% of PE should result in a submission of a Medicaid application. The state has standards that relate to the proportion of individuals who are determined eligible for Medicaid based on the submission of an application before the end of the presumptive eligibility period. Description of standards: 90% of Medicaid applications that are submitted with a PE determination should result in Medicaid eligibility. The presumptive period begins on the date the determination is made. ■ The end date of the presumptive period is the earlier of: ■ The date the eligibility determination for regular Medicaid is made, if an application for Medicaid is filed by the last day of the month following the month in which the determination of presumptive eligibility is made; or The last day of the month following the month in which the determination of presumptive eligibility is made, if no application for Medicaid is filed by that date. Periods of presumptive eligibility are limited as follows: ■ No more than one period within a calendar year. No more than one period within two calendar years. No more than one period within a twelve-month period, starting with the effective date of the initial presumptive eligibility period. Other reasonable limitation: The state requires that a written application be signed by the applicant, parent or representative, as appropriate. Yes No The state uses a single application form for Medicaid and presumptive eligibility, approved by CMS. The state uses a separate application form for presumptive eligibility, approved by CMS. A copy of the application form is included. An attachment is submitted. TN: NM 13-26 Approval Date: 06/13/14 Effective Date: 01/01/14 State: New Mexico Date Received: 3/26/14 Date Approved: 6/13/14 Effective Date: 1/1/14 Transmittal Number: NM 13-26

Page 3 of 3 Medicaid Eligibility The presumptive eligibility determination is based on the following factors: ■ The individual’s categorical or non-financial eligibility for the group for which the individual’s presumptive eligibility is being determined (e.g., based on age, pregnancy status, status as a parent/caretaker relative, disability, or other requirements specified in the Medicaid state plan or a Medicaid 1115 demonstration for that group) ■ Household income must not exceed the applicable income standard for the group for which the individual's presumptive eligibility is being determined, if an income standard is applicable for this group. ■ State residency Citizenship, status as a national, or satisfactory immigration status The state assures that it has communicated the requirements for qualified hospitals, and has provided adequate training to the hospitals. A copy of the training materials has been included. ✔ An attachment is submitted. PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN: NM 13-26 Approval Date: 06/13/14 Effective Date: 01/01/14 State: New Mexico Date Received: 3/26/14 Date Approved: 6/13/14 Effective Date: 1/1/14 Transmittal Number: NM 13-26

Table of Contents

State/Territory Name: New Mexico State Plan Amendment (SPA) #: 13-27 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form 3) Superseding Pages Notice 4) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services

Dallas Regional Office € ei SS 1301 Young Street, Room 714 Dallas, Texas 75202 CENTERS FOR MEDICARE & MEDICAID SERVICES

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

June 13, 2014

Ms. Julie Weinberg, Director

Medical Assistance Division

New Mexico Department of Human Services P.O. Box 2348

Santa Fe, New Mexico 87504

RE: Transmittal Number 13-027

Dear Ms. Weinberg:

The Centers for Medicare and Medicaid Services (CMS) has reviewed the proposed amendment to your Medicaid State Plan submitted under Transmittal Number (TN) 13-27. With the approval of TN 13-27, CMS has reviewed and approved the State’s defined Medicaid State Agency and its delegated Medicaid authority, in accordance with provisions as outlined in 42 CFR 431.10 - 12; 431.50; and the Affordable Care Act (ACA).

TN 13-27 is approved with an effective date of January 1, 2014, as requested. A signed and dated copy of the TN 13-27 summary is enclosed, along with the approved plan pages and their attachments.

If you have any questions, please contact Stacey Shuman at (214) 767-6479.

Sincerely,

Bill Brooks

Associate Regional Administrator

Division of Medicaid &

Children's Health Operations Enclosures

NM.0812.R00.00 - Jan 01, 2014 |

Medicaid State Plan Eligibility: Summary Page (CMS 179)

State/Territory name: New Mexico

Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-Y¥-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered.

NM-13-0027

Proposed Effective Date 01/01/2014

Federal Statute/Regulation Citation 42 CFR 431.10; 42 CFR 431.11; 42 CFR 431.12; 42 CFR 431.50

Federal Budget Impact

Federal Fiscal Year Amount First Year = 2014 $0.00 Second Year 2015 $0.00

Subject of Amendment New Mexico Medicaid Administration: Single State Agency (Al-A3)

Governor's Office Review Governor's office reported no comment

Comments of Governor's office received Describe:

No reply received within 45 days of submittal

Other, as specified Describe: Authority Delegated to Medicaid Director

Signature of State Agency Official

Submitted By: Caitlin Kuennen Breen Last Revision Date: Jun 12, 2014 Submit Date: Mar 18, 2014

DATE RECEIVED: March 18, 2014 DATE APPROVED: June 13, 2014 SIGNATURE OF REGIONAL OFFICIAL: PRINTED NAME AND TITLE:

Bill Brooks, Associate Regional Administrator, Division of Medicaid and Children's Health

https://wms-mmdl.cdsvde.com/MMDL/faces/protected/mac/c01/print/PrintSelector.jsp 06/13/2014

SUPERSEDING PAGES OF STATE PLAN MATERIAL

TRANSMITTAL NUMBER:

13-0027 STATE:

New Mexico

PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

A1 – A3

COMPLETE PAGES SUPERSEDED:

Page 1

Section 1.1 (pages 2-6)

Section 1.2 (page 7)

Section 1.3 (page 8)

Attachment 1.1-A (Attorney General certification)

Attachment 1.2-A (pages 1-4) (Organization and function of State Agency and Organizational chart)

Attachment 1.2-B (pages 1-4) (Organization and Function under Medical Assistance Division and organization chart)

Attachment 1.2-C (Description of professional medical and supporting staff)

PARTIAL PAGES SUPERSEDED:

Section 1.4 (page 9)(State Medical Care Advisory Committee only. Tribal consultation will remain in the state plan.)

State: New Mexico Date Received: 3/18/14 Date Approved: 6/13/14 Effective Date: 1/1/14 Transmittal Number: 13-27 TN: NM 13-27

Approved: 13 June, 2014

Effective: 1 January, 2014

Page 1 of 6 Medicaid Administration OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 State Plan Administration Designation and Authority A1 42 CFR 431.10 Designation and Authority State Name: New Mexico As a condition for receipt of Federal funds under title XIX of the Social Security Act, the single state agency named below submits the following state plan for the medical assistance program, and hereby agrees to administer the program in accordance with the provisions of this state plan, the requirements of titles XI and XIX of the Act, and all applicable Federal regulations and other official issuances of the Department. Name of single state agency: New Mexico Human Services Department Type of Agency: Title IV-A Agency Health Human Resources Other Type of Agency Human Services Agency and Title IV-A Agency The above named agency is the single state agency designated to administer or supervise the administration of the Medicaid program under title XIX of the Social Security Act. (All references in this plan to "the Medicaid agency" mean the agency named as the single state agency.) The state statutory citation for the legal authority under which the single state agency administers the state plan is: Section 9-8-4 (Human Services Department - established) and section 9-8-12 (Cooperation with the federal government; authority of secretary; single state agency status) of New Mexico Statutes The single state agency supervises the administration of the state plan by local political subdivisions. Yes No The certification signed by the state Attorney General identifying the single state agency and citing the legal authority under which it administers or supervises administration of the program has been provided. ✔ An attachment is submitted. The state plan may be administered solely by the single state agency, or some portions may be administered by other agencies. The single state agency administers the entire state plan under title XIX (i.e., no other agency or organization administers any portion of it). Yes No State: New Mexico Date Received: 3/18/14 Date Approved: 6/13/14 Effective Date: 1/1/14 Transmittal Number: 13-27 TN: NM 13-27

Approved: 13 June, 2014

Effective: 1 January, 2014

Page 2 of 6 Medicaid Administration The entity or entities that have responsibility for determinations of eligibility for families, adults, and for individuals under 21 are: The Medicaid agency Single state agency under Title IV-A (in the 50 states or the District of Columbia) or under Title I or XVI (AABD) in Guam, Puerto Rico, or the Virgin Islands An Exchange that is a government agency established under sections 1311(b)(1) or 1321(c)(1) of the Affordable Care Act The entity that has responsibility for determinations of eligibility for the aged, blind, and disabled are: The Medicaid agency Single state agency under Title IV-A (in the 50 states or the District of Columbia) or under Title I or XVI (AABD) in Guam, Puerto Rico, or the Virgin Islands An Exchange that is a government agency established under sections 1311(b)(1) or 1321(c)(1) of the Affordable Care Act The Federal agency administering the SSI program Indicate which agency determines eligibility for any groups whose eligibility is not determined by the Federal agency: Medicaid agency Title IV-A agency An Exchange The entity or entities that have responsibility for conducting fair hearings with respect to denials of eligibility based on the applicable modified adjusted gross income standard are: Medicaid agency An Exchange that is a government agency established under sections 1311(b)(1) or 1321(c)(1) of the Affordable Care Act An Exchange appeals entity, including an entity established under section 1411(f) of the Affordable Care Act The agency has established a review process whereby the agency reviews appeals decisions made by the Exchange or Exchange appeals entity or other state agency, but only with respect to conclusions of law, including interpretations of state or federal policies. Yes No State Plan Administration Organization and Administration A2 42 CFR 431.10 42 CFR 431.11 Organization and Administration Provide a description of the organization and functions of the Medicaid agency.

The Single State Agency designated to administer the Title XIX program in New Mexico is the Human Services Department. The Department is a Cabinet-level agency in the executive branch of the New Mexico state government. The Department's administrative head is the Secretary of the Human Services Department, which is a Governor-appointed Cabinet-level position.

The Department is organized into seven areas led and directed by the Office of the Secretary (OOS): Office of General Counsel State: New Mexico Date Received: 3/18/14 Date Approved: 6/13/14 Effective Date: 1/1/14 Transmittal Number: 13-27 TN: NM 13-27

Approved: 13 June, 2014

Effective: 1 January, 2014

Page 3 of 6 Medicaid Administration (OGC); Behavioral Health Services Division (BHSD); Child Support Enforcement Division (CSED); Income Support Division (ISD); Medical Assistance Division (MAD); Information Technology Division (ITD); and the Administrative Services Division (ASD), which provides finance, accounting and property management support for HSD, the Office of Human Resources (OHR), and the Office of Inspector General (OIG) providing audit, investigations, restitutions services and fair hearings for the department.

The unit responsible for administering the Title XIX program under the Single State Agency in New Mexico is the Medical Assistance Division (MAD).

MAD is lead by the Division Director, who is appointed by the Secretary, and who oversees three deputy directors, the Office of Health Care Reform, the Office of Chief Medical Officer, and several bureaus or units:

- Eligibility Bureau : analyzes eligibility changes required by federal and State legislation, and develops and promulgates all regulations and policies that pertain to Medicaid eligibility.

- Program Policy & Integrity Bureau: responsible for developing and modifying Medicaid program rules related to the Medicaid benefit package for many services and providers, except for waiver services and institutional services.

- Systems Bureau: provides analysis, project management, and contractor oversight related to the information systems used by MAD, including the Medicaid Management Information System (MMIS).

- Centennial Care (managed care) Bureau: responsible for the daily operational oversight and management of the managed care program.

- Communication & Education Bureau: develops and conducts educational outreach and media campaigns for Medical Assistance programs.

- Exempt Services & Programs Bureau: manages the following programs and contracts: Home and Community Based Services (HCBS) waivers for individuals with Developmental Disabilities (DD), HIV/AIDS, and Medically Fragile (MF) condition(s); Third Party Assessor (TPA)/Utilization Review contract; Intermediate Care Facilities for the Mentally Retarded (ICF-MR); and the Mi Via Self-Directed Waivers. The bureau also includes the School Health Office.

- Quality Bureau: ensure quality through oversight of all aspects of care through performance measurement and tracking of systemic quality indicators and issues.

- Budget Planning & Reporting Bureau: manages the financial planning and financial policy affairs of MAD. The bureau is the primary contact with HSD’s Administrative Services Division.

- Financial Management Bureau: reconciles and analyzes managed care State expenditures and enrollment statistical data for appropriateness of payment for all managed care lines of business.

- Director’s Office : The Director’s Office develops strategic goals and objectives, directs activities, and provides guidance to all levels of staff for all programs within MAD and is made up of the New Mexico Medicaid Director and three Deputies; the Office of the Medical Director; the Office of Healthcare Reform; a Healthcare Operations Manager; a Native American Liaison; and various support staff members.

The Fair Hearings Bureau is a division of the Office of Inspector General. The Administrative Law Judges of the Fair Hearings Bureau conduct hearings for the public assistance programs administered by the Human Services Department. The bureau schedules hundreds of hearings each year for more than 17 different categories of public assistance benefits. Hearing decision recommendations are submitted to HSD division directors who issue the final decision in accordance with federal and state regulations.

Medicaid eligibility determinations are made by the Human Services Department/Income Support Division with two exceptions. SSI determinations are made by the Social Security Administration through a 1634 agreement. The Children, Youth, and Families State: New Mexico Date Received: 3/18/14 Date Approved: 6/13/14 Effective Date: 1/1/14 Transmittal Number: 13-27 TN: NM 13-27

Approved: 13 June, 2014

Effective: 1 January, 2014

Page 4 of 6 Medicaid Administration Department makes eligibility determinations for adoption and foster care Medicaid.

Upload an organizational chart of the Medicaid agency. An attachment is submitted. Provide a description of the structure of the state's executive branch which includes how the Medicaid agency fits in with other health, human service and public assistance agencies. New Mexico is led by a Governor who oversees the executive branch, comprised of a number of different Cabinet departments. The Governor appoints the secretaries of each Cabinet department.

The Human Services Department establishes and maintains agreements with the New Mexico Department of Health, Department of Education and Children, Youth and Families Department concerning programs and projects of mutual interest, including the use of Medicaid funding for eligible services provided by or through other departments.

The Department of Health administers various components of New Mexico’s Developmentally Disabled (DD), Medically Fragile and Mi Via waivers including service provider contracting, determining if recipients meet the definition of DD, monitoring of waiver providers, and participation in fair hearings. In addition, the Department of Health assists with the administration of the School Based Health Centers, Nurse Aide Training, and other Public Health services that are reimbursable through Medicaid. The Department of Health assists with the administration of the Family, Infant and Toddler Program (FIT) for reimbursement.

The Public Education Department assists HSD in the administration of the Medicaid School Based Services program. HSD also contracts with school districts, overseen by the Public Education Department, to allow school districts to receive Medicaid reimbursement for Individualized Education Plan (IEP) and Individualized Family Service Plan (IFSP) related services.

The Children, Youth and Families Department provides the licenses and certification for Medical Assistance Division residential placements (Accredited Residential Treatment Centers-ARTC, Residential Treatment Centers-RTC, Group Homes, Treatment Foster Care) agencies and facilities. In addition the Children, Youth and Families Department assist with Medical Assistance Program eligibility determinations for eligible recipients the department has involvement with or responsibility for care.

HSD utilizes a Joint Powers Agreement or Governmental Services Agreement with each of the entities listed above. Entities that determine eligibility other than the Medicaid Agency (if entities are described under Designation and Authority) Remove Type of entity that determines eligibility: Single state agency under Title IV-A (in the 50 states or the District of Columbia) or under Title I or XVI (AABD) in Guam, Puerto Rico, or the Virgin Islands An Exchange that is a government agency established under sections 1311(b)(1) or 1321(c)(1) of the Affordable Care Act The Federal agency administering the SSI program Provide a description of the staff designated by the entity and the functions they perform in carrying out their responsibility. Pursuant to a 1634 agreement, the Social Security Administration determines Medicaid eligibility for Supplemental Security Income recipients. Add Entities that conduct fair hearings other than the Medicaid Agency (if are described under Designation and Authority) State: New Mexico Date Received: 3/18/14 Date Approved: 6/13/14 Effective Date: 1/1/14 Transmittal Number: 13-27 TN: NM 13-27

Approved: 13 June, 2014

Effective: 1 January, 2014

Page 5 of 6 Medicaid Administration Remove Type of entity that conducts fair hearings: An Exchange that is a government agency established under sections 1311(b)(1) or 1321(c)(1) of the Affordable Care Act An Exchange appeals entity, including an entity established under section 1411(f) of the Affordable Care Act Provide a description of the staff designated by the entity and the functions they perform in carrying out their responsibility. Add Supervision of state plan administration by local political subdivisions (if described under Designation and Authority) Is the supervision of the administration done through a state-wide agency which uses local political subdivisions? Yes No State Plan Administration Assurances A3 42 CFR 431.10 42 CFR 431.12 42 CFR 431.50 Assurances The state plan is in operation on a statewide basis, in accordance with all the requirements of 42 CFR 431.50. ✔ All requirements of 42 CFR 431.10 are met. ✔ There is a Medical Care Advisory Committee to the agency director on health and medical services established in accordance with meeting all the requirements of 42 CFR 431.12. ✔ The Medicaid agency does not delegate, to other than its own officials, the authority to supervise the plan or to develop or issue policies, rules, and regulations on program matters. ✔ Assurance for states that have delegated authority to determine eligibility: There is a written agreement between the Medicaid agency and the Exchange or any other state or local agency that has been delegated authority to determine eligibility for Medicaid eligibility in compliance with 42 CFR 431.10(d). Assurances for states that have delegated authority to conduct fair hearings: There is a written agreement between the Medicaid agency and the Exchange or Exchange appeals entity that has been delegated authority to conduct Medicaid fair hearings in compliance with 42 CFR 431.10(d). When authority is delegated to the Exchange or an Exchange appeals entity, individuals who have requested a fair hearing are given the option to have their fair hearing conducted instead by the Medicaid agency. Assurance for states that have delegated authority to determine eligibility and/or to conduct fair hearings: The Medicaid agency does not delegate authority to make eligibility determinations or to conduct fair hearings to entities other than government agencies which maintain personnel standards on a merit basis. ✔ State: New Mexico Date Received: 3/18/14 Date Approved: 6/13/14 Effective Date: 1/1/14 Transmittal Number: 13-27 TN: NM 13-27

Approved: 13 June, 2014

Effective: 1 January, 2014

Page 6 of 6 Medicaid Administration PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. V.20130917 State: New Mexico Date Received: 3/18/14 Date Approved: 6/13/14 Effective Date: 1/1/14 Transmittal Number: 13-27 TN: NM 13-27

Approved: 13 June, 2014

Effective: 1 January, 2014

Table of Contents

State/Territory Name: New Mexico State Plan Amendment (SPA) #: 13-30 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 1301 Young Street, Suite 833

CENTERS FOR MEDICARE & MEDICAID SERVICES

Dallas, Texas 75202 aaamaimaia tae hehe & CHILDREN’S HEALTH OPERATIONS

DIVISION OF MEDICAID & CHILDREN’S HEALTH _- REGION VI

June 12, 2014

Ms. Julie Weinberg, Director

Medical Assistance Division

New Mexico Department of Human Services P.O. Box 2348

Santa Fe, New Mexico 87504

RE: New Mexico State Plan Amendment (SPA) Transmittal Number 13-30

Dear Ms. Weinberg:

Enclosed for your records is an approved copy of New Mexico’s proposed Alternative Benefit Plan (ABP) State Plan Amendment (SPA) TN# 13-30. This ABP, which was submitted on March 18, 2014, meets all federal statutory and regulatory requirements for establishing an ABP. The state has selected (the) Lovelace Classic Preferred Provider Organization (PPO) 2013 base benchmark and has chosen to not align all of the benefits with its currently approved section 1905(a) Medicaid State plan.

All requirements pertaining to Alternative Benefit Plans must be met, including payment rates and reimbursement methodologies, cost-sharing state plan pages, and (if applicable) managed care service delivery systems. These must be updated as necessary to reflect other changes required by federal statute and regulation within allowable parameters.

Please note that we are aware that due to the ongoing system changes occurring with change requests, the State will not be able to immediately apply the revised language CMS approved for the beneficiary notices related to the ABP SPA. However, we respectfully request that the State send out the changes within the revised beneficiary notices no later than 90 days from the approval date of this ABP SPA.

This ABP SPA is approved effective 1/1/2014 as requested by your state. If you have any questions, please contact Stacey Shuman at (214) 767-6479.

Sincerely,

for Bill Brooks Associate Regional Administrator Division of Medicaid & Children’s Health

Enclosures

Medicaid Alternative Benefit Plan: Summary Page (CMS 179)

State/Territory name: New Mexico

Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-Y¥-0000 where ST= the state abbreviation, YY = the last pvo digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered.

NM-13-0030

Proposed Effective Date 01/01/2014

Federal Statute/Regulation Citation Affordable Care Act and Section 1937 of the Social Security Act

Federal Budget Impact Federal Fiscal Year Amount First Year 2014 $621098699.00 Second Year [2015 $ 1102541586.00

Subject of Amendment New Mexico Alternative Benefit Plan (New Adult Group): Populations, Voluntary Benefit Package Selection Assurances - Eligibility Group, Enrollment Assurances , Selection of Benchmark Benefit Package or Benchmark-Equivalent Benefit Package, Cost-Sharing Benefits Description and Assurance: ervice Delivery Systems, Employer Sponsored Insurance and Payment of Premiums, General Assurances and Payment Methodology

Governor's Office Review Governor's office reported no comment

Comments of Governor's office received Describe:

No reply received within 45 days of submittal Other, as specified

Describe:

Authority Delegated to the Medicaid Director

Signature of State Agency Official

Submitted By: Caitlin Kuennen Breen Last Revision Date: Jun 9, 2014 Submit Date: Mar 18, 2014

Date Received: March 18, 2014

Date Approved: June 12, 2014 ro Signature of Regional Official: for

PRINTED NAME and Title: Bill Brooks, Associate Regional Administrator Division of Medicaid and Children's Health

Alternative Benefit Plan Attachment 3.1-C- OMB Control Number: 0938‐1148 OMB Expiration date: 10/31/2014 Alternative Benefit Plan Populations ABP1 Identify and define the population that will participate in the Alternative Benefit Plan. Alternative Benefit Plan Population Name: New Mexico Expansion Alternative Benefit Plan Identify eligibility groups that are included in the Alternative Benefit Plan's population, and which may contain individuals that meet any targeting criteria used to further define the population. Eligibility Groups Included in the Alternative Benefit Plan Population: Eligibility Group: Enrollment is mandatory or voluntary? + Adult Group Mandatory x Enrollment is available for all individuals in these eligibility group(s). Yes Geographic Area The Alternative Benefit Plan population will include individuals from the entire state/territory. Yes Any other information the state/territory wishes to provide about the population (optional) PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 5 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. V.20130724 STATE: New Mexico DATE RECEIVED: 3/18/14 DATE APPROVED: 6/12/14 EFFECTIVE DATE: 1/1/14 TN: 13-30 TN: NM 13-30

Approved: 6/12/14

Effective: 1/1/14

Page 1 of 3 Alternative Benefit Plan Attachment 3.1-C- OMB Control Number: 0938‐1148 OMB Expiration date: 10/31/2014 Voluntary Benefit Package Selection Assurances - Eligibility Group under Section 1902(a)(10)(A) (i)(VIII) of the Act ABP2a The state/territory has fully aligned its benefits in the Alternative Benefit Plan using Essential Health Benefits and subject to 1937 requirements with its Alternative Benefit Plan that is the state’s approved Medicaid state plan that is not subject to 1937 requirements. Therefore the state/territory is deemed to have met the requirements for voluntary choice of benefit package for individuals exempt from mandatory participation in a section 1937 Alternative Benefit Plan. No These assurances must be made by the state/territory if the Adult eligibility group is included in the ABP Population. The state/territory shall enroll all participants in the "Individuals at or below 133% FPL Age 19 through 64" (section 1902(a)(10)(A) (i)(VIII)) eligibility group in the Alternative Benefit Plan specified in this state plan amendment, except as follows: A beneficiary in the eligibility group at section 1902(a)(10)(A)(i)(VIII) who is determined to meet one of the exemption criteria at 45 CFR 440.315 will receive a choice of a benefit package that is either an Alternative Benefit Plan that includes Essential Health Benefits and is subject to all 1937 requirements or an Alternative Benefit Plan that is the state/territory’s approved Medicaid state plan not subject to 1937 requirements. The state/territory’s approved Medicaid state plan includes all approved state plan programs based on any state plan authority, and approved 1915(c) waivers, if the state has amended them to include the eligibility group at section 1902(a)(10)(A) (i)(VIII). ✔ The state/territory must have a process in place to identify individuals that meet the exemption criteria and the state/territory must comply with requirements related to providing the option of enrollment in an Alternative Benefit Plan defined using section 1937 requirements, or an Alternative Benefit Plan defined as the state/territory's approved Medicaid state plan that is not subject to section 1937 requirements. ✔ Once an individual is identified, the state/territory assures it will effectively inform the individual of the following: ✔ a) Enrollment in the specified Alternative Benefit Plan is voluntary; b) The individual may disenroll from the Alternative Benefit Plan defined subject to section 1937 requirements at any time and instead receive an Alternative Benefit Plan defined as the approved state/territory Medicaid state plan that is not subject to section 1937 requirements; and c) What the process is for transferring to the state plan-based Alternative Benefit Plan. The state/territory assures it will inform the individual of: ✔ a) The benefits available as Alternative Benefit Plan coverage defined using section 1937 requirements as compared to Alternative Benefit Plan coverage defined as the state/territory's approved Medicaid state plan and not subject to section 1937 requirements; and b) The costs of the different benefit packages and a comparison of how the Alternative Benefit Plan subject to 1937 requirements differs from the Alternative Benefit Plan defined as the approved Medicaid state/territory plan benefits. How will the state/territory inform individuals about their options for enrollment? (Check all that apply) Letter Email Other STATE: New Mexico DATE RECEIVED: 3/18/14 DATE APPROVED: 6/12/14 EFFECTIVE DATE: 1/1/14 TN: 13-30 TN: NM 13-30

Approved: 6/12/14

Effective: 1/1/14

Page 2 of 3 Alternative Benefit Plan Provide a copy of the letter, email text or other communication text that will be used to inform individuals about their options for enrollment. An attachment is submitted. When did/will the state/territory inform the individuals? Notices of eligibility for the Adult Group will describe Alternative Benefit Plan (ABP) exemption criteria, processes for self- identification, and procedures for choosing to enroll in the Medicaid State Plan benefit package. Individuals who are enrolled in managed care will also receive information about the ABP, the exemption criteria and related processes from their managed care organization (MCO); this information is also contained in each MCO member handbook. Please describe the state/territory's process for allowing individuals in the Section 1902(a)(10)(A)(i)(VIII) eligibility group who meet exemption criteria to disenroll from the Alternative Benefit Plan defined using section 1937 requirements and enroll in the Alternative Benefit Plan defined as the state/territory's approved Medicaid state plan. Individuals in the Adult Group will be automatically enrolled in the ABP when they are determined eligible. Their eligibility notice, referenced and attached above, will describe how they can self-identify as being potentially exempt from the ABP. For managed care recipients, the self-identification process will be facilitated by the member's MCO, which will receive the request for an exemption, evaluate the member based on criteria set forth at 42 CFR 440.315 and further defined by the State, provide benefits counseling to the member (including a description of cost differences between the ABP and the Medicaid State Plan), and facilitate the member's voluntary selection of the ABP that is the Medicaid State Plan, if applicable.

The MCO may also identify members who may be Medically Frail and qualify for an ABP exemption through a mandatory Health Risk Assessment (HRA). The HRA is the first step of care coordination during which the MCO makes contact with their members, asks a series of general health questions, and explains care coordination. The HRA is designed to help the MCO identify members who may be candidates for care coordination due to their medical needs or health status, and is required within the first 30 days of a member's enrollment with the MCO. Members who are identified through the HRA as potentially Medically Frail will receive a Comprehensive Needs Assessment (CNA) to assess the member's physical and behavioral health needs, long-term care needs and disease management needs. The member will also receive a notice from the MCO about the ABP exemption criteria and process. Upon receipt of this notice, the member must initiate the request to be considered for a potential exemption from the ABP through self-identification.

For Native American Medicaid recipients who are exempt from managed care, the state's third-party assessor (TPA) contractor will receive and process the recipient's self-identification and request for an ABP exemption based on criteria set forth at 42 CFR 440.315 and further defined by the State. The TPA contractor will provide benefits counseling and facilitate the recipient's voluntary transition to the ABP that is the Medicaid State Plan, if applicable. The state/territory assures it will document in the exempt individual's eligibility file that the individual: ✔ a) Was informed in accordance with this section prior to enrollment; b) Was given ample time to arrive at an informed choice; and c) Chose to enroll in Alternative Benefit Plan coverage subject to section 1937 requirements or defined as the state/territory's approved Medicaid state plan, which is not subject to section 1937 requirements. Where will the information be documented? (Check all that apply) In the eligibility system. In the hard copy of the case record. Other What documentation will be maintained in the eligibility file? (Check all that apply) STATE: New Mexico DATE RECEIVED: 3/18/14 DATE APPROVED: 6/12/14 EFFECTIVE DATE: 1/1/14 TN: 13-30 TN: NM 13-30

Approved: 6/12/14

Effective: 1/1/14

Page 3 of 3 Alternative Benefit Plan Copy of correspondence sent to the individual. Signed documentation from the individual consenting to enrollment in the Alternative Benefit Plan. Other The state/territory assures that it will maintain data that tracks the total number of individuals who have voluntarily enrolled in either Alternative Benefit Plan coverage subject to section 1937 requirements or Alternative Benefit Plan coverage defined as the state/ territory's approved Medicaid state plan, which is not subject to section 1937 requirements. ✔ Other information related to benefit package selection assurances for exempt participants (optional): PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 5 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. V.20130807 STATE: New Mexico DATE RECEIVED: 3/18/14 DATE APPROVED: 6/12/14 EFFECTIVE DATE: 1/1/14 TN: 13-30 TN: NM 13-30

Approved: 6/12/14

Effective: 1/1/14

Page 1 of 3 Alternative Benefit Plan Attachment 3.1-C- OMB Control Number: 0938‐1148 OMB Expiration date: 10/31/2014 Enrollment Assurances - Mandatory Participants ABP2c These assurances must be made by the state/territory if enrollment is mandatory for any of the target populations or sub-populations. When mandatorily enrolling eligibility groups in an Alternative Benefit Plan (Benchmark or Benchmark-Equivalent Plan) that could have exempt individuals, prior to enrollment: The state/territory assures it will appropriately identify any individuals in the eligibility groups that are exempt from mandatory enrollment in an Alternative Benefit Plan or individuals who meet the exemption criteria and are given a choice of Alternative Benefit Plan coverage defined using section 1937 requirements or Alternative Benefit Plan coverage defined as the state/territory's approved Medicaid state plan, not subject to section 1937 requirements. ✔ How will the state/territory identify these individuals? (Check all that apply) Review of eligibility criteria (e.g., age, disorder/diagnosis/condition) Describe: Only individuals eligible for the Adult Group will be enrolled in the Alternative Benefit Plan (ABP). Individuals eligible for other Medicaid categories on the basis of their eligibility criteria (including age, disability and pregnancy) will be correctly identified at enrollment and placed in the correct category of eligibility. Adult Group members who become pregnant must report their pregnancy to a State eligibility office to facilitate their transition to the pregnancy category, or they will remain in the Adult Group. Self-identification Describe: Individuals in the Adult Group will be automatically enrolled in the ABP when they are determined eligible. Their eligibility notice will describe how they can self-identify as exempt from the ABP. For managed care recipients, the self-identification process will be facilitated by the member's MCO, which will receive the request for an exemption, evaluate the member based on criteria set forth at 42 CFR 440.315 and further defined by the State, provide benefits counseling to the member (including a description of cost differences between the ABP and Medicaid State Plan), and facilitate the member's voluntary selection of the ABP that is the Medicaid State Plan, if applicable.

For Native American Medicaid recipients who are exempt from managed care, the state's third-party assessor (TPA) contractor will receive and process the recipient's self-identification and request for an ABP exemption based on criteria set forth at 42 CFR 440.315 and further defined by the State. The TPA contractor will provide benefits counseling and facilitate the recipient's voluntary transition to the ABP that is the Medicaid State Plan, if applicable. Because Native American Medicaid recipients are exempt from cost-sharing under both the ABP and the Medicaid State Plan, the TPA contractor is not required to describe the cost differences between the two benefit plans, since the recipient will be exempt from cost-sharing in either instance. Other Describe: For managed care recipients, their managed care organization (MCO) may identify members who may be Medically Frail and qualify for an ABP exemption through a mandatory Health Risk Assessment (HRA). The HRA is the first step of care coordination during which the MCO makes contact with their members, asks a series of general health questions, and explains care coordination. The HRA is designed to help the MCO identify members who may be candidates for care coordination due to their medical needs or health status, and is required within the first 30 days of a member's enrollment with the MCO. Members who are identified through the HRA as potentially Medically Frail will receive a Comprehensive Needs Assessment (CNA) to assess the member's physical and behavioral health needs, long-term care needs and disease management needs. The Approval Date: Effective Date: 1/1/2014 STATE: New Mexico DATE RECEIVED: 3/18/14 DATE APPROVED: 6/12/14 EFFECTIVE DATE: 1/1/14 TN: 13-30 TN: NM 13-30

Approved: 6/12/14

Effective: 1/1/14

Page 2 of 3 Alternative Benefit Plan member will also receive a notice from the MCO about the ABP exemption criteria and process. Upon receipt of this notice, the member must initiate the request to be considered for a potential exemption from the ABP through self-identification.

Native American Medicaid recipients who opt-in to managed care will have access to the MCO processes described above, including the HRA, CNA and related care coordination; however, these services are not available to the Native American fee- for-service population. The state/territory must inform the individual they are exempt or meet the exemption criteria and the state/territory must comply with all requirements related to voluntary enrollment or, for beneficiaries in the “Individuals at or below 133% FPL Age 19 through 64” eligibility group, optional enrollment in Alternative Benefit Plan coverage defined using section 1937 requirements or Alternative Benefit Plan coverage defined as the state/territory's approved Medicaid state plan. ✔ The state/territory assures that for individuals who have become exempt from enrollment in an Alternative Benefit Plan, the state/ territory must inform the individual they are now exempt and the state/territory must comply with all requirements related to voluntary enrollment or, for beneficiaries in the “Individuals at or below 133% FPL Age 19 through 64” eligibility group, optional enrollment in Alternative Benefit Plan coverage defined using section 1937 requirements, or Alternative Benefit Plan coverage defined as the state/territory's approved Medicaid state plan. ✔ How will the state/territory identify if an individual becomes exempt? (Check all that apply) Review of claims data Self-identification Review at the time of eligibility redetermination Provider identification Change in eligibility group Other Describe: Managed care members who may be considered Medically Frail may also be identified through the MCO HRA process, described above. How frequently will the state/territory review the Alternative Benefit Plan population to determine if individuals are exempt from mandatory enrollment or meet the exemption criteria? Monthly Quarterly Annually Ad hoc basis Other The state/territory assures that it will promptly process all requests made by exempt individuals for disenrollment from the Alternative Benefit Plan and has in place a process that ensures exempt individuals have access to all standard state/territory plan services or, for beneficiaries in the “Individuals at or below 133% FPL Age 19 through 64” eligibility group, optional enrollment in Alternative Benefit Plan coverage defined using section 1937 requirements, or Alternative Benefit Plan coverage defined as the state/territory's approved Medicaid state plan. ✔ Approval Date: Effective Date: 1/1/2014 STATE: New Mexico DATE RECEIVED: 3/18/14 DATE APPROVED: 6/12/14 EFFECTIVE DATE: 1/1/14 TN: 13-30 TN: NM 13-30

Approved: 6/12/14

Effective: 1/1/14

Page 3 of 3 Alternative Benefit Plan Describe the process for processing requests made by exempt individuals to be disenrolled from the Alternative Benefit Plan: For managed care recipients, the self-identification process will be facilitated by the member's MCO, which will receive the request for an exemption, evaluate the member based on criteria set forth at 42 CFR 440.315 and further defined by the State, provide benefits counseling to the member (including a description of cost differences between the ABP and Medicaid State Plan), and facilitate the member's voluntary selection of the ABP that is the Medicaid State Plan, if applicable.

For Native American Medicaid recipients who are exempt from managed care, the state's third-party assessor (TPA) contractor will receive and process the recipient's self-identification and request for an ABP exemption based on criteria set forth at 42 CFR 440.315 and further defined by the State. The TPA contractor will provide benefits counseling and facilitate the recipient's voluntary transition to the ABP that is the Medicaid State Plan, if applicable. Because Native American Medicaid recipients are exempt from cost-sharing under both the ABP and the Medicaid State Plan, the TPA contractor is not required to describe the cost differences between the two benefit plans, since the recipient will be exempt from cost-sharing in either instance.

The MCOs and TPA contractor will conduct the evaluation of ABP exemption criteria, benefits counseling and voluntary transition to the ABP that is the Medicaid State Plan, if applicable, within 10 working days of receipt of the request from the Medicaid recipient. The recipient will remain enrolled in the ABP until a decision has been made about their exemption and the recipient has made a proactive choice to switch to the Medicaid State Plan benefit package. The recipient will receive a notice informing them of the MCO's or TPA contractor's decision. If the recipient qualifies for an exemption from the ABP, they may then choose whether to remain in the ABP or select the Medicaid State Plan as their benefit package. The MCO or TPA contractor will make an indication of this choice using identifiers that are available in the Medicaid Management Information System (MMIS), which will in turn trigger the recipient's appropriate benefit package. Recipients who are determined by the MCO or TPA contractor as not meeting the criteria set forth at 42 CFR 440.315 and as further defined by the State may request a reconsideration or file a fair hearing in accordance with State regulations. Other Information Related to Enrollment Assurance for Mandatory Participants (optional): PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 5 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. V.20130807 Approval Date: Effective Date: 1/1/2014 STATE: New Mexico DATE RECEIVED: 3/18/14 DATE APPROVED: 6/12/14 EFFECTIVE DATE: 1/1/14 TN: 13-30 TN: NM 13-30

Approved: 6/12/14

Effective: 1/1/14

Page 1 of 2 Alternative Benefit Plan Attachment 3.1-C- OMB Control Number: 0938‐1148 OMB Expiration date: 10/31/2014 Selection of Benchmark Benefit Package or Benchmark-Equivalent Benefit Package ABP3 Select one of the following: The state/territory is amending one existing benefit package for the population defined in Section 1. The state/territory is creating a single new benefit package for the population defined in Section 1. Name of benefit package: Expansion Alternative Benefit Plan (Expansion ABP) Selection of the Section 1937 Coverage Option The state/territory selects as its Section 1937 Coverage option the following type of Benchmark Benefit Package or Benchmark- Equivalent Benefit Package under this Alternative Benefit Plan (check one): Benchmark Benefit Package. Benchmark-Equivalent Benefit Package. The state/territory will provide the following Benchmark Benefit Package (check one that applies): The Standard Blue Cross/Blue Shield Preferred Provider Option offered through the Federal Employee Health Benefit Program (FEHBP). State employee coverage that is offered and generally available to state employees (State Employee Coverage): A commercial HMO with the largest insured commercial, non-Medicaid enrollment in the state/territory (Commercial HMO): Secretary-Approved Coverage. The state/territory offers benefits based on the approved state plan. The state/territory offers an array of benefits from the section 1937 coverage option and/or base benchmark plan benefit packages, or the approved state plan, or from a combination of these benefit packages. Please briefly identify the benefits, the source of benefits and any limitations: New Mexico's Section 1937 coverage option is Secretary-Approved Coverage. Selection of Base Benchmark Plan The state/territory must select a Base Benchmark Plan as the basis for providing Essential Health Benefits in its Benchmark or Benchmark-Equivalent Package. The Base Benchmark Plan is the same as the Section 1937 Coverage option. No Indicate which Benchmark Plan described at 45 CFR 156.100(a) the state/territory will use as its Base Benchmark Plan: Largest plan by enrollment of the three largest small group insurance products in the state's small group market. Any of the largest three state employee health benefit plans by enrollment. STATE: New Mexico DATE RECEIVED: 3/18/14 DATE APPROVED: 6/12/14 EFFECTIVE DATE: 1/1/14 TN: 13-30 TN: NM 13-30

Approved: 6/12/14

Effective: 1/1/14

Page 2 of 2 Alternative Benefit Plan Any of the largest three national FEHBP plan options open to Federal employees in all geographies by enrollment. Largest insured commercial non-Medicaid HMO. Plan name: Lovelace Classic PPO Other Information Related to Selection of the Section 1937 Coverage Option and the Base Benchmark Plan (optional): The Lovelace Classic PPO plan was also chosen by the New Mexico Health Insurance Marketplace as its EHB Base Benchmark Plan. PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 5 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. V.20130801 STATE: New Mexico DATE RECEIVED: 3/18/14 DATE APPROVED: 6/12/14 EFFECTIVE DATE: 1/1/14 TN: 13-30 TN: NM 13-30

Approved: 6/12/14

Effective: 1/1/14

Page 1 of 1 Alternative Benefit Plan Attachment 3.1-C- OMB Control Number: 0938‐1148 OMB Expiration date: 10/31/2014 Alternative Benefit Plan Cost-Sharing ABP4 Any cost sharing described in Attachment 4.18-A applies to the Alternative Benefit Plan. ✔ Attachment 4.18-A may be revised to include cost sharing for ABP services that are not otherwise described in the state plan. Any such cost sharing must comply with Section 1916 of the Social Security Act. The Alternative Benefit Plan for individuals with income over 100% FPL includes cost-sharing other than that described in Attachment 4.18-A. No Other Information Related to Cost Sharing Requirements (optional): PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 5 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. V.20130807 STATE: New Mexico DATE RECEIVED: 3/18/14 DATE APPROVED: 6/12/14 EFFECTIVE DATE: 1/1/14 TN: 13-30 TN: NM 13-30

Approved: 6/12/14

Effective: 1/1/14

Page 1 of 34 Alternative Benefit Plan Attachment 3.1-C- OMB Control Number: 0938‐1148 OMB Expiration date: 10/31/2014 Benefits Description ABP5 The state/territory proposes a “Benchmark-Equivalent” benefit package. No Benefits Included in Alternative Benefit Plan Enter the specific name of the base benchmark plan selected: Lovelace Classic PPO Enter the specific name of the section 1937 coverage option selected, if other than Secretary-Approved. Otherwise, enter “Secretary-Approved.” Secretary-Approved STATE: New Mexico DATE RECEIVED: 3/18/14 DATE APPROVED: 6/12/14 EFFECTIVE DATE: 1/1/14 TN: 13-30 TN: NM 13-30

Approved: 6/12/14

Effective: 1/1/14

Page 2 of 34 Alternative Benefit Plan Essential Health Benefit 1: Ambulatory patient services ■ Collapse All Benefit Provided: Cancer Clinical Trials Source: Base Benchmark Small Group Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: Covers routine patient costs associated with Phase I, II, III and IV cancer clinical trials. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Remove Benefit Provided: Dental Services Source: State Plan 1905(a) Authorization: Other Provider Qualifications: Medicaid State Plan Amount Limit: Annual limits on some services Duration Limit: None Scope Limit: Includes diagnostic dental, dental radiology, preventive dental, restorative dental, removable prosthodontics, oral surgery, and endodontic services for anterior teeth. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: The source plan for this benefit is the New Mexico Medicaid State Plan. This benefit has been added through substitution. Some services subject to a periodicity schedule. Remove Benefit Provided: Dialysis Source: Base Benchmark Small Group Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None STATE: New Mexico DATE RECEIVED: 3/18/14 DATE APPROVED: 6/12/14 EFFECTIVE DATE: 1/1/14 TN: 13-30 TN: NM 13-30

Approved: 6/12/14

Effective: 1/1/14

Page 3 of 34 Alternative Benefit Plan Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Remove Benefit Provided: Holter Monitors & Cardiac Event Monitors Source: Base Benchmark Small Group Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Remove Benefit Provided: Home Health Care & Intravenous Services Source: Base Benchmark Small Group Authorization: Prior Authorization Provider Qualifications: Medicaid State Plan Amount Limit: Limited to 100 four-hour visits per year. Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: The recipient must require skilled care and be unable to receive medical care on an ambulatory outpatient basis. Remove Benefit Provided: Hospice Care Services Source: Base Benchmark Small Group Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None STATE: New Mexico DATE RECEIVED: 3/18/14 DATE APPROVED: 6/12/14 EFFECTIVE DATE: 1/1/14 TN: 13-30 TN: NM 13-30

Approved: 6/12/14

Effective: 1/1/14

Page 4 of 34 Alternative Benefit Plan Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: To be eligible for hospice care, a physician must provide a written certification that the recipient has a terminal illness. Certification statements must include information that is based on the recipient's medical prognosis, and that the life expectancy is six months or less if the terminal illness runs its typical course. Recipients must elect to receive hospice care for the duration of the election period. If the recipient receives hospice benefits beyond 210 days, the hospice must obtain a written recertification statement. For the duration of the recipient's election of hospice care, the recipient waives their right to Medicaid payment of concurrent services related to the treatment of the terminal condition or a related condition; or for services equivalent to hospice care. Recipients who are 19 or 20 years-old may receive curative treatment concurrent with hospice care services. Remove Benefit Provided: Outpatient Diagnostic Labs, X-Ray & Pathology Source: Base Benchmark Small Group Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Remove Benefit Provided: Outpatient Surgery Source: Base Benchmark Small Group Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Remov STATE: New Mexico DATE RECEIVED: 3/18/14 DATE APPROVED: 6/12/14 EFFECTIVE DATE: 1/1/14 TN: 13-30 TN: NM 13-30

Approved: 6/12/14

Effective: 1/1/14

Page 5 of 34 Alternative Benefit Plan Benefit Provided: Primary Care to Treat Illness/Injury Source: Base Benchmark Small Group Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Remove Benefit Provided: Radiation Therapy and Chemotherapy Source: Base Benchmark Small Group Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Remove Benefit Provided: Specialist Visits Source: Base Benchmark Small Group Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Remove STATE: New Mexico DATE RECEIVED: 3/18/14 DATE APPROVED: 6/12/14 EFFECTIVE DATE: 1/1/14 TN: 13-30 TN: NM 13-30

Approved: 6/12/14

Effective: 1/1/14

Page 6 of 34 Alternative Benefit Plan Benefit Provided: Treatment of Diabetes Source: Base Benchmark Small Group Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: This benefit includes medical supplies for the treatment of diabetes. Remove Benefit Provided: Vision Care for Eye Injury or Disease Source: Base Benchmark Small Group Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: Refraction for visual acuity is not covered. Routine vision care is not covered. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Remove Benefit Provided: Vision Hardware Source: Base Benchmark Small Group Authorization: Prior Authorization Provider Qualifications: Medicaid State Plan Amount Limit: One complete set of contact lenses or eyeglasses Duration Limit: None Scope Limit: Covered only following surgery for the removal of cataracts from one or both eyes. Coverage of materials is limited to one set of contact lenses or eyeglasses per surgery. Materials obtained more than 90 days following surgery are not covered. STATE: New Mexico DATE RECEIVED: 3/18/14 DATE APPROVED: 6/12/14 EFFECTIVE DATE: 1/1/14 TN: 13-30 TN: NM 13-30

Approved: 6/12/14

Effective: 1/1/14

Page 7 of 34 Alternative Benefit Plan Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Remove Benefit Provided: Podiatry and Routine Foot Care Source: Base Benchmark Small Group Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: Covered when medically necessary due to malformations, injury, acute trauma or diabetes. Orthopedic shoes, arch supports and foot orthotics are not covered unless they are medically necessary for the treatment of diabetes. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Remove Benefit Provided: Urgent Care Services/Facilities Source: Base Benchmark Small Group Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Remove Add STATE: New Mexico DATE RECEIVED: 3/18/14 DATE APPROVED: 6/12/14 EFFECTIVE DATE: 1/1/14 TN: 13-30 TN: NM 13-30

Approved: 6/12/14

Effective: 1/1/14

Page 8 of 34 Alternative Benefit Plan Essential Health Benefit 2: Emergency services ■ Collapse All Benefit Provided: Emergency Ground or Air Ambulance Services Source: Base Benchmark Small Group Authorization: Other Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Prior authorization required when taking a recipient to a facility over 100 miles from the New Mexico border. Remove Benefit Provided: Emergency Department Services/Facilities Source: Base Benchmark Small Group Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Remove Benefit Provided: Emergency Dental Care Source: Base Benchmark Small Group Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: Covers emergency dental care that is needed because of accidental injury from an outside force to a sound, natural tooth. To be considered sound, the tooth must not have significant decay or prior trauma. STATE: New Mexico DATE RECEIVED: 3/18/14 DATE APPROVED: 6/12/14 EFFECTIVE DATE: 1/1/14 TN: 13-30 TN: NM 13-30

Approved: 6/12/14

Effective: 1/1/14

Page 9 of 34 Alternative Benefit Plan Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Emergency treatment of jawbones or surrounding tissues is also covered. Remove Add STATE: New Mexico DATE RECEIVED: 3/18/14 DATE APPROVED: 6/12/14 EFFECTIVE DATE: 1/1/14 TN: 13-30 TN: NM 13-30

Approved: 6/12/14

Effective: 1/1/14

Page 10 of 34 Alternative Benefit Plan Essential Health Benefit 3: Hospitalization ■ Collapse All Benefit Provided: Bariatric Surgery Source: Base Benchmark Small Group Authorization: Prior Authorization Provider Qualifications: Medicaid State Plan Amount Limit: Limited to one per lifetime Duration Limit: None Scope Limit: Covered for morbid obesity; or for individuals who have a BMI greater than 35 with at least one co- morbidity related to obesity and who have been previously unsuccessful with medical treatment for obesity. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Remove Benefit Provided: Inpatient Medical and Surgical Care Source: Base Benchmark Small Group Authorization: Other Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: Surgeries for cosmetic purposes are not covered. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Prior authorization required for use of a hospital over 100 miles from the New Mexico border, except in an emergency. Remove Benefit Provided: Organ and Tissue Transplants Source: Base Benchmark Small Group Authorization: Prior Authorization Provider Qualifications: Medicaid State Plan Amount Limit: Limited to two per lifetime Duration Limit: None Scope Limit: Limited to heart, heart/lung, lung, liver, cornea, kidney, skin, bone marrow and pancreas transplants. STATE: New Mexico DATE RECEIVED: 3/18/14 DATE APPROVED: 6/12/14 EFFECTIVE DATE: 1/1/14 TN: 13-30 TN: NM 13-30

Approved: 6/12/14

Effective: 1/1/14

Page 11 of 34 Alternative Benefit Plan Covers medical, surgical and hospital services for the recipient; organ procurement costs; certain travel costs; and immunosuppresive drugs. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: The Lovelace Classic PPO transplant benefit is limited to $1 million per lifetime. This limitation was converted to an actuarially-equivalent amount limit, which is reflected in New Mexico's ABP. Outpatient immunosuppresive drugs do not apply toward the transplant benefit limit and are covered without limitation under the prescription drug benefit. Remove Benefit Provided: Reconstructive Surgery Source: Base Benchmark Small Group Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: Covers reconstructive surgery from which an improvement in physiological function can be expected if performed for the correction of functional disorders that result from accidental injury, congenital defects or disease. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Remove Add STATE: New Mexico DATE RECEIVED: 3/18/14 DATE APPROVED: 6/12/14 EFFECTIVE DATE: 1/1/14 TN: 13-30 TN: NM 13-30

Approved: 6/12/14

Effective: 1/1/14

Page 12 of 34 Alternative Benefit Plan Essential Health Benefit 4: Maternity and newborn care ■ Collapse All Benefit Provided: Delivery and Inpatient Maternity Services Source: Base Benchmark Small Group Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Includes lactation support, supplies and counseling. Remove Benefit Provided: Pre- and Post-Natal Care Source: Base Benchmark Small Group Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Amniocentesis, ultrasound or any other procedures requested solely to determine the sex of the fetus are not covered. An exception is made if it is medically necessary to determine the existence of a sex-linked genetic disorder. Determination of the sex of the fetus is covered as part of a medically necessary procedure, but is not covered as an additional visit when the sex of the fetus cannot be determined during the medically necessary procedure. Remove Add STATE: New Mexico DATE RECEIVED: 3/18/14 DATE APPROVED: 6/12/14 EFFECTIVE DATE: 1/1/14 TN: 13-30 TN: NM 13-30

Approved: 6/12/14

Effective: 1/1/14

Page 13 of 34 Alternative Benefit Plan Essential Health Benefit 5: Mental health and substance use disorder services including behavioral health treatment ■ Collapse All Benefit Provided: Inpatient Hospital Services Source: State Plan 1905(a) Authorization: Other Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: Includes services in a psychiatric unit of a general hospital and inpatient substance abuse detoxification. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Does not include inpatient services in Institutions for Mental Diseases (IMDs) for recipients ages 21-64. Prior authorization required for admission to separate psychiatric units within acute care hospitals. The source plan for this benefit is the Medicaid State Plan, since inpatient hospital services covered under the base benchmark plan include IMD services. Remove Benefit Provided: Medication-Assisted Therapy for Opioid Addiction Source: State Plan 1905(a) Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: The source plan for this benefit is the New Mexico Medicaid State Plan. This benefit has been added through substitution. Remove Benefit Provided: Outpatient Behavioral Health Professional Services Source: Base Benchmark Small Group Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None STATE: New Mexico DATE RECEIVED: 3/18/14 DATE APPROVED: 6/12/14 EFFECTIVE DATE: 1/1/14 TN: 13-30 TN: NM 13-30

Approved: 6/12/14

Effective: 1/1/14

Page 14 of 34 Alternative Benefit Plan Scope Limit: Includes evaluation, testing, assessment, medication management, therapy, and Intensive Outpatient Program (IOP) services. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Remove Benefit Provided: Drug/Alcohol Dependency Treatment Services Source: Base Benchmark Small Group Authorization: Other Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: Includes outpatient detoxification, therapy, partial hospitalization, and Intensive Outpatient Program (IOP) services. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Prior authorization required for partial hospitalization. Remove Benefit Provided: Electroconvulsive Therapy (ECT) Source: Base Benchmark Small Group Authorization: Prior Authorization Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Remove Benefit Provided: Assertive Community Treatment (ACT) Source: State Plan 1905(a) Authorization: None Provider Qualifications: Medicaid State Plan STATE: New Mexico DATE RECEIVED: 3/18/14 DATE APPROVED: 6/12/14 EFFECTIVE DATE: 1/1/14 TN: 13-30 TN: NM 13-30

Approved: 6/12/14

Effective: 1/1/14

Page 15 of 34 Alternative Benefit Plan Amount Limit: None Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: The source plan for this benefit is the New Mexico Medicaid State Plan. This benefit has been added through substitution. Remove Benefit Provided: Psychosocial Rehabilitation (PSR) Source: State Plan 1905(a) Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: The source plan for this benefit is the New Mexico Medicaid State Plan. This benefit has been added through substitution. Remove Add STATE: New Mexico DATE RECEIVED: 3/18/14 DATE APPROVED: 6/12/14 EFFECTIVE DATE: 1/1/14 TN: 13-30 TN: NM 13-30

Approved: 6/12/14

Effective: 1/1/14

Page 16 of 34 Alternative Benefit Plan Essential Health Benefit 6: Prescription drugs ■ Benefit Provided: Coverage is at least the greater of one drug in each U.S. Pharmacopeia (USP) category and class or the same number of prescription drugs in each category and class as the base benchmark. Prescription Drug Limits (Check all that apply.): Limit on days supply Limit on number of prescriptions Limit on brand drugs Other coverage limits Preferred drug list Authorization: No Provider Qualifications: State licensed Coverage that exceeds the minimum requirements or other: New Mexico's ABP prescription drug benefit plan is the same as the prescription drug coverage under the Medicaid State Plan. STATE: New Mexico DATE RECEIVED: 3/18/14 DATE APPROVED: 6/12/14 EFFECTIVE DATE: 1/1/14 TN: 13-30 TN: NM 13-30

Approved: 6/12/14

Effective: 1/1/14

Page 17 of 34 Alternative Benefit Plan Essential Health Benefit 7: Rehabilitative and habilitative services and devices ■ Collapse All Benefit Provided: Autism Spectrum Disorder Source: Base Benchmark Small Group Authorization: Other Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: Covers speech, occupational and physical therapy, and applied behavioral analysis for recipients age 21-22 who are enrolled in high school. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Prior authorization required after initial evaluation. This is a state-mandated service. Remove Benefit Provided: Cardiovascular Rehabilitation Source: Base Benchmark Small Group Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: Short-term therapy (two consecutive months) Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Duration limit is per cardiac event. Exceptions made based on medical necessity. Long-term therapy is not covered. Remove Benefit Provided: Durable Medical Equipment & Supplies Source: Base Benchmark Small Group Authorization: Other Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: Coverage of medical supplies is limited to diabetic supplies and contraceptive supplies. STATE: New Mexico DATE RECEIVED: 3/18/14 DATE APPROVED: 6/12/14 EFFECTIVE DATE: 1/1/14 TN: 13-30 TN: NM 13-30

Approved: 6/12/14

Effective: 1/1/14

Page 18 of 34 Alternative Benefit Plan Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Requires a physician's prescription and prior authorization. Remove Benefit Provided: Inpatient Rehabilitative Facilities Source: Base Benchmark Small Group Authorization: Prior Authorization Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: Covers inpatient services at a skilled nursing or acute rehabilitation facility when provided as a step-down level of care following discharge from the hospital prior to discharge to home. Extended care or long-term care hospitals are not covered. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Remove Benefit Provided: Orthotic Appliances Source: Base Benchmark Small Group Authorization: Prior Authorization Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: Foot orthotics, including shoes and arch supports, are only covered when an integral part of a leg brace, or are diabetic shoes. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Requires a provider's prescription and prior authorization. Remove Benefit Provided: Prosthetic Devices, Repair and Replacement Source: Base Benchmark Small Group Authorization: Prior Authorization Provider Qualifications: Medicaid State Plan STATE: New Mexico DATE RECEIVED: 3/18/14 DATE APPROVED: 6/12/14 EFFECTIVE DATE: 1/1/14 TN: 13-30 TN: NM 13-30

Approved: 6/12/14

Effective: 1/1/14

Page 19 of 34 Alternative Benefit Plan Amount Limit: None Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Prior authorization required unless the prosthetic device is surgically implanted. Remove Benefit Provided: Rehabilitative Services - PT/OT/SLP Source: Base Benchmark Small Group Authorization: Prior Authorization Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: Short-term therapy (two consecutive months) Scope Limit: Includes physical and occupational therapy and speech-language pathology. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Physical and occupational therapy require prior authorization, but the initial evaluation does not. Speech language pathology requires prior authorization (including evaluations). Duration limit is per condition; concurrent treatment for separate conditions is covered. Exceptions made based on medical necessity. Long-term therapy is not covered. Remove Benefit Provided: Habilitative Services - PT/OT/SLP Source: Other state-defined Authorization: Prior Authorization Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: Short-term therapy (two consecutive months) Scope Limit: Includes physical and occupational therapy and speech-language pathology. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Physical and occupational therapy require prior authorization, but the initial evaluation does not. Speech language pathology requires prior authorization (including evaluations). Duration limit is per condition; concurrent treatment for separate conditions is covered. Exceptions made based on medical necessity. Long-term therapy is not covered. Remove STATE: New Mexico DATE RECEIVED: 3/18/14 DATE APPROVED: 6/12/14 EFFECTIVE DATE: 1/1/14 TN: 13-30 TN: NM 13-30

Approved: 6/12/14

Effective: 1/1/14

Page 20 of 34 Alternative Benefit Plan Benefit Provided: Pulmonary Therapy Source: Base Benchmark Small Group Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: Short-term therapy (two consecutive months) Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Duration limit is per condition; concurrent treatment for separate conditions is covered. Exceptions made based on medical necessity. Long-term therapy is not covered. Remove Add STATE: New Mexico DATE RECEIVED: 3/18/14 DATE APPROVED: 6/12/14 EFFECTIVE DATE: 1/1/14 TN: 13-30 TN: NM 13-30

Approved: 6/12/14

Effective: 1/1/14

Page 21 of 34 Alternative Benefit Plan Essential Health Benefit 8: Laboratory services ■ Collapse All Benefit Provided: Diagnostic Imaging Source: Base Benchmark Small Group Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Remove Benefit Provided: Lab Tests, X-Ray Services and Pathology Source: Base Benchmark Small Group Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Remove Add STATE: New Mexico DATE RECEIVED: 3/18/14 DATE APPROVED: 6/12/14 EFFECTIVE DATE: 1/1/14 TN: 13-30 TN: NM 13-30

Approved: 6/12/14

Effective: 1/1/14

Page 22 of 34 Alternative Benefit Plan Essential Health Benefit 9: Preventive and wellness services and chronic disease management ■ Collapse All The state/territory must provide, at a minimum, a broad range of preventive services including: “A” and “B” services recommended by the United States Preventive Services Task Force; Advisory Committee for Immunization Practices (ACIP) recommended vaccines; preventive care and screening for infants, children and adults recommended by HRSA’s Bright Futures program/project; and additional preventive services for women recommended by the Institute of Medicine (IOM). Benefit Provided: Allergy Testing and Injections Source: Base Benchmark Small Group Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Remove Benefit Provided: Annual Physical Exam & Consultation Source: Base Benchmark Small Group Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: Includes a health appraisal exam; laboratory and radiological tests; and early detection procedures. Does not include eye refractions, vision hardware or routine vision services; or hearing aids or hearing aid testing. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Remove Benefit Provided: Chronic Disease Management Source: Base Benchmark Small Group Authorization: None Provider Qualifications: Medicaid State Plan STATE: New Mexico DATE RECEIVED: 3/18/14 DATE APPROVED: 6/12/14 EFFECTIVE DATE: 1/1/14 TN: 13-30 TN: NM 13-30

Approved: 6/12/14

Effective: 1/1/14

Page 23 of 34 Alternative Benefit Plan Amount Limit: None Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Remove Benefit Provided: Diabetes Equipment, Supplies & Education Source: Base Benchmark Small Group Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Remove Benefit Provided: Genetic Evaluation & Testing Source: Base Benchmark Small Group Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: Limited to Triple Serum Test and genetic testing for the diagnosis or treatment of a current illness. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Remove Benefit Provided: Immunizations Source: Base Benchmark Small Group STATE: New Mexico DATE RECEIVED: 3/18/14 DATE APPROVED: 6/12/14 EFFECTIVE DATE: 1/1/14 TN: 13-30 TN: NM 13-30

Approved: 6/12/14

Effective: 1/1/14

Page 24 of 34 Alternative Benefit Plan Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: This benefit includes ACIP-recommended vaccines. Remove Benefit Provided: Insertion/Removal of Contraceptive Devices Source: Base Benchmark Small Group Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Remove Benefit Provided: Osteoporosis Treatment & Management Source: Base Benchmark Small Group Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Remove STATE: New Mexico DATE RECEIVED: 3/18/14 DATE APPROVED: 6/12/14 EFFECTIVE DATE: 1/1/14 TN: 13-30 TN: NM 13-30

Approved: 6/12/14

Effective: 1/1/14

Page 25 of 34 Alternative Benefit Plan Benefit Provided: Periodic Glaucoma Test (Age 35 or Older) Source: Base Benchmark Small Group Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: Coverage includes testing every one to two years. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Remove Benefit Provided: Periodic Colorectal Examination (Age 35 or Older) Source: Base Benchmark Small Group Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: Coverage includes a yearly fecal occult blood test (FOBT); flexible sigmoidoscopy every five years; double contrast barium enema every five years; and colonoscopy every 10 years. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Remove Benefit Provided: Periodic Mammograms (Age 35 or Older) Source: Base Benchmark Small Group Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: Coverage includes, at a minimum, one baseline mammogram to persons age 35 through 39; one mammogram biennially to persons age 40 through 49; and one mammogram annually to persons age 50 and over. STATE: New Mexico DATE RECEIVED: 3/18/14 DATE APPROVED: 6/12/14 EFFECTIVE DATE: 1/1/14 TN: 13-30 TN: NM 13-30

Approved: 6/12/14

Effective: 1/1/14

Page 26 of 34 Alternative Benefit Plan Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Remove Benefit Provided: Annual Stool Examination Source: Base Benchmark Small Group Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Remove Benefit Provided: Other Preventive Care and Screenings Source: Other state-defined Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Includes US Preventive Services Task Force "A" and "B" recommendations; preventive care and screening recommendations of the HRSA Bright Futures program; and additional preventive services for women recommended by the Institute of Medicine. Remove Benefit Provided: Voluntary Family Planning Services Source: Base Benchmark Small Group Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None STATE: New Mexico DATE RECEIVED: 3/18/14 DATE APPROVED: 6/12/14 EFFECTIVE DATE: 1/1/14 TN: 13-30 TN: NM 13-30

Approved: 6/12/14

Effective: 1/1/14

Page 27 of 34 Alternative Benefit Plan Scope Limit: Sterilization reversal is not covered. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Remove Add STATE: New Mexico DATE RECEIVED: 3/18/14 DATE APPROVED: 6/12/14 EFFECTIVE DATE: 1/1/14 TN: 13-30 TN: NM 13-30

Approved: 6/12/14

Effective: 1/1/14

Page 28 of 34 Alternative Benefit Plan Essential Health Benefit 10: Pediatric services including oral and vision care ■ Collapse All Benefit Provided: Medicaid State Plan EPSDT Benefits Source: State Plan 1905(a) Authorization: Other Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: The source plan for this benefit is the New Mexico Medicaid State Plan. Prior authorization required for certain services. Some services subject to a periodicity schedule. Remove Add STATE: New Mexico DATE RECEIVED: 3/18/14 DATE APPROVED: 6/12/14 EFFECTIVE DATE: 1/1/14 TN: 13-30 TN: NM 13-30

Approved: 6/12/14

Effective: 1/1/14

Page 29 of 34 Alternative Benefit Plan Other Covered Benefits from Base Benchmark Collapse All STATE: New Mexico DATE RECEIVED: 3/18/14 DATE APPROVED: 6/12/14 EFFECTIVE DATE: 1/1/14 TN: 13-30 TN: NM 13-30

Approved: 6/12/14

Effective: 1/1/14

Page 30 of 34 Alternative Benefit Plan Base Benchmark Benefits Not Covered due to Substitution or Duplication Collapse All Base Benchmark Benefit that was Substituted: Acupuncture ($1,500 per year) Source: Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Substituted with dental services within the Ambulatory Patient Services category. Remove Base Benchmark Benefit that was Substituted: Chiropractic Care ($1,500 per year) Source: Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Substituted with dental services within the Ambulatory Patient Services category. Remove Base Benchmark Benefit that was Substituted: CMJ and TMJ Conditions Source: Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Substituted with dental services within the Ambulatory Patient Services category. Remove Base Benchmark Benefit that was Substituted: Special Medical Foods Source: Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Substituted with dental services within the Ambulatory Patient Services category. Remove Base Benchmark Benefit that was Substituted: Infertility (Diagnosis, Treatment & Correction) Source: Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Substituted with dental services within the Ambulatory Patient Services category. The base benchmark infertility coverage does not include in-vitro fertilization (IVF), gamete intrafallopian transfer (GIFT), zygote intrafallopian transfer (ZIFT) or variations of these procedures; surrogate parenting; reversal of sterilization; or any costs associated with the collection, preparation or storage of sperm for artificial insemination, including donor fees, donor egg or sperm retrieval; or infertility medications, including oral infertility drugs. Remove Base Benchmark Benefit that was Substituted: Inpatient Rehabilitation for Substance Abuse Source: Base Benchmark STATE: New Mexico DATE RECEIVED: 3/18/14 DATE APPROVED: 6/12/14 EFFECTIVE DATE: 1/1/14 TN: 13-30 TN: NM 13-30

Approved: 6/12/14

Effective: 1/1/14

Page 31 of 34 Alternative Benefit Plan Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Substituted with Medication-Assisted Therapy for Opioid Addiction, Assertive Community Treatment (ACT), and Psychosocial Rehabilitation (PSR) within the Mental Health and Substance Use Disorder Services category. Remove Base Benchmark Benefit that was Substituted: Behavioral Health Inpatient Hospital Services Source: Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplicates EHB5 Mental Health and Substance Use Disorder services, including Behavioral Health Treatment: Inpatient Hospital Services. The base benchmark includes coverage of Institutions for Mental Diseases (IMDs) for recipients ages 21-64 as part of this benefit. IMDs are excluded from coverage under the Medicaid ABP. Remove Add STATE: New Mexico DATE RECEIVED: 3/18/14 DATE APPROVED: 6/12/14 EFFECTIVE DATE: 1/1/14 TN: 13-30 TN: NM 13-30

Approved: 6/12/14

Effective: 1/1/14

Page 32 of 34 Alternative Benefit Plan Other Base Benchmark Benefits Not Covered Collapse All Base Benchmark Benefit not Included in the Alternative Benefit Plan: Newborn Child Care Source: Base Benchmark Explain why the state/territory chose not to include this benefit: Newborns who are born to Medicaid-enrolled mothers are automatically deemed eligible for Medicaid, and all newborn services are covered under the Medicaid State Plan. Remove Add STATE: New Mexico DATE RECEIVED: 3/18/14 DATE APPROVED: 6/12/14 EFFECTIVE DATE: 1/1/14 TN: 13-30 TN: NM 13-30

Approved: 6/12/14

Effective: 1/1/14

Page 33 of 34 Alternative Benefit Plan Other 1937 Covered Benefits that are not Essential Health Benefits Collapse All Other 1937 Benefit Provided: Non-Emergency Transportation Source: Section 1937 Coverage Option Benchmark Benefit Package Authorization: Other Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: Covers expenses for transportation, meals and lodging that are determined necessary to secure medical or behavioral health services for an Alternative Benefit Plan recipient. Other: There is no authorization requirement for this benefit. Remove Add STATE: New Mexico DATE RECEIVED: 3/18/14 DATE APPROVED: 6/12/14 EFFECTIVE DATE: 1/1/14 TN: 13-30 TN: NM 13-30

Approved: 6/12/14

Effective: 1/1/14

Page 34 of 34 Alternative Benefit Plan Additional Covered Benefits (This category of benefits is not applicable to the adult group under section 1902(a)(10)(A)(i)(VIII) of the Act.) Collapse All PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 5 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. V.20130814 STATE: New Mexico DATE RECEIVED: 3/18/14 DATE APPROVED: 6/12/14 EFFECTIVE DATE: 1/1/14 TN: 13-30 TN: NM 13-30

Approved: 6/12/14

Effective: 1/1/14

Page 1 of 2 Alternative Benefit Plan Attachment 3.1-C- OMB Control Number: 0938‐1148 OMB Expiration date: 10/31/2014 Benefits Assurances ABP7 EPSDT Assurances If the target population includes persons under 21, please complete the following assurances regarding EPSDT. Otherwise, skip to the Prescription Drug Coverage Assurances below. The alternative benefit plan includes beneficiaries under 21 years of age. Yes The state/territory assures that the notice to an individual includes a description of the method for ensuring access to EPSDT services (42 CFR 440.345). ✔ The state/territory assures EPSDT services will be provided to individuals under 21 years of age who are covered under the state/ territory plan under section 1902(a)(10)(A) of the Act. ✔ Indicate whether EPSDT services will be provided only through an Alternative Benefit Plan or whether the state/territory will provide additional benefits to ensure EPSDT services: Through an Alternative Benefit Plan. Through an Alternative Benefit Plan with additional benefits to ensure EPSDT services as defined in 1905(r). Other Information regarding how ESPDT benefits will be provided to participants under 21 years of age (optional): Prescription Drug Coverage Assurances The state/territory assures that it meets the minimum requirements for prescription drug coverage in section 1937 of the Act and implementing regulations at 42 CFR 440.347. Coverage is at least the greater of one drug in each United States Pharmacopeia (USP) category and class or the same number of prescription drugs in each category and class as the base benchmark. ✔ The state/territory assures that procedures are in place to allow a beneficiary to request and gain access to clinically appropriate prescription drugs when not covered. ✔ The state/territory assures that when it pays for outpatient prescription drugs covered under an Alternative Benefit Plan, it meets the requirements of section 1927 of the Act and implementing regulations at 42 CFR 440.345, except for those requirements that are directly contrary to amount, duration and scope of coverage permitted under section 1937 of the Act. ✔ The state/territory assures that when conducting prior authorization of prescription drugs under an Alternative Benefit Plan, it complies with prior authorization program requirements in section 1927(d)(5) of the Act. ✔ Other Benefit Assurances The state/territory assures that substituted benefits are actuarially equivalent to the benefits they replaced from the base benchmark plan, and that the state/territory has actuarial certification for substituted benefits available for CMS inspection if requested by CMS. ✔ The state/territory assures that individuals will have access to services in Rural Health Clinics (RHC) and Federally Qualified Health Centers (FQHC) as defined in subparagraphs (B) and (C) of section 1905(a)(2) of the Social Security Act. ✔ The state/territory assures that payment for RHC and FQHC services is made in accordance with the requirements of section 1902(bb) of the Social Security Act. ✔ STATE: New Mexico DATE RECEIVED: 3/18/14 DATE APPROVED: 6/12/14 EFFECTIVE DATE: 1/1/14 TN: 13-30 TN: NM 13-30

Approved: 6/12/14

Effective: 1/1/14

Page 2 of 2 Alternative Benefit Plan The state/territory assures that it will comply with the requirement of section 1937(b)(5) of the Act by providing, effective January 1, 2014, to all Alternative Benefit Plan participants at least Essential Health Benefits as described in section 1302(b) of the Patient Protection and Affordable Care Act. ✔ The state/territory assures that it will comply with the mental health and substance use disorder parity requirements of section 1937(b)(6) of the Act by ensuring that the financial requirements and treatment limitations applicable to mental health or substance use disorder benefits comply with the requirements of section 2705(a) of the Public Health Service Act in the same manner as such requirements apply to a group health plan. ✔ The state/territory assures that it will comply with section 1937(b)(7) of the Act by ensuring that benefits provided to Alternative Benefit Plan participants include, for any individual described in section 1905(a)(4)(C), medical assistance for family planning services and supplies in accordance with such section. ✔ The state/territory assures transportation (emergency and non-emergency) for individuals enrolled in an Alternative Benefit Plan in accordance with 42 CFR 431.53. ✔ The state/territory assures, in accordance with 45 CFR 156.115(a)(4) and 45 CFR 147.130, that it will provide as Essential Health Benefits a broad range of preventive services including: “A” and “B” services recommended by the United States Preventive Services Task Force; Advisory Committee for Immunization Practices (ACIP) recommended vaccines; preventive care and screening for infants, children and adults recommended by HRSA's Bright Futures program/project; and additional preventive services for women recommended by the Institute of Medicine (IOM). ✔ PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 5 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. V.20130807 STATE: New Mexico DATE RECEIVED: 3/18/14 DATE APPROVED: 6/12/14 EFFECTIVE DATE: 1/1/14 TN: 13-30 TN: NM 13-30

Approved: 6/12/14

Effective: 1/1/14

Page 1 of 3 Alternative Benefit Plan Attachment 3.1-C- OMB Control Number: 0938‐1148 OMB Expiration date: 10/31/2014 Service Delivery Systems ABP8 Provide detail on the type of delivery system(s) the state/territory will use for the Alternative Benefit Plan's benchmark benefit package or benchmark-equivalent benefit package, including any variation by the participants' geographic area. Type of service delivery system(s) the state/territory will use for this Alternative Benefit Plan(s). Select one or more service delivery systems: Managed care. Managed Care Organizations (MCO). Prepaid Inpatient Health Plans (PIHP). Prepaid Ambulatory Health Plans (PAHP). Primary Care Case Management (PCCM). Fee-for-service. Other service delivery system. Managed Care Options Managed Care Assurance The state/territory certifies that it will comply with all applicable Medicaid laws and regulations, including but not limited to sections 1903(m), 1905(t), and 1932 of the Act and 42 CFR Part 438, in providing managed care services through this Alternative Benefit Plan. This includes the requirement for CMS approval of contracts and rates pursuant to 42 CFR 438.6. ✔ Managed Care Implementation Please describe the implementation plan for the Alternative Benefit Plan under managed care including member, stakeholder, and provider outreach efforts. As part of New Mexico's efforts to roll-out its new Section 1115 waiver for Centennial Care on January 1 (which includes both the Other Adult Group and the ABP), the state held more than 200 public education events in every region of the state, including 52 events that were held in Native American communities. The state began running radio, print and online advertisements about Centennial Care in August 2013.

A tribal consultation was held in August 2013, during which the state discussed the ABP services package, as well as the intended selection of New Mexico's Section 1937 option and base benchmark plan. These topics were also discussed at every quarterly Medicaid Advisory Committee (MAC) meeting throughout 2013 and early 2014 to ensure communication with stakeholders. A meeting with tribal providers was held in November 2013 and a second provider meeting took place in March 2014.

In addition, New Mexico began a year-long comprehensive readiness review of its four Centennial Care managed care organizations (MCOs) in early 2013 to ensure that the MCOs are fully operational and compliant with the standards and conditions outlined in the Centennial Care waiver. Ten workgroups were created to focus on certain areas of implementation, such as reporting, care coordination, IT systems, and other issues pertinent to implementing the waiver and, more specifically, the ABP. MCO: Managed Care Organization The managed care delivery system is the same as an already approved managed care program. Yes The managed care program is operating under (select one): STATE: New Mexico DATE RECEIVED: 3/18/14 DATE APPROVED: 6/12/14 EFFECTIVE DATE: 1/1/14 TN: 13-30 TN: NM 13-30

Approved: 6/12/14

Effective: 1/1/14

Page 2 of 3 Alternative Benefit Plan Section 1915(a) voluntary managed care program. Section 1915(b) managed care waiver. Section 1932(a) mandatory managed care state plan amendment. Section 1115 demonstration. Section 1937 Alternative (Benchmark) Benefit Plan state plan amendment. Identify the date the managed care program was approved by CMS: July 12, 2013 Describe program below: New Mexico Centennial Care provides managed physical, behavioral health and long-term care services through four managed care organizations (MCOs). New Mexico's vision for Centennial Care is to build a health care system that delivers the right amount of care at the right time and in the right setting. This vision includes educating recipients to become savvy health care consumers, promoting integrated care, delivering proper care coordination for the most at-risk recipients, involving recipients in their own wellness, and paying providers for good health outcomes. More detailed information about New Mexico Centennial Care can be found online at www.state.nm.us/centennialcare. Additional Information: MCO (Optional) Provide any additional details regarding this service delivery system (optional): Fee-For-Service Options Indicate whether the state/territory offers traditional fee-for-service and/or services managed under an administrative services organization: Traditional state-managed fee-for-service Services managed under an administrative services organization (ASO) arrangement Please describe this fee-for-service delivery system, including any bundled payment arrangements, pay for performance, fee-for- service care management models/non-risk, contractual incentives as well as the population served via this delivery system. In New Mexico, most Native American Medicaid recipients maintain a choice to opt-in to the Centennial Care (managed care) program, or to access care through a traditional state-managed fee-for-service delivery system; however, Native American recipients who are dually eligible for Medicare and Medicaid or who have a nursing facility level of care, are required to enroll in Centennial Care. Native American recipients who access care through fee-for-service may opt-in to Centennial Care at any time during their eligibility.

The base services offered in the ABP are the same for both fee-for-service and Centennial Care recipients, and are detailed in Section 5 of this State Plan Amendment; however, Centennial Care recipients may receive additional "value-added services" from their MCOs that are not available to fee-for-service recipients. Additional Information: Fee-For-Service (Optional) Provide any additional details regarding this service delivery system (optional): STATE: New Mexico DATE RECEIVED: 3/18/14 DATE APPROVED: 6/12/14 EFFECTIVE DATE: 1/1/14 TN: 13-30 TN: NM 13-30

Approved: 6/12/14

Effective: 1/1/14

Page 3 of 3 Alternative Benefit Plan PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 5 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. V.20130718 STATE: New Mexico DATE RECEIVED: 3/18/14 DATE APPROVED: 6/12/14 EFFECTIVE DATE: 1/1/14 TN: 13-30 TN: NM 13-30

Approved: 6/12/14

Effective: 1/1/14

Page 1 of 1 Alternative Benefit Plan Attachment 3.1-C- OMB Control Number: 0938‐1148 OMB Expiration date: 10/31/2014 Employer Sponsored Insurance and Payment of Premiums ABP9 The state/territory provides the Alternative Benefit Plan through the payment of employer sponsored insurance for participants with such coverage, with additional benefits and services provided through a Benchmark or Benchmark-Equivalent Benefit Package. No The state/territory otherwise provides for payment of premiums. No Other Information Regarding Employer Sponsored Insurance or Payment of Premiums: PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 5 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. STATE: New Mexico DATE RECEIVED: 3/18/14 DATE APPROVED: 6/12/14 EFFECTIVE DATE: 1/1/14 TN: 13-30 TN: NM 13-30

Approved: 6/12/14

Effective: 1/1/14

Page 1 of 1 Alternative Benefit Plan Attachment 3.1-C- OMB Control Number: 0938‐1148 OMB Expiration date: 10/31/2014 General Assurances ABP10 Economy and Efficiency of Plans The state/territory assures that Alternative Benefit Plan coverage is provided in accordance with Federal upper payment limit requirements and other economy and efficiency principles that would otherwise be applicable to the services or delivery system through which the coverage and benefits are obtained. ✔ Economy and efficiency will be achieved using the same approach as used for Medicaid state plan services. Yes Compliance with the Law The state/territory will continue to comply with all other provisions of the Social Security Act in the administration of the state/ territory plan under this title. ✔ The state/territory assures that Alternative Benefit Plan benefits designs shall conform to the non-discrimination requirements at 42 CFR 430.2 and 42 CFR 440.347(e). ✔ The state/territory assures that all providers of Alternative Benefit Plan benefits shall meet the provider qualification requirements of the Base Benchmark Plan and/or the Medicaid state plan. ✔ PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 5 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. V.20130807 STATE: New Mexico DATE RECEIVED: 3/18/14 DATE APPROVED: 6/12/14 EFFECTIVE DATE: 1/1/14 TN: 13-30 TN: NM 13-30

Approved: 6/12/14

Effective: 1/1/14

Page 1 of 1 Alternative Benefit Plan Attachment 3.1-C- OMB Control Number: 0938‐1148 OMB Expiration date: 10/31/2014 Payment Methodology ABP11 Alternative Benefit Plans - Payment Methodologies The state/territory provides assurance that, for each benefit provided under an Alternative Benefit Plan that is not provided through managed care, it will use the payment methodology in its approved state plan or hereby submits state plan amendment Attachment 4.19a, 4.19b or 4.19d, as appropriate, describing the payment methodology for the benefit. ✔ An attachment is submitted. PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 5 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. V.20130807 STATE: New Mexico DATE RECEIVED: 3/18/14 DATE APPROVED: 6/12/14 EFFECTIVE DATE: 1/1/14 TN: 13-30 TN: NM 13-30

Approved: 6/12/14

Effective: 1/1/14

Table of Contents State/Territory Name: New Mexico State Plan Amendment (SPA) #: 15-0010 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Page

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Dallas Regional Office 1301 Young Street, Suite 833 Dallas, Texas 75202

DIVISION OF MEDICAID & CHILDREN’S HEALTH - REGION VI

September 9, 2015

Ms. Nancy Smith-Leslie, Director Medical Assistance Division New Mexico Department of Human Services P.O. Box 2348 Santa Fe, New Mexico 87504

Dear Ms. Smith-Leslie:

We have reviewed the proposed amendment to your Medicaid State Plan submitted under Transmittal Number (TN) 15-0010. With the approval of TN 15-0010, the Centers for Medicare and Medicaid Services (CMS) has approved the State’s request to cover children who were in foster care and on Medicaid in any state at the time they turned 18 or aged out of the foster care system providing they are under age 26, as outlined in 42 CFR 435.150, and 1902(a)(10)(A)(i)(IX) of the Social Security Act (The Act).

Transmittal Number 15-0010 is approved with an effective date of October 1, 2015, as requested. A signed and dated copy of the Transmittal No. 15-0010 summary is attached, along with the approved plan pages.

If you have any questions, please contact Stacey Shuman at (214) 767-6479.

Sincerely,

Bill Brooks Associate Regional Administrator Division of Medicaid & Children’s Health Operations

Cc: Bill Bob Farrell, DMCH

Mary Corddry, CMS Baltimore

Judith Cash, CMS Baltimore

Stephanie Kaminsky, CMS Baltimore

Tallie Tolen, NMHSD

Ellen Costilla, NMHSD

State/Territory name: New Mexico Submitted By: Tallie Tolen Last Revision Date: Aug 26, 2015 Submit Date: Jul 15, 2015 Medicaid State Plan Eligibility: Summary Page (CMS 179) Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. NM-15-0010 Proposed Effective Date 10/01/2015 (mm/dd/yyyy) Federal Statute/Regulation Citation 42 CFR 435.150 and 1902(a)(10)(A)(i)(IX) Federal Budget Impact Federal Fiscal Year Amount First Year 2016 $ 75805.00 Second Year 2017 $ 156173.00 Subject of Amendment Eligibility Groups - Mandatory Coverage Former Foster Care Children S33 Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe:   No reply received within 45 days of submittal Other, as specified Describe: Authority Delegated to State Medicaid Director Signature of State Agency Official NM.1877.R00.00 - Oct 01, 2015 ____________________________________________________________________________________________________________ Date Received: 7/15/2015 Date Approved: 9/9/2015 Signature of Regional Official: Printed Name and Title: Bill Brooks, Associate Regional Administrator (ARA), Division of Medicaid and Children's Health (DMCH)

Page 1 of 1 Medicaid Eligibility Transmittal Number: NM State Name: New Mexico OMB Control Number: 0938‐1148 Expiration date: 10/31/2014 - 15 - 0010 Eligibility Groups - Mandatory Coverage Former Foster Care Children S33 42 CFR 435.150 1902(a)(10)(A)(i)(IX) Former Foster Care Children - Individuals under the age of 26, not otherwise mandatorily eligible, who were on Medicaid and in foster care when they turned age 18 or aged out of foster care. ■ The state attests that it operates this eligibility group under the following provisions: ✔ Individuals qualifying under this eligibility group must meet the following criteria: ■ Are under age 26. ■ Are not otherwise eligible for and enrolled for mandatory coverage under the state plan, except that eligibility under this group takes precedence over eligibility under the Adult Group. ■ Were in foster care under the responsibility of the state or Tribe and were enrolled in Medicaid under the state's state plan or 1115 demonstration when they turned 18 or at the time of aging out of that state's or Tribe's foster care program. ■ The state elects to cover children who were in foster care and on Medicaid in any state at the time they turned 18 or aged out of the foster care system. Yes No The state covers individuals under this group when determined presumptively eligible by a qualified entity. The state assures it also covers individuals under the Pregnant Women (42 CFR 435.116) and/or Infants and Children under Age 19 (42 CFR 435.118) eligibility groups when determined presumptively eligible. Yes No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938‐1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4‐26‐05, Baltimore, Maryland 21244‐1850. V.20140415 TN NO: 15-0010 Supersedes TN NO: New Page Approval Date: 9 September, 2015 Effective Date: 1 October, 2015 STATE: New Mexico Date Received: 7/15/15 Date Approved: 9/9/15 Effective Date: 10/01/15 Transmittal Number: 15-0010

Table of Contents State/Territory Name: New Mexico State Plan Amendment (SPA) #: 17-0005 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved Page

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Dallas Regional Office 1301 Young Street, Suite 833 Dallas, Texas 75202

DIVISION OF MEDICAID & CHILDREN’S HEALTH - REGION VI

July 6, 2017

Our Reference: NM SPA 17-0005

Ms. Nancy Smith-Leslie, Director Medical Assistance Division New Mexico Department of Human Services P.O. Box 2348 Santa Fe, New Mexico 87504

Dear Ms. Smith-Leslie,

We have reviewed the State’s proposed amendment to your Medicaid State Plan submitted under Transmittal Number (TN) 17-0005, dated May 19, 2017. This plan amendment eliminates Medicaid eligibility to individuals formerly in other states’ foster care systems who have turned age 18 or aged out of the foster care system. This is a Medicaid Modernized Data Lab (MMDL) related SPA.

Based on the information submitted, we have approved the amendment for incorporation into the official New Mexico State Plan with an effective date of April 1, 2017, as requested. A copy of the CMS – 179 and the approved plan pages are included with this letter.

If you have any questions please contact Ford Blunt of my staff. Mr. Blunt may be reached at (214) 767-6381 or by E-mail at Ford.Blunt@cms.hhs.gov.

Sincerely,

Bill Brooks

Associate Regional Administrator

Cc: Jennifer Mondragon

July 6, 2017 April 1, 2017 Bill Brooks Associate Regional Administrator Division of Medicaid and Children's Health May 19, 2017

Page of Medicaid Eligibility Transmittal Number: State Name: OMB Control Number: 0938ӡ1148 - - Eligibility Groups - Mandatory Coverage Former Foster Care Children S33 42 CFR 435.150 1902(a)(10)(A)(i)(IX) Former Foster Care Children - Individuals under the age of 26, not otherwise mandatorily eligible, who were on Medicaid and in foster care when they turned age 18 or aged out of foster care. The state attests that it operates this eligibility group under the following provisions: Individuals qualifying under this eligibility group must meet the following criteria: Are under age 26. Are not otherwise eligible for and enrolled for mandatory coverage under the state plan, except that eligibility under this group takes precedence over eligibility under the Adult Group. Were in foster care under the responsibility of the state or Tribe and were enrolled in Medicaid under the state's state plan or 1115 demonstration when they turned 18 or at the time of aging out of that state's or Tribe's foster care program. The state elects to cover children who were in foster care and on Medicaid in any state at the time they turned 18 or aged out of the foster care system. Yes No The state covers individuals under this group when determined presumptively eligible by a qualified entity. The state assures it also covers individuals under the Pregnant Women (42 CFR 435.116) and/or Infants and Children under Age 19 (42 CFR 435.118) eligibility groups when determined presumptively eligible. Yes No The presumptive period begins on the date the determination is made. The end date of the presumptive period is the earlier of: The date the eligibility determination for regular Medicaid is made, if an application for Medicaid is filed by the last day of the month following the month in which the determination of presumptive eligibility is made; or The last day of the month following the month in which the determination of presumptive eligibility is made, if no application for Medicaid is filed by that date. Periods of presumptive eligibility are limited as follows: No more than one period within a calendar year. No more than one period within two calendar years. No more than one period within a twelve-month period, starting with the effective date of the initial presumptive eligibility period. Other reasonable limitation: TN 17-0005 Approval Date 7/06/17 Effective 4/01/17 Supersedes TN 15-0010 State: New Mexico Date Received: 5-19-17 Date Effective 04-01-17 Date Approved: 07-06-17 Transmittal # 17-0005 NM New Mexico 17 0005 ■ ■ ■ ■ ■ ■ ■ ■

Page of Medicaid Eligibility Name of limitation Description The state requires that a written application be signed by the applicant or representative. Yes No The state uses a single application form for Medicaid and presumptive eligibility, approved by CMS. The state uses a separate application form for presumptive eligibility, approved by CMS. A copy of the application form is included. The presumptive eligibility determination is based on the following factors: The individual must meet the categorical requirements of 42 CFR 435.150. State residency Citizenship, status as a national, or satisfactory immigration status The state uses qualified entities, as defined in section 1920A of the Act, to determine eligibility presumptively for this eligibility group. List of Qualified Entities S17 A qualified entity is an entity that is determined by the agency to be capable of making presumptive eligibility determinations based on an individual’s household income and other requirements, and that meets at least one of the following requirements. Select one or more of the following types of entities used to determine presumptive eligibility for this eligibility group: Furnishes health care items or services covered under the state's approved Medicaid state plan and is eligible to receive payments under the plan Is authorized to determine a child's eligibility to participate in a Head Start program under the Head Start Act Is authorized to determine a child's eligibility to receive child care services for which financial assistance is provided under the Child Care and Development Block Grant Act of 1990 Is authorized to determine a child's eligibility to receive assistance under the Special Supplemental Food Program for Women, Infants and Children (WIC) under section 17 of the Child Nutrition Act of 1966 Is authorized to determine a child's eligibility under the Medicaid state plan or for child health assistance under the Children's Health Insurance Program (CHIP) Is an elementary or secondary school, as defined in section 14101 of the Elementary and Secondary Education Act of 1965 (20 U.S.C. 8801) Is an elementary or secondary school operated or supported by the Bureau of Indian Affairs Is a state or Tribal child support enforcement agency under title IV-D of the Act Is an organization that provides emergency food and shelter under a grant under the Stewart B. McKinney Homeless Assistance Act TN 17-0005 Approval Date 7/06/17 Effective 4/01/17 Supersedes: None-New Page State: New Mexico Date Received: 5-19-17 Date Effective 04-01-17 Date Approved: 07-06-17 Transmittal # 17-0005 + x An attachment is submitted. ■ ■ ■

Page of Medicaid Eligibility Is a state or Tribal office or entity involved in enrollment in the program under Medicaid, CHIP, or title IV-A of the Act Is an organization that determines eligibility for any assistance or benefits provided under any program of public or assisted housing that receives Federal funds, including the program under section 8 or any other section of the United States Housing Act of 1937 (42 U.S.C. 1437) or under the Native American Housing Assistance and Self Determination Act of 1996 (25 U.S.C. 4101 et seq.) Is a health facility operated by the Indian Health Service, a Tribe, or Tribal organization, or an Urban Indian Organization Other entity the agency determines is capable of making presumptive eligibility determinations: Name of entity Description The state assures that it has communicated the requirements for qualified entities, at 1920A(b)(3) of the Act, and has provided adequate training to the entities and organizations involved. A copy of the training materials has been included. PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938ӡ1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4ӡ26ӡ05, Baltimore, Maryland 21244ӡ1850. V.20160722 TN 17-0005 Approval Date 7/06/17 Effective 4/01/17 Supersedes: None-New Page State: New Mexico Date Received: 5-19-17 Date Effective 04-01-17 Date Approved: 07-06-17 Transmittal # 17-0005 + x An attachment is submitted.

Table of Contents State/Territory Name: New Mexico State Plan Amendment (SPA) #: 19-0002 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved Page(s)

Table of Contents State/Territory Name: New Mexico State Plan Amendment (SPA) #: 19-0002 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved Page(s)

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 1301 Young Street Dallas, Texas 75202

Regional Operations Group

October 22, 2019

Our Reference: SPA NM 19-0002

Ms. Nicole Comeaux Director Medical Assistance Division P.O. Box 2348 Santa Fe, NM 87504-2348

Attention: Jennifer Vigil Dear Ms. Comeaux: We have reviewed the State’s proposed amendment to the New Mexico State Plan submitted under Transmittal Number 19-0002, dated March 1, 2019. This state plan amendment proposes to add a Substance Use Disorder (SUD) Continuum of Services to the New Mexico State plan.

Based on the information submitted, we have approved the amendment for incorporation into the official New Mexico State Plan with an effective date change of January 1, 2019. A copy of the CMS- 179 and the approved plan page are enclosed with this letter.

If you have any questions, please contact Ford Blunt of my staff. Mr. Blunt may be reached at (214) 767-6381 or by e-mail at Ford.Blunt@cms.hhs.gov.

Sincerely, Bill Brooks Director Centers for Medicaid & CHIP Services Regional Operations Group

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 1301 Young Street Dallas, Texas 75202

Regional Operations Group

October 22, 2019

Our Reference: SPA NM 19-0002

Ms. Nicole Comeaux Director Medical Assistance Division P.O. Box 2348 Santa Fe, NM 87504-2348

Attention: Jennifer Vigil Dear Ms. Comeaux: We have reviewed the State’s proposed amendment to the New Mexico State Plan submitted under Transmittal Number 19-0002, dated March 1, 2019. This state plan amendment proposes to add a Substance Use Disorder (SUD) Continuum of Services to the New Mexico State plan.

Based on the information submitted, we have approved the amendment for incorporation into the official New Mexico State Plan with an effective date change of January 1, 2019. A copy of the CMS- 179 and the approved plan page are enclosed with this letter.

If you have any questions, please contact Ford Blunt of my staff. Mr. Blunt may be reached at (214) 767-6381 or by e-mail at Ford.Blunt@cms.hhs.gov.

Sincerely, Bill Brooks Director Centers for Medicaid & CHIP Services Regional Operations Group

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES 1, TRANSMITTAL NUMBER 2,STATE FORM APPROVED 0MB No. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL 1 9 0 0 2 New Mexico FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE & MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES 5, TYPE OF PLAN MATERIAL (Check One) 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) 4. PROPOSED EFFECTIVE DATE January 1, 2019 0 NEW STATE PLAN O AMENDMENT TO BE CONSIDERED AS NEW PLAN Kl AMENDMENT COMPLETE BLOCKS 6 THAU 10 IF THIS IS AN AMENDMENT (Separate transmittal for each amendment) 6, FEDERAL STATUTE/REGULATION CITATION 7. FEDERAL BUDGET IMPACT a, FFY 2019 $ 2,000,000 Section 1905(a) of the Social Security Act, 42 CFR 441.57; 42 CFR 456.201-456.245; 42 CFR 8, 42 CFR 440.130(d) b. FFY 2020 $ 2.700,000 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT State Supplement A to Attachment 3. lA, page 21 State Supplement A to Attachment 3.1A, pages 21c and 21c1, 21c2, 21c3, 21c4 (new) Attachment 4.19-B Page 3 Attachment 4.19-B Page 3aa (new) 10. SUBJECT OF AMENDMENT Substance Use Disorder (SUD) Continuum of Services 11. GOVERNOR'S REVIEW (Check One) 0 GOVERNOR'S OFFICE REPORTED NO COMMENT 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED 0 NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 14. TITLE Director, Medical Assistance Division 15. DATE SUBMITTED 9, PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable) State Supplement A to Attachment 3.1A, page 21 (NM Amendment 04-008) State Supplement A page 21c (NM SPA 06-07) Attachment 4.19-B Page 3 (NM SPA 19-0005) Ix] OTHER, AS SPECIFIED Authority Delegated to the Medicaid Director 16. RETURN TO Nicole Comeaux, Director Medical Assistance Division P.O. Box 2348 Santa Fe, NM 87504 - 2348 FORM CMS•179 (07/92) Instructions on Back March 1, 2019 March 1, 2019 October 22, 2019 January 1, 2019 Bill Brooks Director Regional Operations Group

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES 1, TRANSMITTAL NUMBER 2,STATE FORM APPROVED 0MB No. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL 1 9 0 0 2 New Mexico FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE & MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES 5, TYPE OF PLAN MATERIAL (Check One) 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) 4. PROPOSED EFFECTIVE DATE January 1, 2019 0 NEW STATE PLAN O AMENDMENT TO BE CONSIDERED AS NEW PLAN Kl AMENDMENT COMPLETE BLOCKS 6 THAU 10 IF THIS IS AN AMENDMENT (Separate transmittal for each amendment) 6, FEDERAL STATUTE/REGULATION CITATION 7. FEDERAL BUDGET IMPACT a, FFY 2019 $ 2,000,000 Section 1905(a) of the Social Security Act, 42 CFR 441.57; 42 CFR 456.201-456.245; 42 CFR 8, 42 CFR 440.130(d) b. FFY 2020 $ 2.700,000 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT State Supplement A to Attachment 3. lA, page 21 State Supplement A to Attachment 3.1A, pages 21c and 21c1, 21c2, 21c3, 21c4 (new) Attachment 4.19-B Page 3 Attachment 4.19-B Page 3aa (new) 10. SUBJECT OF AMENDMENT Substance Use Disorder (SUD) Continuum of Services 11. GOVERNOR'S REVIEW (Check One) 0 GOVERNOR'S OFFICE REPORTED NO COMMENT 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED 0 NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 14. TITLE Director, Medical Assistance Division 15. DATE SUBMITTED 9, PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable) State Supplement A to Attachment 3.1A, page 21 (NM Amendment 04-008) State Supplement A page 21c (NM SPA 06-07) Attachment 4.19-B Page 3 (NM SPA 19-0005) Ix] OTHER, AS SPECIFIED Authority Delegated to the Medicaid Director 16. RETURN TO Nicole Comeaux, Director Medical Assistance Division P.O. Box 2348 Santa Fe, NM 87504 - 2348 FORM CMS•179 (07/92) Instructions on Back March 1, 2019 March 1, 2019 October 22, 2019 January 1, 2019 Bill Brooks Director Regional Operations Group As per email request, the State requested a pen and ink change to correct the superseded page for State Supplement A to Attachment 3.1-A, Page 21 from (04-008) to (10-0008). 10-008

TN No._________________________ Approval Date _________________ Supersedes TN No. _______________ Effective Date _________________ State Supplement A to Attachment 3.1A 4. Contact Lenses, except when prior authorized. 5. Glass cases, anti-scratch lenses, anti-reflective coatings, progressive lenses, trifocals and other items not related to medical necessity. 6. Routine vision exams and glasses are allowed only once in a 24-month period except as provided as an EPSDT service or the medical condition of the client requires more frequent examination, treatment or follow up. Item 13d Rehabilitative Services The rehabilitative services listed below must be recommended by a physician or OLP. Services are limited to mental health rehabilitation services for eligible recipients for whom the medical necessity of such services has been determined and who are not residents of an institution for mental illness. The services are limited to goal oriented mental health rehabilitative services individually designed to accommodate the level of the recipient's functioning and which reduce the disability and to restore the recipient to his/her best possible level of functioning. Services are limited to assessment, treatment planning, and specific services which reduce symptomatology and restore basic skills necessary to function independently in the community including: 1. Therapeutic lnterventions: Provides face to face therapeutic services which include assessments, treatment planning, ongoing treatment, and transition planning. 2. Medication Services: Provides for the assessment of the efficacy of medication and evaluation of side effects, and administration of medication by qualified personnel when it cannot be self administered. Also provides educationally structured face to face activities delivered to patients, their families and others who provide care to patients regarding medication management. 3. Community Based Crisis Interventions: Provides coordinated services utilizing a crisis team. The service includes immediate access, evaluation, crisis intervention and respite care to patients. 4. Professional Consultation: Provides consultation services by mental health professionals as part of treatment team, to patients for the purpose of clinical case review, treatment plan development and ongoing treatment. 21 10-22-19 01-01-19 19-0002 04-0008 State: New Mexico Date Received: 03-01-19 Date Approved: 10-22-19 Date Effective: 01-01-19 Transmittal Number: 19-0002

TN No._________________________ Approval Date _________________ Supersedes TN No. _______________ Effective Date _________________ State Supplement A to Attachment 3.1A 4. Contact Lenses, except when prior authorized. 5. Glass cases, anti-scratch lenses, anti-reflective coatings, progressive lenses, trifocals and other items not related to medical necessity. 6. Routine vision exams and glasses are allowed only once in a 24-month period except as provided as an EPSDT service or the medical condition of the client requires more frequent examination, treatment or follow up. Item 13d Rehabilitative Services The rehabilitative services listed below must be recommended by a physician or OLP. Services are limited to mental health rehabilitation services for eligible recipients for whom the medical necessity of such services has been determined and who are not residents of an institution for mental illness. The services are limited to goal oriented mental health rehabilitative services individually designed to accommodate the level of the recipient's functioning and which reduce the disability and to restore the recipient to his/her best possible level of functioning. Services are limited to assessment, treatment planning, and specific services which reduce symptomatology and restore basic skills necessary to function independently in the community including: 1. Therapeutic lnterventions: Provides face to face therapeutic services which include assessments, treatment planning, ongoing treatment, and transition planning. 2. Medication Services: Provides for the assessment of the efficacy of medication and evaluation of side effects, and administration of medication by qualified personnel when it cannot be self administered. Also provides educationally structured face to face activities delivered to patients, their families and others who provide care to patients regarding medication management. 3. Community Based Crisis Interventions: Provides coordinated services utilizing a crisis team. The service includes immediate access, evaluation, crisis intervention and respite care to patients. 4. Professional Consultation: Provides consultation services by mental health professionals as part of treatment team, to patients for the purpose of clinical case review, treatment plan development and ongoing treatment. 21 10-22-19 01-01-19 19-0002 08-0008 State: New Mexico Date Received: 03-01-19 Date Approved: 10-22-19 Date Effective: 01-01-19 Transmittal Number: 19-0002

TN No._____________________________ Approval Date ___________________ Supersedes TN No. ___________________ Effective Date ____________________ State Supplement A to Attachment 3.1A Page 21c 8. Multi-Systemic Therapy (MST). MST provides an intensive family preservation model of treatment for youth and their families who are at risk of out-of-home placement. MST is for the benefit of the child. The MST model is based on evidence-based interventions that target specific behaviors with individualized behavioral interventions. Services include an initial assessment to identify the focus of the MST intervention and face-to-face therapeutic interventions with the youth and family in the following functional domains: adaptive, communication, psychosocial, problem solving, and behavior management. Specialized therapeutic and rehabilitative interventions are available to address special areas such as substance abuse, sexual abuse, sex offending, and domestic violence. Any agency that seeks and is certified by MST, Inc. can provide MST services. Services are available in-home, at school and in other community settings including a federally qualified health center (FQHC), an Indian Health Service (IHS) facility, a PL 93-638 tribally-operated facility, an agency licensed by the Children, Youth, and Families’ Department as a Children’s Core Service Agency, and private agencies and schools certified by the New Mexico Department of Health or the Children, Youth, and Families’ Department. All agencies must be able to provide twenty-four (24) hour coverage, seven (7) days per week, by licensed Masters and/or Bachelors level staff. Bachelor’s level staff must have a degree in social work, counseling, psychology or a related human services field and must have at least three (3) years of experience working with the target population that is, children/adolescents and their families. Staffing for MST services shall be comprised of no more than one-third Bachelors level staff and, at minimum, two-thirds licensed Masters level staff. 9. Substance Use Disorder Continuum of Services The comprehensive continuum of services for the screening, assessment, and treatment of substance use disorders includes several new services based upon the American Society of Addiction Medicine’s levels of care (ASAM LOC) including placement criteria, staffing, and standards. These services are designed for an individual’s restoration to a functional level within his or her life and community. 1. Screening, Brief Intervention, and Referral to Treatment (SBIRT) A. Definition: SBIRT is a community-based practice designed to identify, reduce and prevent problematic substance use or misuse and co-occurring mental health disorders as an early intervention. SBIRT is a universal screening specific to age, face-to-face brief intervention for positive screening results, and a referral to behavioral health services if indicated. B. Practitioners delivering the service must be trained in a state-approved educational curriculum and include: 1. Registered nurses; 2. Certified nurse practitioners; 3. Clinical nurse specialists; 4. Behavioral health practitioners at all educational levels; 5. Behavioral health interns under the supervision of an independently licensed behavioral health practitioner; 6. Certified peer support workers; 7. Certified family peer support workers; 8. Licensed physician assistants; 10-22-19 01-01-19 19-0002 06-0007 State: New Mexico Date Received: 03-01-19 Date Approved: 10-22-19 Date Effective: 01-01-19 Transmittal Number: 19-0002

TN No._____________________________ Approval Date ___________________ Supersedes TN No. ___________________ Effective Date ____________________ State Supplement A to Attachment 3.1A Page 21c 8. Multi-Systemic Therapy (MST). MST provides an intensive family preservation model of treatment for youth and their families who are at risk of out-of-home placement. MST is for the benefit of the child. The MST model is based on evidence-based interventions that target specific behaviors with individualized behavioral interventions. Services include an initial assessment to identify the focus of the MST intervention and face-to-face therapeutic interventions with the youth and family in the following functional domains: adaptive, communication, psychosocial, problem solving, and behavior management. Specialized therapeutic and rehabilitative interventions are available to address special areas such as substance abuse, sexual abuse, sex offending, and domestic violence. Any agency that seeks and is certified by MST, Inc. can provide MST services. Services are available in-home, at school and in other community settings including a federally qualified health center (FQHC), an Indian Health Service (IHS) facility, a PL 93-638 tribally-operated facility, an agency licensed by the Children, Youth, and Families’ Department as a Children’s Core Service Agency, and private agencies and schools certified by the New Mexico Department of Health or the Children, Youth, and Families’ Department. All agencies must be able to provide twenty-four (24) hour coverage, seven (7) days per week, by licensed Masters and/or Bachelors level staff. Bachelor’s level staff must have a degree in social work, counseling, psychology or a related human services field and must have at least three (3) years of experience working with the target population that is, children/adolescents and their families. Staffing for MST services shall be comprised of no more than one-third Bachelors level staff and, at minimum, two-thirds licensed Masters level staff. 9. Substance Use Disorder Continuum of Services The comprehensive continuum of services for the screening, assessment, and treatment of substance use disorders includes several new services based upon the American Society of Addiction Medicine’s levels of care (ASAM LOC) including placement criteria, staffing, and standards. These services are designed for an individual’s restoration to a functional level within his or her life and community. 1. Screening, Brief Intervention, and Referral to Treatment (SBIRT) A. Definition: SBIRT is a community-based practice designed to identify, reduce and prevent problematic substance use or misuse and co-occurring mental health disorders as an early intervention. SBIRT is a universal screening specific to age, face-to-face brief intervention for positive screening results, and a referral to behavioral health services if indicated. B. Practitioners delivering the service must be trained in a state-approved educational curriculum and include: 1. Registered nurses; 2. Certified nurse practitioners; 3. Clinical nurse specialists; 4. Behavioral health practitioners at all educational levels; 5. Behavioral health interns under the supervision of an independently licensed behavioral health practitioner; 6. Certified peer support workers; 7. Certified family peer support workers; 8. Licensed physician assistants; 10-22-19 01-01-19 19-0002 06-0007 State: New Mexico Date Received: 03-01-19 Date Approved: 10-22-19 Date Effective: 01-01-19 Transmittal Number: 19-0002

TN No._____________________________ Approval Date ___________________ Supersedes TN No. ___________________ Effective Date ____________________ State Supplement A to Attachment 3.1A Page 21c1 9. Physicians; 10. Medical assistants; and 11. Community health workers. 2. Peer Support Services A. Definition: Peer support services are an evidence-based mental health model of care which consists of a qualified peer support provider who assists individuals with their recovery from mental illness and substance use disorders. Recovery is a rehabilitative process characterized by continual growth and improvement in one’s health and wellness, social and spiritual connection, and renewed purpose. Family Peer Support Services (FPSS) enable parents and other primary caregivers to gain the knowledge, skills and confidence to effectively manage their own needs and the needs of the family member with the condition, ultimately moving to more family independence. B. Practitioners: 1. Certified Peer Support Workers a. Must complete the educational program offered at the Behavioral Health Services Division of the Human Services Department or the Family Peer Support training by the Children, Youth and Families Department b. Must complete the test and be certified by the Counseling and Therapy Practice Board c. Must be supervised by an independent practitioner or someone trained and certified to supervise peers. 2. Certified Family Peer Support Workers a. Must complete the educational program offered at the Children, Youth and Families Department b. Must complete the test and be certified by the Counseling and Therapy Practice Board c. Must be supervised by an independent practitioner or someone trained and certified to supervise peers. 3. Dyadic and triadic therapy for a baby or child diagnosed with a behavioral health condition or at risk because of the caregiver’s behavioral health condition includes the mother, father, or primary caregiver together with the child. Dyadic and triadic therapies are types of family therapies for the direct benefit of the child. Independently licensed practitioners represent the dyadic and triadic providers. 4. Outpatient withdrawal management (WM): A. Definition: Withdrawal signs and symptoms are sufficiently resolved so that the patient can be safely managed outside of the clinic; at night has supportive living situation. 1. Ambulatory WM without extended on-site management a. Services: a comprehensive medical history and physical examination; medication or non-medication methods of WM; patient education; non- pharmacological clinical support; involvement of family members or significant others in the WM process; and discharge or transfer planning including referral for counseling and involvement in community recovery support groups. 10-22-19 01-01-19 19-0002 None-new page State: New Mexico Date Received: 03-01-19 Date Approved: 10-22-19 Date Effective: 01-01-19 Transmittal Number: 19-0002

TN No._____________________________ Approval Date ___________________ Supersedes TN No. ___________________ Effective Date ____________________ State Supplement A to Attachment 3.1A Page 21c1 9. Physicians; 10. Medical assistants; and 11. Community health workers. 2. Peer Support Services A. Definition: Peer support services are an evidence-based mental health model of care which consists of a qualified peer support provider who assists individuals with their recovery from mental illness and substance use disorders. Recovery is a rehabilitative process characterized by continual growth and improvement in one’s health and wellness, social and spiritual connection, and renewed purpose. Family Peer Support Services (FPSS) enable parents and other primary caregivers to gain the knowledge, skills and confidence to effectively manage their own needs and the needs of the family member with the condition, ultimately moving to more family independence. B. Practitioners: 1. Certified Peer Support Workers a. Must complete the educational program offered at the Behavioral Health Services Division of the Human Services Department or the Family Peer Support training by the Children, Youth and Families Department b. Must complete the test and be certified by the Counseling and Therapy Practice Board c. Must be supervised by an independent practitioner or someone trained and certified to supervise peers. 2. Certified Family Peer Support Workers a. Must complete the educational program offered at the Children, Youth and Families Department b. Must complete the test and be certified by the Counseling and Therapy Practice Board c. Must be supervised by an independent practitioner or someone trained and certified to supervise peers. 3. Dyadic and triadic therapy for a baby or child diagnosed with a behavioral health condition or at risk because of the caregiver’s behavioral health condition includes the mother, father, or primary caregiver together with the child. Dyadic and triadic therapies are types of family therapies for the direct benefit of the child. Independently licensed practitioners represent the dyadic and triadic providers. 4. Outpatient withdrawal management (WM): A. Definition: Withdrawal signs and symptoms are sufficiently resolved so that the patient can be safely managed outside of the clinic; at night has supportive living situation. 1. Ambulatory WM without extended on-site management a. Services: a comprehensive medical history and physical examination; medication or non-medication methods of WM; patient education; non- pharmacological clinical support; involvement of family members or significant others in the WM process; and discharge or transfer planning including referral for counseling and involvement in community recovery support groups. 10-22-19 01-01-19 19-0002 None-new page State: New Mexico Date Received: 03-01-19 Date Approved: 10-22-19 Date Effective: 01-01-19 Transmittal Number: 19-0002

TN No._____________________________ Approval Date ___________________ Supersedes TN No. ___________________ Effective Date ____________________ State Supplement A to Attachment 3.1A Page 21c2 b. Staff: i. on call physician, nurse, psychologist ii. on-site nurse, counselors, social workers, peer support workers 2. Ambulatory WM with extended on-site monitoring a. services include the above services plus an addiction-focused history; sufficient biopsychosocial screening to determine the level of care; an individualized treatment plan; and monitoring and assessment of progress throughout the day b. Staff: i. on call physician, nurse, psychologist ii. on-site nurse, counselors, social workers, peer support workers 5. Crisis Stabilization A. Definition: Crisis Stabilization is an outpatient service providing up to 24-hour stabilization of crisis conditions. Crisis Stabilization includes services that are designed to ameliorate or minimize an acute crisis episode or to prevent incarceration, emergency department, inpatient psychiatric hospitalization, or medical detoxification. Services are provided to eligible recipients who have suffered a breakdown of their normal strategies or resources and who exhibit acute problems or disturbed thoughts, behaviors, or moods which could threaten the safety of self or others. Ambulatory withdrawal management may be included. Some Centers may also offer navigational services for individuals transitioning to the community from correctional facilities upon official release from custody/detention. B. Staffing: Crisis stabilization community centers must be minimally staffed during all hours of operation with: 1. one registered nurse with experience or training in crisis triage and managing intoxication and withdrawal management if offered; 2. one licensed master’s level mental health practitioner; 3. one certified peer support worker; and 4. either on-site or on call one board certified physician or licensed clinical nurse specialist, or licensed certified nurse practitioner. 6. Intensive Outpatient for SUD: A. Definition: Time limited IOP services utilizing a multi-faceted approach to treatment for an eligible recipient who requires structure and support to achieve and sustain recovery. IOP must utilize a research and evidence-based model approved by the IOP Interagency Council and target specific behaviors with individualized behavioral interventions. IOP core services include: individual substance use disorder related therapy; group therapy and psycho-education. B. Staff: IOP services are provided through an integrated interdisciplinary approach including staff expertise in both addiction and mental health treatment 1. Each IOP program must have an independently licensed clinical supervisor 2. The team may have services rendered by non-independent practitioners under the direction of the IOP supervisor including LMSW, LMHC, LADAC, CADC, LSAA, and master’s level psych associates. 10-22-19 01-01-19 19-0002 None-new page State: New Mexico Date Received: 03-01-19 Date Approved: 10-22-19 Date Effective: 01-01-19 Transmittal Number: 19-0002

TN No._____________________________ Approval Date ___________________ Supersedes TN No. ___________________ Effective Date ____________________ State Supplement A to Attachment 3.1A Page 21c2 b. Staff: i. on call physician, nurse, psychologist ii. on-site nurse, counselors, social workers, peer support workers 2. Ambulatory WM with extended on-site monitoring a. services include the above services plus an addiction-focused history; sufficient biopsychosocial screening to determine the level of care; an individualized treatment plan; and monitoring and assessment of progress throughout the day b. Staff: i. on call physician, nurse, psychologist ii. on-site nurse, counselors, social workers, peer support workers 5. Crisis Stabilization A. Definition: Crisis Stabilization is an outpatient service providing up to 24-hour stabilization of crisis conditions. Crisis Stabilization includes services that are designed to ameliorate or minimize an acute crisis episode or to prevent incarceration, emergency department, inpatient psychiatric hospitalization, or medical detoxification. Services are provided to eligible recipients who have suffered a breakdown of their normal strategies or resources and who exhibit acute problems or disturbed thoughts, behaviors, or moods which could threaten the safety of self or others. Ambulatory withdrawal management may be included. Some Centers may also offer navigational services for individuals transitioning to the community from correctional facilities upon official release from custody/detention. B. Staffing: Crisis stabilization community centers must be minimally staffed during all hours of operation with: 1. one registered nurse with experience or training in crisis triage and managing intoxication and withdrawal management if offered; 2. one licensed master’s level mental health practitioner; 3. one certified peer support worker; and 4. either on-site or on call one board certified physician or licensed clinical nurse specialist, or licensed certified nurse practitioner. 6. Intensive Outpatient for SUD: A. Definition: Time limited IOP services utilizing a multi-faceted approach to treatment for an eligible recipient who requires structure and support to achieve and sustain recovery. IOP must utilize a research and evidence-based model approved by the IOP Interagency Council and target specific behaviors with individualized behavioral interventions. IOP core services include: individual substance use disorder related therapy; group therapy and psycho-education. B. Staff: IOP services are provided through an integrated interdisciplinary approach including staff expertise in both addiction and mental health treatment 1. Each IOP program must have an independently licensed clinical supervisor 2. The team may have services rendered by non-independent practitioners under the direction of the IOP supervisor including LMSW, LMHC, LADAC, CADC, LSAA, and master’s level psych associates. 10-22-19 01-01-19 19-0002 None-new page State: New Mexico Date Received: 03-01-19 Date Approved: 10-22-19 Date Effective: 01-01-19 Transmittal Number: 19-0002

TN No._____________________________ Approval Date ___________________ Supersedes TN No. ___________________ Effective Date ____________________ State Supplement A to Attachment 3.1A Page 21c3 7. Intensive Outpatient for Mental Health Conditions: All conditions as IOP for SUD apply. 8. Partial hospitalization: 20 or more hours of service/week for multi-dimensional instability, not requiring 24-hour care. A. Partial hospitalization updated coverage criteria: 1. Extend coverage to youth as part of EPSDT in a psychiatric hospital; 2. Include SUD in addition to mental health; 3. Qualified agency types include acute care hospitals with psychiatric services and psychiatric hospitals as specialty hospitals. 9. Accredited Residential Treatment Centers (ARTC) for adults with SUD with three sub-levels: A. Definition: Accredited Residential Treatment Centers for Adults with Substance Use Disorder are facilities for adult recipients, who have been diagnosed as having a substance use disorder (SUD). B. Sub-levels of care 1. Level 3.1: Clinically managed low-intensity residential service: 24-hour structure with trained personnel; at least 5 hours of clinical service/week. This level is often a step down from a higher level of care and prepares the recipient for outpatient treatment and community life. 2. Level 3.3, 3.5, and 3.2 withdrawal management are clustered together in a second level of service with specific programming for each sub type: a. Level 3.3, clinically managed population specific high intensity residential services: 24-hour structure with trained counselors to stabilize multi- dimensional imminent danger; less intense programming and group treatment for those with cognitive or other impairments unable to use full therapeutic community; and preparation for outpatient treatment. b. Level 3.5, clinically managed high intensity residential services: 24-hour care with trained counselors to stabilize multi-dimensional imminent danger; and preparation for outpatient treatment. c. Level 3.2 withdrawal management, clinically managed residential withdrawal management: Moderate withdrawal, but needs 24-hour support to complete withdrawal management and increase likelihood of continuing treatment or recovery. The recipient remains in a Level 3.2 withdrawal management program until: i. withdrawal signs and symptoms are sufficiently resolved that he or she can be safely managed at a less intensive level of care; or ii. the recipient’s signs and symptoms of withdrawal have failed to respond to treatment and have intensified such that transfer to a more intensive level of withdrawal management services is indicated. 3. Level 3.7 and 3.7 withdrawal management are clustered together in a third level of service with specific programming for each sub type. Services are provided by an interdisciplinary staff of nurses, counselors, social workers, addiction specialists, peer support workers or other health and technical personnel under the direction of a licensed physician. 10-22-19 01-01-19 19-0002 None- new page State: New Mexico Date Received: 03-01-19 Date Approved: 10-22-19 Date Effective: 01-01-19 Transmittal Number: 19-0002

TN No._____________________________ Approval Date ___________________ Supersedes TN No. ___________________ Effective Date ____________________ State Supplement A to Attachment 3.1A Page 21c3 7. Intensive Outpatient for Mental Health Conditions: All conditions as IOP for SUD apply. 8. Partial hospitalization: 20 or more hours of service/week for multi-dimensional instability, not requiring 24-hour care. A. Partial hospitalization updated coverage criteria: 1. Extend coverage to youth as part of EPSDT in a psychiatric hospital; 2. Include SUD in addition to mental health; 3. Qualified agency types include acute care hospitals with psychiatric services and psychiatric hospitals as specialty hospitals. 9. Accredited Residential Treatment Centers (ARTC) for adults with SUD with three sub-levels: A. Definition: Accredited Residential Treatment Centers for Adults with Substance Use Disorder are facilities for adult recipients, who have been diagnosed as having a substance use disorder (SUD). B. Sub-levels of care 1. Level 3.1: Clinically managed low-intensity residential service: 24-hour structure with trained personnel; at least 5 hours of clinical service/week. This level is often a step down from a higher level of care and prepares the recipient for outpatient treatment and community life. 2. Level 3.3, 3.5, and 3.2 withdrawal management are clustered together in a second level of service with specific programming for each sub type: a. Level 3.3, clinically managed population specific high intensity residential services: 24-hour structure with trained counselors to stabilize multi- dimensional imminent danger; less intense programming and group treatment for those with cognitive or other impairments unable to use full therapeutic community; and preparation for outpatient treatment. b. Level 3.5, clinically managed high intensity residential services: 24-hour care with trained counselors to stabilize multi-dimensional imminent danger; and preparation for outpatient treatment. c. Level 3.2 withdrawal management, clinically managed residential withdrawal management: Moderate withdrawal, but needs 24-hour support to complete withdrawal management and increase likelihood of continuing treatment or recovery. The recipient remains in a Level 3.2 withdrawal management program until: i. withdrawal signs and symptoms are sufficiently resolved that he or she can be safely managed at a less intensive level of care; or ii. the recipient’s signs and symptoms of withdrawal have failed to respond to treatment and have intensified such that transfer to a more intensive level of withdrawal management services is indicated. 3. Level 3.7 and 3.7 withdrawal management are clustered together in a third level of service with specific programming for each sub type. Services are provided by an interdisciplinary staff of nurses, counselors, social workers, addiction specialists, peer support workers or other health and technical personnel under the direction of a licensed physician. 10-22-19 01-01-19 19-0002 None- new page State: New Mexico Date Received: 03-01-19 Date Approved: 10-22-19 Date Effective: 01-01-19 Transmittal Number: 19-0002

TN No._____________________________ Approval Date ___________________ Supersedes TN No. ___________________ Effective Date ____________________ State Supplement A to Attachment 3.1A Page 21c4 a. Level 3.7: medically monitored intensive inpatient services: 24-hour nursing care with physician availability for significant problems; 16 hour/day counselor availability. b. Level 3.7 withdrawal management: medically monitored inpatient withdrawal management: Severe withdrawal, 24-hour nursing care and physician visits; unlikely to complete withdrawal management without medical monitoring. The recipient remains in a level 3.7 withdrawal management program until: i. withdrawal signs and symptoms are sufficiently resolved that he or she can be safely managed at a less intensive level of care; or ii. the recipient’s signs and symptoms of withdrawal have failed to respond to treatment and have intensified such that transfer to a more intensive level of withdrawal management services is indicated. 10. Crisis Triage Centers (CTCs) A. Definition: Crisis Triage Centers are community-based alternatives to hospitalization or incarceration authorized by 2014 NM HB212 Crisis Triage Center legislation. The facilities are either outpatient only (providing crisis stabilization as indicated above), or outpatient and residential, with no more than 16 beds. They serve youth and adults to provide voluntary stabilization of behavioral health crises including emergency mental health evaluation, withdrawal management, and care. Services include physical and mental health assessment, de-escalation and stabilization; brief intervention and psychological counseling; clinical consultation and supervision for bio-medical, emotional, behavioral, and cognitive problems; psychological and psychiatric consultation; other services determined through the assessment process; and may include ambulatory withdrawal management; and, if residential, all level 3 withdrawal management services. B. The following individuals and practitioners must be contracted or employed by the provider agency as part of its crisis triage center service delivery: 1. an administrator which can be the same person as the clinical director; 2. a full-time clinical director; 3. a charge nurse on duty 24 hours/day, seven days/week; 4. an on-call physician 24 hours/day, seven days/week; 5. a master’s level licensed mental health practitioner; 6. two certified peer support workers; 7. a part time psychiatric consultant, hours dependent on the size of the facility; and 8. at least one staff trained in basic cardiac life support (BCLS), the use of the automated external defibrillator (AED) equipment, and first aid. The ratio of direct care staff to individuals shall increase on the basis of the clinical care needs of the individuals in residence as well as the number of operational beds. 10-22-19 01-01-19 19-0002 None - new page State: New Mexico Date Received: 03-01-19 Date Approved: 10-22-19 Date Effective: 01-01-19 Transmittal Number: 19-0002

TN No._____________________________ Approval Date ___________________ Supersedes TN No. ___________________ Effective Date ____________________ State Supplement A to Attachment 3.1A Page 21c4 a. Level 3.7: medically monitored intensive inpatient services: 24-hour nursing care with physician availability for significant problems; 16 hour/day counselor availability. b. Level 3.7 withdrawal management: medically monitored inpatient withdrawal management: Severe withdrawal, 24-hour nursing care and physician visits; unlikely to complete withdrawal management without medical monitoring. The recipient remains in a level 3.7 withdrawal management program until: i. withdrawal signs and symptoms are sufficiently resolved that he or she can be safely managed at a less intensive level of care; or ii. the recipient’s signs and symptoms of withdrawal have failed to respond to treatment and have intensified such that transfer to a more intensive level of withdrawal management services is indicated. 10. Crisis Triage Centers (CTCs) A. Definition: Crisis Triage Centers are community-based alternatives to hospitalization or incarceration authorized by 2014 NM HB212 Crisis Triage Center legislation. The facilities are either outpatient only (providing crisis stabilization as indicated above), or outpatient and residential, with no more than 16 beds. They serve youth and adults to provide voluntary stabilization of behavioral health crises including emergency mental health evaluation, withdrawal management, and care. Services include physical and mental health assessment, de-escalation and stabilization; brief intervention and psychological counseling; clinical consultation and supervision for bio-medical, emotional, behavioral, and cognitive problems; psychological and psychiatric consultation; other services determined through the assessment process; and may include ambulatory withdrawal management; and, if residential, all level 3 withdrawal management services. B. The following individuals and practitioners must be contracted or employed by the provider agency as part of its crisis triage center service delivery: 1. an administrator which can be the same person as the clinical director; 2. a full-time clinical director; 3. a charge nurse on duty 24 hours/day, seven days/week; 4. an on-call physician 24 hours/day, seven days/week; 5. a master’s level licensed mental health practitioner; 6. two certified peer support workers; 7. a part time psychiatric consultant, hours dependent on the size of the facility; and 8. at least one staff trained in basic cardiac life support (BCLS), the use of the automated external defibrillator (AED) equipment, and first aid. The ratio of direct care staff to individuals shall increase on the basis of the clinical care needs of the individuals in residence as well as the number of operational beds. 10-22-19 01-01-19 19-0002 None - new page State: New Mexico Date Received: 03-01-19 Date Approved: 10-22-19 Date Effective: 01-01-19 Transmittal Number: 19-0002

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE OF NEW MEXICO AND STANDARDS FOR ESTABLISHING PAYMENT RATES --OTHER TYPES OF CARE

Approval Date TN No. 19-0002 Supersedes TN No. 19-0005 Effective Date _____________________ Attachment 4.19-B Page 3 A. Other Practitioners Services 1. Behavioral health professional services are reimbursed on a fee schedule basis applicable to psychologists, counselors, therapists, licensed alcohol and drug abuse counselors, behavioral health agencies, licensed independent social workers and psychiatric clinical nurse specialists. This also includes the professional services rendered under Screening, Brief Intervention, and Referral to Treatment (SBIRT), behavior health screening tools, peer support services, dyadic and triadic therapy, outpatient withdrawal management, crisis stabilization, intensive outpatient for substance use disorder or mental health condition and partial hospitalization. Except as otherwise noted in the state plan, state developed fee schedule rates are the same for both governmental and private providers. The agency’s fee schedule rates were set as of January 1, 2019 and are effective for services provided on or after that date. All rates are published at http://www.hsd.state.nm.us/providers/fee-schedules.aspx. Peer support services delivered through IHS or a tribal 638 clinic are reimbursed at the OMB rate. Non-independent behavioral health practitioners who are required by state law to be supervised are not paid directly for their services. Rather, payment is made to the supervising practitioner, or the appropriate group, licensed treatment and diagnostic center or agency to which the behavioral health worker belongs. 2. Independently practicing certified Nurse Practitioners and Clinical Nurse Specialists are reimbursed at 90% of the physician fee schedule as described in Item I. A of Attachment 4.19 B, including preventive services for alternative benefit plan recipients. Except as otherwise noted in the state plan, state developed fee schedule rates are the same for both governmental and private providers. The agency’s fee schedule rates were set as of January 1, 2019 and are effective for services provided on or after that date. All rates are published at http://www.hsd.state.nm.us/providers/fee-schedules.aspx. 3. Certified nurse anesthetists and anesthesiology assistants are reimbursed a rate per anesthesia unit for the procedure and for units of time for medically directed and non-medically directed services. Except as otherwise noted in the state plan, state developed fee schedule rates are the same for both governmental and private providers. The agency’s fee schedule rates were set as of March 31, 2014 and are effective for services provided on or after that date. All rates are published at http://www.hsd.state.nm.us/providers/fee-schedules.aspx. 10-22-19 01-01-19 State: New Mexico Date Received: 03-01-19 Date Approved: 10-22-19 Date Effective: 01-01-19 Transmittal Number: 19-0002

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE OF NEW MEXICO AND STANDARDS FOR ESTABLISHING PAYMENT RATES --OTHER TYPES OF CARE

Approval Date TN No. 19-0002 Supersedes TN No. 19-0005 Effective Date _____________________ Attachment 4.19-B Page 3 A. Other Practitioners Services 1. Behavioral health professional services are reimbursed on a fee schedule basis applicable to psychologists, counselors, therapists, licensed alcohol and drug abuse counselors, behavioral health agencies, licensed independent social workers and psychiatric clinical nurse specialists. This also includes the professional services rendered under Screening, Brief Intervention, and Referral to Treatment (SBIRT), behavior health screening tools, peer support services, dyadic and triadic therapy, outpatient withdrawal management, crisis stabilization, intensive outpatient for substance use disorder or mental health condition and partial hospitalization. Except as otherwise noted in the state plan, state developed fee schedule rates are the same for both governmental and private providers. The agency’s fee schedule rates were set as of January 1, 2019 and are effective for services provided on or after that date. All rates are published at http://www.hsd.state.nm.us/providers/fee-schedules.aspx. Peer support services delivered through IHS or a tribal 638 clinic are reimbursed at the OMB rate. Non-independent behavioral health practitioners who are required by state law to be supervised are not paid directly for their services. Rather, payment is made to the supervising practitioner, or the appropriate group, licensed treatment and diagnostic center or agency to which the behavioral health worker belongs. 2. Independently practicing certified Nurse Practitioners and Clinical Nurse Specialists are reimbursed at 90% of the physician fee schedule as described in Item I. A of Attachment 4.19 B, including preventive services for alternative benefit plan recipients. Except as otherwise noted in the state plan, state developed fee schedule rates are the same for both governmental and private providers. The agency’s fee schedule rates were set as of January 1, 2019 and are effective for services provided on or after that date. All rates are published at http://www.hsd.state.nm.us/providers/fee-schedules.aspx. 3. Certified nurse anesthetists and anesthesiology assistants are reimbursed a rate per anesthesia unit for the procedure and for units of time for medically directed and non-medically directed services. Except as otherwise noted in the state plan, state developed fee schedule rates are the same for both governmental and private providers. The agency’s fee schedule rates were set as of March 31, 2014 and are effective for services provided on or after that date. All rates are published at http://www.hsd.state.nm.us/providers/fee-schedules.aspx. 10-22-19 01-01-19 State: New Mexico Date Received: 03-01-19 Date Approved: 10-22-19 Date Effective: 01-01-19 Transmittal Number: 19-0002

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State of NEW MEXICO METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES – OTHER TYPES OF CARE ________________________________________________________________________________________________ Attachment 4.19 - B TN No. 19-0002 Approval Date __________________________ Supersedes TN. No. None Effective Date __________________________ Page 3aa 4. Accredited Residential Treatment Centers for Adults with Substance Use Disorders – Reimbursement is made at a daily rate established by the agency state audit agent after analyzing the costs to provide services. Room and board costs are not included in the rate and are not reimbursable. Cost that are considered in the rate are: direct service costs, direct supervision costs, therapy costs including all salaries, wages, and benefits associated with health care personnel, admission discharge planning, clinical support costs, non-personnel operating costs including expenses incurred for program related supplies and general administration costs. 5. Crisis Triage Centers – Reimbursement is made at service rates that are uniquely determined for each provider based on provider costs as determined by the state agency contracted audit agency. Costs are determined by considering: direct service costs, direct supervision costs, therapy costs including all salaries, wages and benefits associated with health care personnel, clinical support costs, non-personnel operating costs and general administration costs. 10-22-19 01-01-19 State: New Mexico Date Received: 03-01-19 Date Approved: 10-22-19 Date Effective: 01-01-19 Transmittal Number: 19-0002

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State of NEW MEXICO METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES – OTHER TYPES OF CARE ________________________________________________________________________________________________ Attachment 4.19 - B TN No. 19-0002 Approval Date __________________________ Supersedes TN. No. None Effective Date __________________________ Page 3aa 4. Accredited Residential Treatment Centers for Adults with Substance Use Disorders – Reimbursement is made at a daily rate established by the agency state audit agent after analyzing the costs to provide services. Room and board costs are not included in the rate and are not reimbursable. Cost that are considered in the rate are: direct service costs, direct supervision costs, therapy costs including all salaries, wages, and benefits associated with health care personnel, admission discharge planning, clinical support costs, non-personnel operating costs including expenses incurred for program related supplies and general administration costs. 5. Crisis Triage Centers – Reimbursement is made at service rates that are uniquely determined for each provider based on provider costs as determined by the state agency contracted audit agency. Costs are determined by considering: direct service costs, direct supervision costs, therapy costs including all salaries, wages and benefits associated with health care personnel, clinical support costs, non-personnel operating costs and general administration costs. 10-22-19 01-01-19 State: New Mexico Date Received: 03-01-19 Date Approved: 10-22-19 Date Effective: 01-01-19 Transmittal Number: 19-0002

Table of Contents State/Territory Name: New Mexico State Plan Amendment (SPA) #: 19-0003 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved Page

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 1301 Young Street Dallas, Texas 75202

Regional Operations Group

November 4, 2019

Our Reference: SPA NM 19-0003

Ms. Nicole Comeaux Director Medical Assistance Division P.O. Box 2348 Santa Fe, NM 87504-2348

Attention: Jennifer Vigil Dear Ms. Comeaux: We have reviewed the State’s proposed amendment to the New Mexico State Plan submitted under Transmittal Number 19-0003, dated March 7, 2019. This state plan amendment proposes to add a Substance Use Disorder (SUD) Continuum of Services to the Alternative Benefit Plan (ABP) of the New Mexico State plan.

Based on the information submitted, we have approved the amendment for incorporation into the official New Mexico State Plan with an effective date change of January 1, 2019. A copy of the CMS- 179 and the approved plan page are enclosed with this letter.

If you have any questions, please contact Ford Blunt of my staff. Mr. Blunt may be reached at (214) 767-6381 or by e-mail at Ford.Blunt@cms.hhs.gov.

Sincerely,

Bill Brooks Director Centers for Medicaid & CHIP Services Regional Operations Group for

Medicaid Alternative Benefit Plan: Summary Page (CMS 179) Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. Proposed Effective Date (mm/dd/yyyy) Federal Statute/Regulation Citation Federal Budget Impact Subject of Amendment Substance Use Disorder (SUD) Continuum of Services - Alternative Benefit Plan (ABP) Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Authority Delegated to the Medicaid Director Signature of State Agency Official State/Territory name: New Mexico NM-19-0003 01/01/2019 Affordable Care Act and Section 1937 of the Social Security Act Federal Fiscal Year Amount First Year 2019 $ 1000000.00 Second Year 2020 $ 1000000.00   Submitted By: Jennifer Vigil Last Revision Date: Nov 4, 2019 Submit Date: Mar 7, 2019 Page 1 of 1 NM.0811.R00.02 - Jan 01, 2019 (as of Nov 04, 2019) 11/12/2019 https://wms-mmdl.cms.gov/MMDL/faces/protected/abp/d01/print/PrintSelector.jsp Date Received: 3 March, 2019 Date Approved: 4 November, 2019 Signature of Approving Official: Printed Name and Title: BILL Brooks, Associated Regional Administrator

Division of Medicaid & Children’s Health for

Page 1 of 1 Alternative Benefit Plan Attachment 3.1-C- OMB Control Number: 0938-1148 OMB Expiration date: 10/31/2014 Alternative Benefit Plan Populations ABP1 Identify and define the population that will participate in the Alternative Benefit Plan. Alternative Benefit Plan Population Name: New Mexico Expansion Alternative Benefit Plan Identify eligibility groups that are included in the Alternative Benefit Plan's population, and which may contain individuals that meet any targeting criteria used to further define the population. Eligibility Groups Included in the Alternative Benefit Plan Population: Eligibility Group: Enrollment is mandatory or voluntary? + Adult Group Mandatory x Enrollment is available for all individuals in these eligibility group(s). Yes Geographic Area The Alternative Benefit Plan population will include individuals from the entire state/territory. Yes Any other information the state/territory wishes to provide about the population (optional) PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 5 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. V.20130724 State: New Mexico Date Received: 03-07-19 Date Approved: 11-04-19 Date Effective: 01-01-19 Transmittal Number: 19-0003 TN: NM 19-0003 Date Approved: 11/04/2019 Date Effective: 01/01/2019 Supersedes: NM 13-0030

Page 1 of 1 Alternative Benefit Plan Attachment 3.1-C- OMB Control Number: 0938‐1148 OMB Expiration date: 10/31/2014 Alternative Benefit Plan Populations ABP1 Identify and define the population that will participate in the Alternative Benefit Plan. Alternative Benefit Plan Population Name: New Mexico Expansion Alternative Benefit Plan Identify eligibility groups that are included in the Alternative Benefit Plan's population, and which may contain individuals that meet any targeting criteria used to further define the population. Eligibility Groups Included in the Alternative Benefit Plan Population: Eligibility Group: Enrollment is mandatory or voluntary? + Adult Group Mandatory x Enrollment is available for all individuals in these eligibility group(s). Yes Geographic Area The Alternative Benefit Plan population will include individuals from the entire state/territory. Yes Any other information the state/territory wishes to provide about the population (optional) PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 5 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. V.20130724 TN: NM 19-0003 Date Approved: 11/04/2019 Date Effective: 01/01/2019 Supersedes: NM 13-0030 State: New Mexico Date Received: 03-07-19 Date Approved: 11-04-19 Date Effective: 01-01-19 Transmittal Number: 19-0003

Page 1 of 3 Alternative Benefit Plan Attachment 3.1-C- OMB Control Number: 0938-1148 OMB Expiration date: 10/31/2014 Voluntary Benefit Package Selection Assurances - Eligibility Group under Section 1902(a)(10)(A)(i)(VIII) of the Act ABP2a The state/territory has fully aligned its benefits in the Alternative Benefit Plan using Essential Health Benefits and subject to 1937 requirements with its Alternative Benefit Plan that is the state’s approved Medicaid state plan that is not subject to 1937 requirements. Therefore the state/territory is deemed to have met the requirements for voluntary choice of benefit package for individuals exempt from mandatory participation in a section 1937 Alternative Benefit Plan. No These assurances must be made by the state/territory if the Adult eligibility group is included in the ABP Population. The state/territory shall enroll all participants in the "Individuals at or below 133% FPL Age 19 through 64" (section 1902(a)(10)(A)(i)(VIII)) eligibility group in the Alternative Benefit Plan specified in this state plan amendment, except as follows: A beneficiary in the eligibility group at section 1902(a)(10)(A)(i)(VIII) who is determined to meet one of the exemption criteria at 45 CFR 440.315 will receive a choice of a benefit package that is either an Alternative Benefit Plan that includes Essential Health Benefits and is subject to all 1937 requirements or an Alternative Benefit Plan that is the state/territory’s approved Medicaid state plan not subject to 1937 requirements. The state/territory’s approved Medicaid state plan includes all approved state plan programs based on any state plan authority, and approved 1915(c) waivers, if the state has amended them to include the eligibility group at section 1902(a)(10)(A)(i)(VIII). The state/territory must have a process in place to identify individuals that meet the exemption criteria and the state/territory must comply with requirements related to providing the option of enrollment in an Alternative Benefit Plan defined using section 1937 requirements, or an Alternative Benefit Plan defined as the state/territory's approved Medicaid state plan that is not subject to section 1937 requirements. Once an individual is identified, the state/territory assures it will effectively inform the individual of the following: a) Enrollment in the specified Alternative Benefit Plan is voluntary; b) The individual may disenroll from the Alternative Benefit Plan defined subject to section 1937 requirements at any time and instead receive an Alternative Benefit Plan defined as the approved state/territory Medicaid state plan that is not subject to section 1937 requirements; and c) What the process is for transferring to the state plan-based Alternative Benefit Plan. The state/territory assures it will inform the individual of: a) The benefits available as Alternative Benefit Plan coverage defined using section 1937 requirements as compared to Alternative Benefit Plan coverage defined as the state/territory's approved Medicaid state plan and not subject to section 1937 requirements; and b) The costs of the different benefit packages and a comparison of how the Alternative Benefit Plan subject to 1937 requirements differs from the Alternative Benefit Plan defined as the approved Medicaid state/territory plan benefits. How will the state/territory inform individuals about their options for enrollment? (Check all that apply) Letter Email Other State: New Mexico Date Received: 03-07-19 Date Approved: 11-04-19 Date Effective: 01-01-19 Transmittal Number: 19-0003 TN: NM 19-0003 Date Approved: 11/04/2019 Date Effective: 01/01/2019 Supersedes: NM 13-0030

Page 2 of 3 Alternative Benefit Plan Provide a copy of the letter, email text or other communication text that will be used to inform individuals about their options for enrollment. An attachment is submitted. When did/will the state/territory inform the individuals? Notices of eligibility for the Adult Group will describe Alternative Benefit Plan (ABP) exemption criteria, processes for self- identification, and procedures for choosing to enroll in the Medicaid State Plan benefit package. Individuals who are enrolled in managed care will also receive information about the ABP, the exemption criteria and related processes from their managed care organization (MCO); this information is also contained in each MCO member handbook. Please describe the state/territory's process for allowing individuals in the Section 1902(a)(10)(A)(i)(VIII) eligibility group who meet exemption criteria to disenroll from the Alternative Benefit Plan defined using section 1937 requirements and enroll in the Alternative Benefit Plan defined as the state/territory's approved Medicaid state plan. Individuals in the Adult Group will be automatically enrolled in the ABP when they are determined eligible. Their eligibility notice, referenced and attached above, will describe how they can self-identify as being potentially exempt from the ABP. For managed care recipients, the self-identification process will be facilitated by the member's MCO, which will receive the request for an exemption, evaluate the member based on criteria set forth at 42 CFR 440.315 and further defined by the State, provide benefits counseling to the member (including a description of cost differences between the ABP and the Medicaid State Plan), and facilitate the member's voluntary selection of the ABP that is the Medicaid State Plan, if applicable. The MCO may also identify members who may be Medically Frail and qualify for an ABP exemption through a mandatory Health Risk Assessment (HRA). The HRA is the first step of care coordination during which the MCO makes contact with their members, asks a series of general health questions, and explains care coordination. The HRA is designed to help the MCO identify members who may be candidates for care coordination due to their medical needs or health status, and is required within the first 30 days of a member's enrollment with the MCO. Members who are identified through the HRA as potentially Medically Frail will receive a Comprehensive Needs Assessment (CNA) to assess the member's physical and behavioral health needs, long-term care needs and disease management needs. The member will also receive a notice from the MCO about the ABP exemption criteria and process. Upon receipt of this notice, the member must initiate the request to be considered for a potential exemption from the ABP through self-identification. For Native American Medicaid recipients who are exempt from managed care, the state's third-party assessor (TPA) contractor will receive and process the recipient's self-identification and request for an ABP exemption based on criteria set forth at 42 CFR 440.315 and further defined by the State. The TPA contractor will provide benefits counseling and facilitate the recipient's voluntary transition to the ABP that is the Medicaid State Plan, if applicable. The state/territory assures it will document in the exempt individual's eligibility file that the individual: a) Was informed in accordance with this section prior to enrollment; b) Was given ample time to arrive at an informed choice; and c) Chose to enroll in Alternative Benefit Plan coverage subject to section 1937 requirements or defined as the state/territory's approved Medicaid state plan, which is not subject to section 1937 requirements. Where will the information be documented? (Check all that apply) In the eligibility system. In the hard copy of the case record. Other What documentation will be maintained in the eligibility file? (Check all that apply) State: New Mexico Date Received: 03-07-19 Date Approved: 11-04-19 Date Effective: 01-01-19 Transmittal Number: 19-0003 TN: NM 19-0003 Date Approved: 11/04/2019 Date Effective: 01/01/2019 Supersedes: NM 13-0030

Page 3 of 3 Alternative Benefit Plan Copy of correspondence sent to the individual. Signed documentation from the individual consenting to enrollment in the Alternative Benefit Plan. Other The state/territory assures that it will maintain data that tracks the total number of individuals who have voluntarily enrolled in either Alternative Benefit Plan coverage subject to section 1937 requirements or Alternative Benefit Plan coverage defined as the state/territory's approved Medicaid state plan, which is not subject to section 1937 requirements. Other information related to benefit package selection assurances for exempt participants (optional): PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 5 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. V.20130807 State: New Mexico Date Received: 03-07-19 Date Approved: 11-04-19 Date Effective: 01-01-19 Transmittal Number: 19-0003 TN: NM 19-0003 Date Approved: 11/04/2019 Date Effective: 01/01/2019 Supersedes: NM 13-0030

Page 1 of 3 Alternative Benefit Plan Attachment 3.1-C- OMB Control Number: 0938-1148 OMB Expiration date: 10/31/2014 Enrollment Assurances - Mandatory Participants ABP2c These assurances must be made by the state/territory if enrollment is mandatory for any of the target populations or sub-populations. When mandatorily enrolling eligibility groups in an Alternative Benefit Plan (Benchmark or Benchmark-Equivalent Plan) that could have exempt individuals, prior to enrollment: The state/territory assures it will appropriately identify any individuals in the eligibility groups that are exempt from mandatory enrollment in an Alternative Benefit Plan or individuals who meet the exemption criteria and are given a choice of Alternative Benefit Plan coverage defined using section 1937 requirements or Alternative Benefit Plan coverage defined as the state/territory's approved Medicaid state plan, not subject to section 1937 requirements. How will the state/territory identify these individuals? (Check all that apply) Review of eligibility criteria (e.g., age, disorder/diagnosis/condition) Describe: Only individuals eligible for the Adult Group will be enrolled in the Alternative Benefit Plan (ABP). Individuals eligible for other Medicaid categories on the basis of their eligibility criteria (including age, disability and pregnancy) will be correctly identified at enrollment and placed in the correct category of eligibility. Adult Group members who become pregnant must report their pregnancy to a State eligibility office to facilitate their transition to the pregnancy category, or they will remain in the Adult Group. Self-identification Describe: Individuals in the Adult Group will be automatically enrolled in the ABP when they are determined eligible. Their eligibility notice will describe how they can self-identify as exempt from the ABP. For managed care recipients, the self-identification process will be facilitated by the member's MCO, which will receive the request for an exemption, evaluate the member based on criteria set forth at 42 CFR 440.315 and further defined by the State, provide benefits counseling to the member (including a description of cost differences between the ABP and Medicaid State Plan), and facilitate the member's voluntary selection of the ABP that is the Medicaid State Plan, if applicable. For Native American Medicaid recipients who are exempt from managed care, the state's third-party assessor (TPA) contractor will receive and process the recipient's self-identification and request for an ABP exemption based on criteria set forth at 42 CFR 440.315 and further defined by the State. The TPA contractor will provide benefits counseling and facilitate the recipient's voluntary transition to the ABP that is the Medicaid State Plan, if applicable. Because Native American Medicaid recipients are exempt from cost-sharing under both the ABP and the Medicaid State Plan, the TPA contractor is not required to describe the cost differences between the two benefit plans, since the recipient will be exempt from cost-sharing in either instance. Other Describe: For managed care recipients, their managed care organization (MCO) may identify members who may be Medically Frail and qualify for an ABP exemption through a mandatory Health Risk Assessment (HRA). The HRA is the first step of care coordination during which the MCO makes contact with their members, asks a series of general health questions, and explains care coordination. The HRA is designed to help the MCO identify members who may be candidates for care coordination due to their medical needs or health status, and is required within the first 30 days of a member's enrollment with the MCO. Members who are identified through the HRA as potentially Medically Frail will receive a Comprehensive Needs Assessment (CNA) to assess the member's physical and behavioral health needs, long-term care needs and disease management needs. The member will also receive a notice from the MCO about the ABP exemption criteria and process. Upon receipt of this notice, the State: New Mexico Date Received: 03-07-19 Date Approved: 11-04-19 Date Effective: 01-01-19 Transmittal Number: 19-0003 TN: NM 19-0003 Date Approved: 11/04/2019 Date Effective: 01/01/2019 Supersedes: NM 13-0030

Page 2 of 3 Alternative Benefit Plan member must initiate the request to be considered for a potential exemption from the ABP through self-identification. Native American Medicaid recipients who opt-in to managed care will have access to the MCO processes described above, including the HRA, CNA and related care coordination; however, these services are not available to the Native American fee- for-service population. The state/territory must inform the individual they are exempt or meet the exemption criteria and the state/territory must comply with all requirements related to voluntary enrollment or, for beneficiaries in the “Individuals at or below 133% FPL Age 19 through 64” eligibility group, optional enrollment in Alternative Benefit Plan coverage defined using section 1937 requirements or Alternative Benefit Plan coverage defined as the state/territory's approved Medicaid state plan. The state/territory assures that for individuals who have become exempt from enrollment in an Alternative Benefit Plan, the state/territory must inform the individual they are now exempt and the state/territory must comply with all requirements related to voluntary enrollment or, for beneficiaries in the “Individuals at or below 133% FPL Age 19 through 64” eligibility group, optional enrollment in Alternative Benefit Plan coverage defined using section 1937 requirements, or Alternative Benefit Plan coverage defined as the state/territory's approved Medicaid state plan. How will the state/territory identify if an individual becomes exempt? (Check all that apply) Review of claims data Self-identification Review at the time of eligibility redetermination Provider identification Change in eligibility group Other Describe: Managed care members who may be considered Medically Frail may also be identified through the MCO HRA process, described above. How frequently will the state/territory review the Alternative Benefit Plan population to determine if individuals are exempt from mandatory enrollment or meet the exemption criteria? Monthly Quarterly Annually Ad hoc basis Other The state/territory assures that it will promptly process all requests made by exempt individuals for disenrollment from the Alternative Benefit Plan and has in place a process that ensures exempt individuals have access to all standard state/territory plan services or, for beneficiaries in the “Individuals at or below 133% FPL Age 19 through 64” eligibility group, optional enrollment in Alternative Benefit Plan coverage defined using section 1937 requirements, or Alternative Benefit Plan coverage defined as the state/territory's approved Medicaid state plan. State: New Mexico Date Received: 03-07-19 Date Approved: 11-04-19 Date Effective: 01-01-19 Transmittal Number: 19-0003 TN: NM 19-0003 Date Approved: 11/04/2019 Date Effective: 01/01/2019 Supersedes: NM 13-0030

Page 3 of 3 Alternative Benefit Plan Describe the process for processing requests made by exempt individuals to be disenrolled from the Alternative Benefit Plan: For managed care recipients, the self-identification process will be facilitated by the member's MCO, which will receive the request for an exemption, evaluate the member based on criteria set forth at 42 CFR 440.315 and further defined by the State, provide benefits counseling to the member (including a description of cost differences between the ABP and Medicaid State Plan), and facilitate the member's voluntary selection of the ABP that is the Medicaid State Plan, if applicable. For Native American Medicaid recipients who are exempt from managed care, the state's third-party assessor (TPA) contractor will receive and process the recipient's self-identification and request for an ABP exemption based on criteria set forth at 42 CFR 440.315 and further defined by the State. The TPA contractor will provide benefits counseling and facilitate the recipient's voluntary transition to the ABP that is the Medicaid State Plan, if applicable. Because Native American Medicaid recipients are exempt from cost-sharing under both the ABP and the Medicaid State Plan, the TPA contractor is not required to describe the cost differences between the two benefit plans, since the recipient will be exempt from cost-sharing in either instance. The MCOs and TPA contractor will conduct the evaluation of ABP exemption criteria, benefits counseling and voluntary transition to the ABP that is the Medicaid State Plan, if applicable, within 10 working days of receipt of the request from the Medicaid recipient. The recipient will remain enrolled in the ABP until a decision has been made about their exemption and the recipient has made a proactive choice to switch to the Medicaid State Plan benefit package. The recipient will receive a notice informing them of the MCO's or TPA contractor's decision. If the recipient qualifies for an exemption from the ABP, they may then choose whether to remain in the ABP or select the Medicaid State Plan as their benefit package. The MCO or TPA contractor will make an indication of this choice using identifiers that are available in the Medicaid Management Information System (MMIS), which will in turn trigger the recipient's appropriate benefit package. Recipients who are determined by the MCO or TPA contractor as not meeting the criteria set forth at 42 CFR 440.315 and as further defined by the State may request a reconsideration or file a fair hearing in accordance with State regulations. Other Information Related to Enrollment Assurance for Mandatory Participants (optional): PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 5 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. V.20130807 State: New Mexico Date Received: 03-07-19 Date Approved: 11-04-19 Date Effective: 01-01-19 Transmittal Number: 19-0003 TN: NM 19-0003 Date Approved: 11/04/2019 Date Effective: 01/01/2019 Supersedes: NM 13-0030

Page 1 of 2 Alternative Benefit Plan Transmittal Number: NM State Name: New Mexico Attachment 3.1-L- OMB Control Number: 0938-1148 - 19 - 0003 Selection of Benchmark Benefit Package or Benchmark-Equivalent Benefit Package ABP3 Select one of the following: The state/territory is amending one existing benefit package for the population defined in Section 1. The state/territory is creating a single new benefit package for the population defined in Section 1. Name of benefit package: Expansion Alternative Benefit Plan (Expansion ABP) Selection of the Section 1937 Coverage Option The state/territory selects as its Section 1937 Coverage option the following type of Benchmark Benefit Package or Benchmark- Equivalent Benefit Package under this Alternative Benefit Plan (check one): Benchmark Benefit Package. Benchmark-Equivalent Benefit Package. The state/territory will provide the following Benchmark Benefit Package (check one that applies): The Standard Blue Cross/Blue Shield Preferred Provider Option offered through the Federal Employee Health Benefit Program (FEHBP). State employee coverage that is offered and generally available to state employees (State Employee Coverage): A commercial HMO with the largest insured commercial, non-Medicaid enrollment in the state/territory (Commercial HMO): Secretary-Approved Coverage. The state/territory offers benefits based on the approved state plan. The state/territory offers an array of benefits from the section 1937 coverage option and/or base benchmark plan benefit packages, or the approved state plan, or from a combination of these benefit packages. Please briefly identify the benefits, the source of benefits and any limitations: New Mexico's Section 1937 coverage option is Secretary-Approved Coverage. New Mexico will use benefits from the selected base benchmark plan, which is Presbyterian Health Plan - Individual Silver C HMO, as the basis of the Alternative Benefit Plan (ABP). The selected base benchmark complies with the regulations set forth for ABPs under 42 CFR 440.347 as related to essential health benefits (EHBs). Selection of Base Benchmark Plan The state/territory must select a Base Benchmark Plan as the basis for providing Essential Health Benefits in its Benchmark or Benchmark-Equivalent Package. The Base Benchmark Plan is the same as the Section 1937 Coverage option. No Indicate which Benchmark Plan described at 45 CFR 156.100(a) the state/territory will use as its Base Benchmark Plan: Largest plan by enrollment of the three largest small group insurance products in the state's small group market. State: New Mexico Date Received: 03-07-19 Date Approved: 11-04-19 Date Effective: 01-01-19 Transmittal Number: 19-0003 TN: NM 19-0003 Date Approved: 11/04/2019 Date Effective: 01/01/2019 Supersedes: NM 13-0030

Page 2 of 2 Alternative Benefit Plan Any of the largest three state employee health benefit plans by enrollment. Any of the largest three national FEHBP plan options open to Federal employees in all geographies by enrollment. Largest insured commercial non-Medicaid HMO. Plan name: Presbyterian Health Plan - Individual Silver C HMO Other Information Related to Selection of the Section 1937 Coverage Option and the Base Benchmark Plan (optional): The Presbyterian Health Plan - Individual Silver C HMO plan was also chosen by the New Mexico Health Insurance Marketplace as its EHB Base Benchmark Plan. PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 5 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. V.20160722 State: New Mexico Date Received: 03-07-19 Date Approved: 11-04-19 Date Effective: 01-01-19 Transmittal Number: 19-0003 TN: NM 19-0003 Date Approved: 11/04/2019 Date Effective: 01/01/2019 Supersedes: NM 13-0030

Page 1 of 1 Alternative Benefit Plan Attachment 3.1-C- OMB Control Number: 0938-1148 OMB Expiration date: 10/31/2014 Alternative Benefit Plan Cost-Sharing ABP4 Any cost sharing described in Attachment 4.18-A applies to the Alternative Benefit Plan. Attachment 4.18-A may be revised to include cost sharing for ABP services that are not otherwise described in the state plan. Any such cost sharing must comply with Section 1916 of the Social Security Act. The Alternative Benefit Plan for individuals with income over 100% FPL includes cost-sharing other than that described in Attachment 4.18-A. No Other Information Related to Cost Sharing Requirements (optional): PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 5 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. V.20130807 State: New Mexico Date Received: 03-07-19 Date Approved: 11-04-19 Date Effective: 01-01-19 Transmittal Number: 19-0003 TN: NM 19-0003 Date Approved: 11/04/2019 Date Effective: 01/01/2019 Supersedes: NM 13-0030

Page 1 of 33 Alternative Benefit Plan State Name: New Mexico Attachment 3.1-L- OMB Control Number: 0938-1148 Transmittal Number: NM - 19 - 0003 Benefits Description ABP5 The state/territory proposes a “Benchmark-Equivalent” benefit package. No Benefits Included in Alternative Benefit Plan Enter the specific name of the base benchmark plan selected: Presbyterian Health Plan - Individual Silver C HMO Enter the specific name of the section 1937 coverage option selected, if other than Secretary-Approved. Otherwise, enter “Secretary- Approved.” Secretary-Approved State: New Mexico Date Received: 03-07-19 Date Approved: 11-04-19 Date Effective: 01-01-19 Transmittal Number: 19-0003 TN: NM 19-0003 Date Approved: 11/04/2019 Date Effective: 01/01/2019 Supersedes: NM 13-0030

Page 2 of 33 Alternative Benefit Plan 1. Essential Health Benefit: Ambulatory patient services Collapse All Benefit Provided: Cancer Clinical Trials Source: Base Benchmark Small Group Remove Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: Covers routine patient costs associated with Phase I, II, III and IV cancer clinical trials. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Benefit Provided: Dental Services Source: State Plan 1905(a) Remove Authorization: No Provider Qualifications: Medicaid State Plan Amount Limit: Annual limits on some services Duration Limit: None Scope Limit: Refer to State Plan 1905(a) Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Refer to State Plan 1905(a) Benefit Provided: Dialysis Source: Base Benchmark Small Group Remove Authorization: Other Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None State: New Mexico Date Received: 03-07-19 Date Approved: 11-04-19 Date Effective: 01-01-19 Transmittal Number: 19-0003 TN: NM 19-0003 Date Approved: 11/04/2019 Date Effective: 01/01/2019 Supersedes: NM 13-0030

Page 3 of 33 Alternative Benefit Plan Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Benefit Provided: Home Health Care & Intravenous Services Source: Base Benchmark Small Group Remove Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: Limited to 100 four-hour visits per year. Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: The recipient must require skilled care and be unable to receive medical care on an ambulatory outpatient basis. Benefit Provided: Hospice Care Services Source: Base Benchmark Small Group Remove Authorization: Prior Authorization Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: To be eligible for hospice care, a physician must provide a written certification that the recipient has a terminal illness. Certification statements must include information that is based on the recipient's medical prognosis, and that the life expectancy is six months or less if the terminal illness runs its typical course. Recipients must elect to receive hospice care for the duration of the election period. If the recipient receives hospice benefits beyond 210 days, the hospice must obtain a written recertification statement. For the duration of the recipient's election of hospice care, the recipient waives their right to Medicaid payment of concurrent services related to the treatment of the terminal condition or a related condition; or for services equivalent to hospice care. Benefit Provided: Outpatient Diagnostic Labs, X-Ray & Pathology Source: Base Benchmark Small Group Remove State: New Mexico Date Received: 03-07-19 Date Approved: 11-04-19 Date Effective: 01-01-19 Transmittal Number: 19-0003 TN: NM 19-0003 Date Approved: 11/04/2019 Date Effective: 01/01/2019 Supersedes: NM 13-0030

Page 4 of 33 Alternative Benefit Plan Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Benefit Provided: Outpatient Surgery Source: Base Benchmark Small Group Remove Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Benefit Provided: Primary Care to Treat Illness/Injury Source: Base Benchmark Small Group Remove Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: State: New Mexico Date Received: 03-07-19 Date Approved: 11-04-19 Date Effective: 01-01-19 Transmittal Number: 19-0003 TN: NM 19-0003 Date Approved: 11/04/2019 Date Effective: 01/01/2019 Supersedes: NM 13-0030

Page 5 of 33 Alternative Benefit Plan Benefit Provided: Radiation Therapy and Chemotherapy Source: Base Benchmark Small Group Remove Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Benefit Provided: Specialist Visits Source: Base Benchmark Small Group Remove Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Benefit Provided: Treatment of Diabetes Source: Base Benchmark Small Group Remove Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: This benefit includes medical supplies for the treatment of diabetes. State: New Mexico Date Received: 03-07-19 Date Approved: 11-04-19 Date Effective: 01-01-19 Transmittal Number: 19-0003 TN: NM 19-0003 Date Approved: 11/04/2019 Date Effective: 01/01/2019 Supersedes: NM 13-0030

Page 6 of 33 Alternative Benefit Plan Benefit Provided: Vision Care for Eye Injury or Disease Source: Base Benchmark Small Group Remove Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: Refraction for visual acuity is not covered. Routine vision care is not covered. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Benefit Provided: Vision Hardware Source: Base Benchmark Small Group Remove Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: One complete set of contact lenses or eyeglasses Duration Limit: None Scope Limit: Covered only following surgery for the removal of cataracts from one or both eyes. Coverage of materials is limited to one set of contact lenses or eyeglasses per surgery. Materials obtained more than 90 days following surgery are not covered. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Benefit Provided: Podiatry and Routine Foot Care Source: Base Benchmark Small Group Remove Authorization: Prior Authorization Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: Covered when medically necessary due to malformations, injury, acute trauma or diabetes. Orthopedic shoes, arch supports and foot orthotics are not covered unless they are medically necessary for the treatment of diabetes. State: New Mexico Date Received: 03-07-19 Date Approved: 11-04-19 Date Effective: 01-01-19 Transmittal Number: 19-0003 TN: NM 19-0003 Date Approved: 11/04/2019 Date Effective: 01/01/2019 Supersedes: NM 13-0030

Page 7 of 33 Alternative Benefit Plan Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Benefit Provided: Urgent Care Services/Facilities Source: Base Benchmark Small Group Remove Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Benefit Provided: Observation Services Source: Base Benchmark Small Group Remove Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: Observation services for greater than 24 hours will require Prior Authorization. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Defined as outpatient services furnished by a hospital and practitioner/provider on the hospital's premises. Observation services may include the use of a bed and periodic monitoring to evaluate an outpatient's condition. Benefit Provided: Source: Remove Authorization: Authorization required in excess of limitation Provider Qualifications: Amount Limit: Duration Limit: State: New Mexico Date Received: 03-07-19 Date Approved: 11-04-19 Date Effective: 01-01-19 Transmittal Number: 19-0003 TN: NM 19-0003 Date Approved: 11/04/2019 Date Effective: 01/01/2019 Supersedes: NM 13-0030

Page 8 of 33 Alternative Benefit Plan Scope Limit: Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Add State: New Mexico Date Received: 03-07-19 Date Approved: 11-04-19 Date Effective: 01-01-19 Transmittal Number: 19-0003 TN: NM 19-0003 Date Approved: 11/04/2019 Date Effective: 01/01/2019 Supersedes: NM 13-0030

Page 9 of 33 Alternative Benefit Plan 2. Essential Health Benefit: Emergency services Collapse All Benefit Provided: Emergency Ground or Air Ambulance Services Source: Base Benchmark Small Group Remove Authorization: Other Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Prior authorization required when taking a recipient to a facility over 100 miles from the New Mexico border. Benefit Provided: Emergency Department Services/Facilities Source: Base Benchmark Small Group Remove Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Benefit Provided: Emergency Dental Care Source: Base Benchmark Small Group Remove Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: Covers emergency dental care that is needed because of accidental injury from an outside force to a sound, natural tooth. To be considered sound, the tooth must not have significant decay or prior trauma. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: State: New Mexico Date Received: 03-07-19 Date Approved: 11-04-19 Date Effective: 01-01-19 Transmittal Number: 19-0003 TN: NM 19-0003 Date Approved: 11/04/2019 Date Effective: 01/01/2019 Supersedes: NM 13-0030

Page 10 of 33 Alternative Benefit Plan Emergency treatment of jawbones or surrounding tissues is also covered. Add State: New Mexico Date Received: 03-07-19 Date Approved: 11-04-19 Date Effective: 01-01-19 Transmittal Number: 19-0003 TN: NM 19-0003 Date Approved: 11/04/2019 Date Effective: 01/01/2019 Supersedes: NM 13-0030

Page 11 of 33 Alternative Benefit Plan 3. Essential Health Benefit: Hospitalization Collapse All Benefit Provided: Bariatric Surgery Source: Base Benchmark Small Group Remove Authorization: Prior Authorization Provider Qualifications: Medicaid State Plan Amount Limit: Limited to one per lifetime Duration Limit: None Scope Limit: Covered for morbid obesity; or for individuals who have a BMI greater than 35 with at least one co- morbidity related to obesity and who have been previously unsuccessful with medical treatment for obesity. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Benefit Provided: Inpatient Medical and Surgical Care Source: Base Benchmark Small Group Remove Authorization: Other Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: Surgeries for cosmetic purposes are not covered. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Prior authorization required for use of a hospital over 100 miles from the New Mexico border, except in an emergency. Benefit Provided: Organ and Tissue Transplants Source: Base Benchmark Small Group Remove Authorization: Prior Authorization Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: Covers medical, surgical and hospital services for the recipient; organ procurement costs; certain travel costs; and immunosuppressive drugs. State: New Mexico Date Received: 03-07-19 Date Approved: 11-04-19 Date Effective: 01-01-19 Transmittal Number: 19-0003 TN: NM 19-0003 Date Approved: 11/04/2019 Date Effective: 01/01/2019 Supersedes: NM 13-0030

Page 12 of 33 Alternative Benefit Plan Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Benefit Provided: Reconstructive Surgery Source: Base Benchmark Small Group Remove Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: Covers reconstructive surgery from which an improvement in physiological function can be expected if performed for the correction of functional disorders that result from accidental injury, congenital defects or disease. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Add State: New Mexico Date Received: 03-07-19 Date Approved: 11-04-19 Date Effective: 01-01-19 Transmittal Number: 19-0003 TN: NM 19-0003 Date Approved: 11/04/2019 Date Effective: 01/01/2019 Supersedes: NM 13-0030

Page 13 of 33 Alternative Benefit Plan 4. Essential Health Benefit: Maternity and newborn care Collapse All Benefit Provided: Delivery and Inpatient Maternity Services Source: Base Benchmark Small Group Remove Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Includes lactation support, supplies and counseling. Benefit Provided: Pre- and Post-Natal Care Source: Base Benchmark Small Group Remove Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Amniocentesis, ultrasound or any other procedures requested solely to determine the sex of the fetus are not covered. An exception is made if it is medically necessary to determine the existence of a sex-linked genetic disorder. Determination of the sex of the fetus is covered as part of a medically necessary procedure, but is not covered as an additional visit when the sex of the fetus cannot be determined during the medically necessary procedure. Add TN: NM 19-0003 Date Approved: 11/04/2019 Date Effective: 01/01/2019 Supersedes: NM 13-0030 State: New Mexico Date Received: 03-07-19 Date Approved: 11-04-19 Date Effective: 01-01-19 Transmittal Number: 19-0003

Page 14 of 33 Alternative Benefit Plan 5. Essential Health Benefit: Mental health and substance use disorder services including behavioral health treatment Collapse All Benefit Provided: Inpatient Hospital Services Source: State Plan 1905(a) Remove Authorization: Other Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: Refer to State Plan 1905(a) Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Refer to State Plan 1905(a) Benefit Provided: Medication-Assisted Therapy for Opioid Addiction Source: State Plan 1905(a) Remove Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: Refer to State Plan 1905(a) Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Refer to State Plan 1905(a) Benefit Provided: Outpatient Behavioral Health Professional Services Source: Base Benchmark Small Group Remove Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: Includes screening, evaluation, testing, assessment, medication management, therapy, and Intensive Outpatient Program (IOP) services. TN: NM 19-0003 Date Approved: 11/04/2019 Date Effective: 01/01/2019 Supersedes: NM 13-0030 State: New Mexico Date Received: 03-07-19 Date Approved: 11-04-19 Date Effective: 01-01-19 Transmittal Number: 19-0003

Page 15 of 33 Alternative Benefit Plan Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Benefit Provided: Drug/Alcohol Dependency Treatment Services Source: State Plan 1905(a) Remove Authorization: Other Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: Refer to State Plan 1905(a) Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Refer to State Plan 1905(a) Benefit Provided: Electroconvulsive Therapy (ECT) Source: Base Benchmark Small Group Remove Authorization: Prior Authorization Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Benefit Provided: Assertive Community Treatment (ACT) Source: State Plan 1905(a) Remove Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None TN: NM 19-0003 Date Approved: 11/04/2019 Date Effective: 01/01/2019 Supersedes: NM 13-0030 State: New Mexico Date Received: 03-07-19 Date Approved: 11-04-19 Date Effective: 01-01-19 Transmittal Number: 19-0003

Page 16 of 33 Alternative Benefit Plan Scope Limit: Refer to State Plan 1905(a) Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Refer to State Plan 1905(a) Benefit Provided: Psychosocial Rehabilitation (PSR) Source: State Plan 1905(a) Remove Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: Refer to State Plan 1905(a) Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Refer to State Plan 1905(a) Add TN: NM 19-0003 Date Approved: 11/04/2019 Date Effective: 01/01/2019 Supersedes: NM 13-0030 State: New Mexico Date Received: 03-07-19 Date Approved: 11-04-19 Date Effective: 01-01-19 Transmittal Number: 19-0003

Page 17 of 33 Alternative Benefit Plan 6. Essential Health Benefit: Prescription drugs Benefit Provided: Coverage is at least the greater of one drug in each U.S. Pharmacopeia (USP) category and class or the same number of prescription drugs in each category and class as the base benchmark. Prescription Drug Limits (Check all that apply.): Limit on days supply Limit on number of prescriptions Limit on brand drugs Other coverage limits Preferred drug list Authorization: No Provider Qualifications: State licensed Coverage that exceeds the minimum requirements or other: New Mexico's ABP prescription drug benefit plan is the same as the prescription drug coverage under the Medicaid State Plan. TN: NM 19-0003 Date Approved: 11/04/2019 Date Effective: 01/01/2019 Supersedes: NM 13-0030 State: New Mexico Date Received: 03-07-19 Date Approved: 11-04-19 Date Effective: 01-01-19 Transmittal Number: 19-0003

Page 18 of 33 Alternative Benefit Plan 7. Essential Health Benefit: Rehabilitative and habilitative services and devices Collapse All Benefit Provided: Autism Spectrum Disorder Source: Base Benchmark Small Group Remove Authorization: Other Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: Covers speech, occupational and physical therapy, and applied behavioral analysis for recipients age 21-22 who are enrolled in high school. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Prior authorization required after initial evaluation. This is a state-mandated service. Benefit Provided: Cardiovascular Rehabilitation Source: Base Benchmark Small Group Remove Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: Short-term therapy (two consecutive months) Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Duration limit is per cardiac event. Exceptions made based on medical necessity. Long-term therapy is not covered. Benefit Provided: Durable Medical Equipment & Supplies Source: Base Benchmark Small Group Remove Authorization: Other Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: Coverage of medical supplies is limited to diabetic supplies, contraceptive supplies, lactation supplies, cardiac event monitors, and holter monitors. TN: NM 19-0003 Date Approved: 11/04/2019 Date Effective: 01/01/2019 Supersedes: NM 13-0030 State: New Mexico Date Received: 03-07-19 Date Approved: 11-04-19 Date Effective: 01-01-19 Transmittal Number: 19-0003

Page 19 of 33 Alternative Benefit Plan Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Requires a physician's prescription and prior authorization. Benefit Provided: Inpatient Rehabilitative Facilities Source: Base Benchmark Small Group Remove Authorization: Prior Authorization Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: Covers inpatient services at a skilled nursing or acute rehabilitation facility when provided as a step-down level of care following discharge from the hospital prior to discharge to home. Extended care or long-term care not covered. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Benefit Provided: Orthotic Appliances Source: Base Benchmark Small Group Remove Authorization: Prior Authorization Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: Foot orthotics, including shoes and arch supports, are only covered when an integral part of a leg brace, or are diabetic shoes. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Requires a provider's prescription and prior authorization. Benefit Provided: Prosthetic Devices, Repair and Replacement Source: Base Benchmark Small Group Remove Authorization: Prior Authorization Provider Qualifications: Medicaid State Plan TN: NM 19-0003 Date Approved: 11/04/2019 Date Effective: 01/01/2019 Supersedes: NM 13-0030 State: New Mexico Date Received: 03-07-19 Date Approved: 11-04-19 Date Effective: 01-01-19 Transmittal Number: 19-0003

Page 20 of 33 Alternative Benefit Plan Amount Limit: None Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Prior authorization required unless the prosthetic device is surgically implanted. Benefit Provided: Rehabilitative Services - PT/OT/SLP Source: Base Benchmark Small Group Remove Authorization: Prior Authorization Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: Short-term therapy (two consecutive months) Scope Limit: Includes physical and occupational therapy and speech-language pathology. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Physical and occupational therapy require prior authorization, but the initial evaluation does not. Speech language pathology requires prior authorization (including evaluations). Duration limit is per condition; concurrent treatment for separate conditions is covered. Exceptions made based on medical necessity. Long-term therapy is not covered. Benefit Provided: Habilitative Services - PT/OT/SLP Source: Other state-defined Remove Authorization: Prior Authorization Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: Short-term therapy (two consecutive months) Scope Limit: Includes physical and occupational therapy and speech-language pathology. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Physical and occupational therapy require prior authorization, but the initial evaluation does not. Speech language pathology requires prior authorization (including evaluations). Duration limit is per condition; concurrent treatment for separate conditions is covered. Exceptions made based on medical necessity. Long-term therapy is not covered. TN: NM 19-0003 Date Approved: 11/04/2019 Date Effective: 01/01/2019 Supersedes: NM 13-0030 State: New Mexico Date Received: 03-07-19 Date Approved: 11-04-19 Date Effective: 01-01-19 Transmittal Number: 19-0003

Page 21 of 33 Alternative Benefit Plan Benefit Provided: Pulmonary Therapy Source: Base Benchmark Small Group Remove Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: Short-term therapy (two consecutive months) Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Duration limit is per condition; concurrent treatment for separate conditions is covered. Exceptions made based on medical necessity. Long-term therapy is not covered. Add TN: NM 19-0003 Date Approved: 11/04/2019 Date Effective: 01/01/2019 Supersedes: NM 13-0030 State: New Mexico Date Received: 03-07-19 Date Approved: 11-04-19 Date Effective: 01-01-19 Transmittal Number: 19-0003

Page 22 of 33 Alternative Benefit Plan 8. Essential Health Benefit: Laboratory services Collapse All Benefit Provided: Diagnostic Imaging Source: Base Benchmark Small Group Remove Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Benefit Provided: Lab Tests, X-Ray Services and Pathology Source: Base Benchmark Small Group Remove Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Add TN: NM 19-0003 Date Approved: 11/04/2019 Date Effective: 01/01/2019 Supersedes: NM 13-0030 State: New Mexico Date Received: 03-07-19 Date Approved: 11-04-19 Date Effective: 01-01-19 Transmittal Number: 19-0003

Page 23 of 33 Alternative Benefit Plan 9. Essential Health Benefit: Preventive and wellness services and chronic disease management Collapse All The state/territory must provide, at a minimum, a broad range of preventive services including: “A” and “B” services recommended by the United States Preventive Services Task Force; Advisory Committee for Immunization Practices (ACIP) recommended vaccines; preventive care and screening for infants, children and adults recommended by HRSA’s Bright Futures program/project; and additional preventive services for women recommended by the Institute of Medicine (IOM). Benefit Provided: Allergy Testing and Injections Source: Base Benchmark Small Group Remove Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Benefit Provided: Annual Physical Exam & Consultation Source: Base Benchmark Small Group Remove Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: Includes a health appraisal exam; laboratory and radiological tests; and early detection procedures. Does not include eye refractions, vision hardware or routine vision services; or hearing aids or hearing aid testing. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Benefit Provided: Chronic Disease Management Source: Base Benchmark Small Group Remove Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None TN: NM 19-0003 Date Approved: 11/04/2019 Date Effective: 01/01/2019 Supersedes: NM 13-0030 State: New Mexico Date Received: 03-07-19 Date Approved: 11-04-19 Date Effective: 01-01-19 Transmittal Number: 19-0003

Page 24 of 33 Alternative Benefit Plan Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Benefit Provided: Diabetes Equipment, Supplies & Education Source: Base Benchmark Small Group Remove Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Benefit Provided: Genetic Evaluation & Testing Source: Base Benchmark Small Group Remove Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: Limited to Triple Serum Test and genetic testing for the diagnosis or treatment of a current illness. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Benefit Provided: Immunizations Source: Base Benchmark Small Group Remove Authorization: None Provider Qualifications: Medicaid State Plan TN: NM 19-0003 Date Approved: 11/04/2019 Date Effective: 01/01/2019 Supersedes: NM 13-0030 State: New Mexico Date Received: 03-07-19 Date Approved: 11-04-19 Date Effective: 01-01-19 Transmittal Number: 19-0003

Page 25 of 33 Alternative Benefit Plan Amount Limit: None Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: This benefit includes ACIP-recommended vaccines. Benefit Provided: Insertion/Removal of Contraceptive Devices Source: Base Benchmark Small Group Remove Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Benefit Provided: Osteoporosis Treatment & Management Source: Base Benchmark Small Group Remove Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Benefit Provided: Periodic Glaucoma Test (Age 35 or older) Source: Base Benchmark Small Group Remove TN: NM 19-0003 Date Approved: 11/04/2019 Date Effective: 01/01/2019 Supersedes: NM 13-0030 State: New Mexico Date Received: 03-07-19 Date Approved: 11-04-19 Date Effective: 01-01-19 Transmittal Number: 19-0003

Page 26 of 33 Alternative Benefit Plan Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: Coverage includes testing every one to two years. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Benefit Provided: Preventive Care and Screenings Source: State Plan 1905(a) Remove Authorization: No Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: Refer to State Plan 1905(a) Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Refer to State Plan 1905(a) Benefit Provided: Voluntary Family Planning Services Source: Base Benchmark Small Group Remove Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: Sterilization reversal is not covered. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: TN: NM 19-0003 Date Approved: 11/04/2019 Date Effective: 01/01/2019 Supersedes: NM 13-0030 State: New Mexico Date Received: 03-07-19 Date Approved: 11-04-19 Date Effective: 01-01-19 Transmittal Number: 19-0003

Page 27 of 33 Alternative Benefit Plan Benefit Provided: Source: Remove Authorization: None Provider Qualifications: Amount Limit: Duration Limit: Scope Limit: Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Add TN: NM 19-0003 Date Approved: 11/04/2019 Date Effective: 01/01/2019 Supersedes: NM 13-0030 State: New Mexico Date Received: 03-07-19 Date Approved: 11-04-19 Date Effective: 01-01-19 Transmittal Number: 19-0003

Page 28 of 33 Alternative Benefit Plan 10. Essential Health Benefit: Pediatric services including oral and vision care Collapse All Benefit Provided: Medicaid State Plan EPSDT Benefits Source: State Plan 1905(a) Remove Authorization: Other Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: The source plan for this benefit is the New Mexico Medicaid State Plan. Prior authorization required for certain services. Some services subject to a periodicity schedule. Add TN: NM 19-0003 Date Approved: 11/04/2019 Date Effective: 01/01/2019 Supersedes: NM 13-0030 State: New Mexico Date Received: 03-07-19 Date Approved: 11-04-19 Date Effective: 01-01-19 Transmittal Number: 19-0003

Page 29 of 33 Alternative Benefit Plan 11. Other Covered Benefits from Base Benchmark Collapse All TN: NM 19-0003 Date Approved: 11/04/2019 Date Effective: 01/01/2019 Supersedes: NM 13-0030 State: New Mexico Date Received: 03-07-19 Date Approved: 11-04-19 Date Effective: 01-01-19 Transmittal Number: 19-0003

Page 30 of 33 Alternative Benefit Plan 12. Base Benchmark Benefits Not Covered due to Substitution or Duplication Collapse All Base Benchmark Benefit that was Substituted: Acupuncture (20 visits per year) Source: Base Benchmark Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Substituted with dental services within the Ambulatory Patient Services category. Base Benchmark Benefit that was Substituted: Chiropractic Care (20 visits per year) Source: Base Benchmark Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Substituted with dental services within the Ambulatory Patient Services category. Base Benchmark Benefit that was Substituted: CMJ and TMJ Conditions Source: Base Benchmark Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Substituted with dental services within the Ambulatory Patient Services category. Base Benchmark Benefit that was Substituted: Special Medical Foods Source: Base Benchmark Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Substituted with dental services within the Ambulatory Patient Services category. Base Benchmark Benefit that was Substituted: Infertility (Diagnosis, Treatment & Correction) Source: Base Benchmark Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Substituted with dental services within the Ambulatory Patient Services category. The base benchmark infertility coverage does not include in-vitro fertilization (IVF), gamete intrafallopian transfer (GIFT), zygote intrafallopian transfer (ZIFT) or variations of these procedures; surrogate parenting; reversal of sterilization; or any costs associated with the collection, preparation or storage of sperm for artificial insemination, including donor fees, donor egg or sperm retrieval; or infertility medications, including oral infertility drugs. Add TN: NM 19-0003 Date Approved: 11/04/2019 Date Effective: 01/01/2019 Supersedes: NM 13-0030 State: New Mexico Date Received: 03-07-19 Date Approved: 11-04-19 Date Effective: 01-01-19 Transmittal Number: 19-0003

Page 31 of 33 Alternative Benefit Plan 13. Other Base Benchmark Benefits Not Covered Collapse All Base Benchmark Benefit not Included in the Alternative Benefit Plan: Newborn Child Care Source: Base Benchmark Remove Explain why the state/territory chose not to include this benefit: Newborns who are born to Medicaid-enrolled mothers are automatically deemed eligible for Medicaid or CHIP, and all newborn services are covered under the Medicaid State Plan. Add TN: NM 19-0003 Date Approved: 11/04/2019 Date Effective: 01/01/2019 Supersedes: NM 13-0030 State: New Mexico Date Received: 03-07-19 Date Approved: 11-04-19 Date Effective: 01-01-19 Transmittal Number: 19-0003

Page 32 of 33 Alternative Benefit Plan 14. Other 1937 Covered Benefits that are not Essential Health Benefits Collapse All Other 1937 Benefit Provided: Non-Emergency Transportation Source: Section 1937 Coverage Option Benchmark Benefit Package Remove Authorization: Other Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: Covers expenses for transportation, meals and lodging that are determined necessary to secure medical or behavioral health services for an Alternative Benefit Plan recipient. Other: There is no authorization requirement for this benefit. Add TN: NM 19-0003 Date Approved: 11/04/2019 Date Effective: 01/01/2019 Supersedes: NM 13-0030 State: New Mexico Date Received: 03-07-19 Date Approved: 11-04-19 Date Effective: 01-01-19 Transmittal Number: 19-0003

Page 33 of 33 Alternative Benefit Plan 15. Additional Covered Benefits (This category of benefits is not applicable to the adult group under section 1902(a)(10)(A)(i)(VIII) of the Act.) Collapse All PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 5 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. V.20160722 TN: NM 19-0003 Date Approved: 11/04/2019 Date Effective: 01/01/2019 Supersedes: NM 13-0030 State: New Mexico Date Received: 03-07-19 Date Approved: 11-04-19 Date Effective: 01-01-19 Transmittal Number: 19-0003

Page 1 of 2 Alternative Benefit Plan Attachment 3.1-C- OMB Control Number: 0938-1148 OMB Expiration date: 10/31/2014 Benefits Assurances ABP7 EPSDT Assurances If the target population includes persons under 21, please complete the following assurances regarding EPSDT. Otherwise, skip to the Prescription Drug Coverage Assurances below. The alternative benefit plan includes beneficiaries under 21 years of age. Prescription Drug Coverage Assurances The state/territory assures that it meets the minimum requirements for prescription drug coverage in section 1937 of the Act and implementing regulations at 42 CFR 440.347. Coverage is at least the greater of one drug in each United States Pharmacopeia (USP) category and class or the same number of prescription drugs in each category and class as the base benchmark. The state/territory assures that procedures are in place to allow a beneficiary to request and gain access to clinically appropriate prescription drugs when not covered. The state/territory assures that when it pays for outpatient prescription drugs covered under an Alternative Benefit Plan, it meets the requirements of section 1927 of the Act and implementing regulations at 42 CFR 440.345, except for those requirements that are directly contrary to amount, duration and scope of coverage permitted under section 1937 of the Act. The state/territory assures that when conducting prior authorization of prescription drugs under an Alternative Benefit Plan, it complies with prior authorization program requirements in section 1927(d)(5) of the Act. Other Benefit Assurances The state/territory assures that substituted benefits are actuarially equivalent to the benefits they replaced from the base benchmark plan, and that the state/territory has actuarial certification for substituted benefits available for CMS inspection if requested by CMS. The state/territory assures that individuals will have access to services in Rural Health Clinics (RHC) and Federally Qualified Health Centers (FQHC) as defined in subparagraphs (B) and (C) of section 1905(a)(2) of the Social Security Act. The state/territory assures that payment for RHC and FQHC services is made in accordance with the requirements of section 1902(bb) of the Social Security Act. The state/territory assures that it will comply with the requirement of section 1937(b)(5) of the Act by providing, effective January 1, 2014, to all Alternative Benefit Plan participants at least Essential Health Benefits as described in section 1302(b) of the Patient Protection and Affordable Care Act. The state/territory assures that it will comply with the mental health and substance use disorder parity requirements of section 1937(b)(6) of the Act by ensuring that the financial requirements and treatment limitations applicable to mental health or substance use disorder benefits comply with the requirements of section 2705(a) of the Public Health Service Act in the same manner as such requirements apply to a group health plan. The state/territory assures that it will comply with section 1937(b)(7) of the Act by ensuring that benefits provided to Alternative Benefit Plan participants include, for any individual described in section 1905(a)(4)(C), medical assistance for family planning services and supplies in accordance with such section. The state/territory assures transportation (emergency and non-emergency) for individuals enrolled in an Alternative Benefit Plan in accordance with 42 CFR 431.53. TN: NM 19-0003 Date Approved: 11/04/2019 Date Effective: 01/01/2019 Supersedes: NM 13-0030 State: New Mexico Date Received: 03-07-19 Date Approved: 11-04-19 Date Effective: 01-01-19 Transmittal Number: 19-0003

Page 2 of 2 Alternative Benefit Plan The state/territory assures, in accordance with 45 CFR 156.115(a)(4) and 45 CFR 147.130, that it will provide as Essential Health Benefits a broad range of preventive services including: “A” and “B” services recommended by the United States Preventive Services Task Force; Advisory Committee for Immunization Practices (ACIP) recommended vaccines; preventive care and screening for infants, children and adults recommended by HRSA's Bright Futures program/project; and additional preventive services for women recommended by the Institute of Medicine (IOM). PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 5 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. V.20130807 TN: NM 19-0003 Date Approved: 11/04/2019 Date Effective: 01/01/2019 Supersedes: NM 13-0030 State: New Mexico Date Received: 03-07-19 Date Approved: 11-04-19 Date Effective: 01-01-19 Transmittal Number: 19-0003

Page 1 of 3 Alternative Benefit Plan Attachment 3.1-C- OMB Control Number: 0938‐1148 OMB Expiration date: 10/31/2014 Service Delivery Systems ABP8 Provide detail on the type of delivery system(s) the state/territory will use for the Alternative Benefit Plan's benchmark benefit package or benchmark-equivalent benefit package, including any variation by the participants' geographic area. Type of service delivery system(s) the state/territory will use for this Alternative Benefit Plan(s). Select one or more service delivery systems: Managed care. Managed Care Organizations (MCO). Prepaid Inpatient Health Plans (PIHP). Prepaid Ambulatory Health Plans (PAHP). Primary Care Case Management (PCCM). Fee-for-service. Other service delivery system. Managed Care Options Managed Care Assurance The state/territory certifies that it will comply with all applicable Medicaid laws and regulations, including but not limited to sections 1903(m), 1905(t), and 1932 of the Act and 42 CFR Part 438, in providing managed care services through this Alternative Benefit Plan. This includes the requirement for CMS approval of contracts and rates pursuant to 42 CFR 438.6. ✔ Managed Care Implementation Please describe the implementation plan for the Alternative Benefit Plan under managed care including member, stakeholder, and provider outreach efforts. As part of New Mexico's efforts to roll-out its new Section 1115 waiver for Centennial Care on January 1 (which includes both the Other Adult Group and the ABP), the state held more than 200 public education events in every region of the state, including 52 events that were held in Native American communities. The state began running radio, print and online advertisements about Centennial Care in August 2013.

A tribal consultation was held in August 2013, during which the state discussed the ABP services package, as well as the intended selection of New Mexico's Section 1937 option and base benchmark plan. These topics were also discussed at every quarterly Medicaid Advisory Committee (MAC) meeting throughout 2013 and early 2014 to ensure communication with stakeholders. A meeting with tribal providers was held in November 2013 and a second provider meeting took place in March 2014.

In addition, New Mexico began a year-long comprehensive readiness review of its four Centennial Care managed care organizations (MCOs) in early 2013 to ensure that the MCOs are fully operational and compliant with the standards and conditions outlined in the Centennial Care waiver. Ten workgroups were created to focus on certain areas of implementation, such as reporting, care coordination, IT systems, and other issues pertinent to implementing the waiver and, more specifically, the ABP. MCO: Managed Care Organization The managed care delivery system is the same as an already approved managed care program. Yes The managed care program is operating under (select one): TN: NM 19-0003 Date Approved: 11/04/2019 Date Effective: 01/01/2019 Supersedes: NM 13-0030 State: New Mexico Date Received: 03-07-19 Date Approved: 11-04-19 Date Effective: 01-01-19 Transmittal Number: 19-0003

Page 2 of 3 Alternative Benefit Plan Section 1915(a) voluntary managed care program. Section 1915(b) managed care waiver. Section 1932(a) mandatory managed care state plan amendment. Section 1115 demonstration. Section 1937 Alternative (Benchmark) Benefit Plan state plan amendment. Identify the date the managed care program was approved by CMS: July 12, 2013 Describe program below: New Mexico Centennial Care provides managed physical, behavioral health and long-term care services through four managed care organizations (MCOs). New Mexico's vision for Centennial Care is to build a health care system that delivers the right amount of care at the right time and in the right setting. This vision includes educating recipients to become savvy health care consumers, promoting integrated care, delivering proper care coordination for the most at-risk recipients, involving recipients in their own wellness, and paying providers for good health outcomes. More detailed information about New Mexico Centennial Care can be found online at www.state.nm.us/centennialcare. Additional Information: MCO (Optional) Provide any additional details regarding this service delivery system (optional): Fee-For-Service Options Indicate whether the state/territory offers traditional fee-for-service and/or services managed under an administrative services organization: Traditional state-managed fee-for-service Services managed under an administrative services organization (ASO) arrangement Please describe this fee-for-service delivery system, including any bundled payment arrangements, pay for performance, fee-for- service care management models/non-risk, contractual incentives as well as the population served via this delivery system. In New Mexico, most Native American Medicaid recipients maintain a choice to opt-in to the Centennial Care (managed care) program, or to access care through a traditional state-managed fee-for-service delivery system; however, Native American recipients who are dually eligible for Medicare and Medicaid or who have a nursing facility level of care, are required to enroll in Centennial Care. Native American recipients who access care through fee-for-service may opt-in to Centennial Care at any time during their eligibility.

The base services offered in the ABP are the same for both fee-for-service and Centennial Care recipients, and are detailed in Section 5 of this State Plan Amendment; however, Centennial Care recipients may receive additional "value-added services" from their MCOs that are not available to fee-for-service recipients. Additional Information: Fee-For-Service (Optional) Provide any additional details regarding this service delivery system (optional): State: New Mexico Date Received: 03-07-19 Date Approved: 11-04-19 Date Effective: 01-01-19 Transmittal Number: 19-0003 TN: NM 19-0003 Date Approved: 11/04/2019 Date Effective: 01/01/2019 Supersedes: NM 13-0030

Page 3 of 3 Alternative Benefit Plan PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 5 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. V.20130718 State: New Mexico Date Received: 03-07-19 Date Approved: 11-04-19 Date Effective: 01-01-19 Transmittal Number: 19-0003 TN: NM 19-0003 Date Approved: 11/04/2019 Date Effective: 01/01/2019 Supersedes: NM 13-0030

Page 1 of 1 Alternative Benefit Plan Attachment 3.1-C- OMB Control Number: 0938‐1148 OMB Expiration date: 10/31/2014 Employer Sponsored Insurance and Payment of Premiums ABP9 The state/territory provides the Alternative Benefit Plan through the payment of employer sponsored insurance for participants with such coverage, with additional benefits and services provided through a Benchmark or Benchmark-Equivalent Benefit Package. No The state/territory otherwise provides for payment of premiums. No Other Information Regarding Employer Sponsored Insurance or Payment of Premiums: PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 5 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN: NM 19-0003 Date Approved: 11/04/2019 Date Effective: 01/01/2019 Supersedes: NM 13-0030 State: New Mexico Date Received: 03-07-19 Date Approved: 11-04-19 Date Effective: 01-01-19 Transmittal Number: 19-0003

Page 1 of 1 Alternative Benefit Plan Attachment 3.1-C- OMB Control Number: 0938‐1148 OMB Expiration date: 10/31/2014 General Assurances ABP10 Economy and Efficiency of Plans The state/territory assures that Alternative Benefit Plan coverage is provided in accordance with Federal upper payment limit requirements and other economy and efficiency principles that would otherwise be applicable to the services or delivery system through which the coverage and benefits are obtained. ✔ Economy and efficiency will be achieved using the same approach as used for Medicaid state plan services. Yes Compliance with the Law The state/territory will continue to comply with all other provisions of the Social Security Act in the administration of the state/ territory plan under this title. ✔ The state/territory assures that Alternative Benefit Plan benefits designs shall conform to the non-discrimination requirements at 42 CFR 430.2 and 42 CFR 440.347(e). ✔ The state/territory assures that all providers of Alternative Benefit Plan benefits shall meet the provider qualification requirements of the Base Benchmark Plan and/or the Medicaid state plan. ✔ PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 5 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. V.20130807 State: New Mexico Date Received: 03-07-19 Date Approved: 11-04-19 Date Effective: 01-01-19 Transmittal Number: 19-0003 TN: NM 19-0003 Date Approved: 11/04/2019 Date Effective: 01/01/2019 Supersedes: NM 13-0030

Page 1 of 1 Alternative Benefit Plan Attachment 3.1-C- OMB Control Number: 0938-1148 OMB Expiration date: 10/31/2014 Payment Methodology ABP11 Alternative Benefit Plans - Payment Methodologies The state/territory provides assurance that, for each benefit provided under an Alternative Benefit Plan that is not provided through managed care, it will use the payment methodology in its approved state plan or hereby submits state plan amendment Attachment 4.19a, 4.19b or 4.19d, as appropriate, describing the payment methodology for the benefit. An attachment is submitted. PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 5 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. V.20130807 State: New Mexico Date Received: 03-07-19 Date Approved: 11-04-19 Date Effective: 01-01-19 Transmittal Number: 19-0003 TN: NM 19-0003 Date Approved: 11/04/2019 Date Effective: 01/01/2019 Supersedes: NM 13-0030

Table of Contents State/Territory Name: New Mexico State Plan Amendment (SPA) #: 19-0009 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved Pages

Records / Submission Packages NM - Submission Package - NM2019MS0004O - (NM-19-0009) - Eligibility CMS-10434 OMB 0938-1188 Package Information Package ID NM2019MS0004O Program Name N/A SPA ID NM-19-0009 Version Number 6 Submitted By Donna Lopez Package Disposition Priority Code P2 Submission Type OŰcial State NM Region Dallas, TX Package Status Approved Submission Date 8/1/2019 Approval Date 10/18/2019 5:22 PM EDT Summary Reviewable Units Versions Correspondence Log Compare Doc Change Report Analyst Notes Review Assessment Report Approval Letter Transaction Logs News Related Actions

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Dallas Regional OŰce 1301 Young Street, Suite 833 Dallas, TX 75202 Division of Medicaid and Children's Health Operations October 18, 2019 David Scrase Cabinet Secretary, NM Human Services Department NM Human Services Department, Medical Assistance Division PO Box 2348 2025 S. Pacheco Street Santa Fe, NM 87504 Re: Approval of State Plan Amendment NM-19-0009 Dear David Scrase : On August 01, 2019, the Centers for Medicare and Medicaid Services (CMS) received New Mexico State Plan Amendment (SPA) NM-19-0009 to disregard census bureau income/wages from the calculation of Medicaid eligibility. New Mexico also made a technical correction to its coverage of optional eligibility groups.. We approve New Mexico State Plan Amendment (SPA) NM-19-0009 on October 18, 2019 with an eſective date(s) of July 01, 2019. Name Date Created No items available If you have any questions regarding this amendment, please contact Ford Blunt at 2147676381 or ford.blunt@cms.hhs.gov. Sincerely, Bill Brooks Director Regional Operations Group (ROG) Division of Medicaid and Children's Health Operations Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | NM2019MS0004O | NM-19-0009 Package Header Package ID NM2019MS0004O Submission Type OŰcial Approval Date 10/18/2019 Superseded SPA ID N/A SPA ID NM-19-0009 Initial Submission Date 8/1/2019 Eſective Date N/A State Information State/Territory Name: New Mexico Medicaid Agency Name: NM Human Services Department, Medical Assistance Division Submission Component State Plan Amendment Medicaid CHIP

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | NM2019MS0004O | NM-19-0009 Package Header Package ID NM2019MS0004O Submission Type OŰcial Approval Date 10/18/2019 Superseded SPA ID N/A SPA ID NM-19-0009 Initial Submission Date 8/1/2019 Eſective Date N/A SPA ID and Eſective Date SPA ID NM-19-0009 Reviewable Unit Proposed Eſective Date Superseded SPA ID Eligibility Determinations of Individuals Age 65 or Older or Who Have Blindness or a Disability 7/1/2019 NM-19-0001 Non-MAGI Methodologies 7/1/2019 NM-19-0001 Optional Eligibility Groups 7/1/2019 NM-19-0001 Individuals Eligible for Cash Except for Institutionalization 7/1/2019 NM-19-0001 Work Incentives 7/1/2019 NM-19-0001 Page Number of the Superseded Plan Section or Attachment (If Applicable):

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | NM2019MS0004O | NM-19-0009 Package Header Package ID NM2019MS0004O Submission Type OŰcial Approval Date 10/18/2019 Superseded SPA ID N/A SPA ID NM-19-0009 Initial Submission Date 8/1/2019 Eſective Date N/A Executive Summary Summary Description Including Goals and Objectives The purpose of this State Plan is to exclude all wages paid by the Census Bureau for temporary employment related to census activities and is applicable to only aged, blind, and disabled (ABD) categories. New Mexico's current SPA limits the census wage exclusion to Census 2000 activities for ABD categories. The new SPA will request a general census wage exclusion for temporary employment related to census activities; it will not cite a speciţc year. Federal Budget Impact and Statute/Regulation Citation Federal Budget Impact Federal Fiscal Year Amount First 2020 $1750000 Second 2021 $7000000 Federal Statute / Regulation Citation 1902(r)(2) Supporting documentation of budget impact is uploaded (optional). Name Date Created 19-0009 Census Bureau Wages Exclusion CMS 179 8/1/2019 10:28 AM EDT

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | NM2019MS0004O | NM-19-0009 Package Header Package ID NM2019MS0004O Submission Type OŰcial Approval Date 10/18/2019 Superseded SPA ID N/A SPA ID NM-19-0009 Initial Submission Date 8/1/2019 Eſective Date N/A Governor's OŰce Review No comment Comments received No response within 45 days Other

Submission - Public Comment MEDICAID | Medicaid State Plan | Eligibility | NM2019MS0004O | NM-19-0009 Package Header Package ID NM2019MS0004O Submission Type OŰcial Approval Date 10/18/2019 Superseded SPA ID N/A SPA ID NM-19-0009 Initial Submission Date 8/1/2019 Eſective Date N/A Indicate whether public comment was solicited with respect to this submission. Indicate how public comment was solicited: Name of Paper: Date of Publication: Locations covered: Albuquerque Journal 6/28/2019 Northern and Central New Mexico Las Cruces Sun-News 6/28/2019 Southern New Mexico Select the type of website Date of Posting: Jun 28, 2019 Website URL: https://www.hsd.state.nm.us/2017- comment-period-open.aspx Upload copies of public notices and other documents used Name Date Created 19-0009 Las Cruces Sun-News AŰdavit 7/29/2019 3:48 PM EDT 19-0009 Albuquerque Journal AŰdavit 7/29/2019 3:48 PM EDT 19-0009 Census Bureau Wages Exclusion NEWSPAPER NOTICE 053119 7/29/2019 3:48 PM EDT 19-0009 Census Bureau Wages Exclusion INTERESTED PARTIES 7/29/2019 4:00 PM EDT Upload with this application a written summary of public comments received (optional) Name Date Created No items available Indicate the key issues raised during the public comment period (optional) Public notice was not federally required and comment was not solicited Public notice was not federally required, but comment was solicited Public notice was federally required and comment was solicited Newspaper Announcement Publication in state's administrative record, in accordance with the administrative procedures requirements Email to Electronic Mailing List or Similar Mechanism Website Notice Website of the State Medicaid Agency or Responsible Agency Website for State Regulations Other Public Hearing or Meeting Other method Access

Quality Cost Payment methodology Eligibility Beneţts Service delivery Other issue

Submission - Tribal Input MEDICAID | Medicaid State Plan | Eligibility | NM2019MS0004O | NM-19-0009 Package Header Package ID NM2019MS0004O Submission Type OŰcial Approval Date 10/18/2019 Superseded SPA ID N/A SPA ID NM-19-0009 Initial Submission Date 8/1/2019 Eſective Date N/A One or more Indian Health Programs or Urban Indian Organizations furnish health care services in this state This state plan amendment is likely to have a direct eſect on Indians, Indian Health Programs or Urban Indian Organizations, as described in the state consultation plan. Complete the following information regarding any solicitation of advice and/or tribal consultation conducted with respect to this submission: Solicitation of advice and/or Tribal consultation was conducted in the following manner: Date of solicitation/consultation: Method of solicitation/consultation: 6/28/2019 Letter to all Native American Tribes in New Mexico Date of solicitation/consultation: Method of solicitation/consultation: 6/28/2019 Letter to all Native American Tribes in New Mexico States are not required to consult with Indian tribal governments, but if such consultation was conducted voluntarily, provide information about such consultation below: Date of consultation: Method of consultation: 6/28/2019 Letter to all Native American Tribes in New Mexico The state must upload copies of documents that support the solicitation of advice in accordance with statutory requirements, including any notices sent to Indian Health Programs and/or Urban Indian Organizations, as well as attendee lists if face-to-face meetings were held. Also upload documents with comments received from Indian Health Programs or Urban Indian Organizations and the state's responses to any issues raised. Alternatively indicate the key issues and summarize any comments received below and describe how the state incorporated them into the design of its program. Name Date Created 19-0009 Census Bureau Wages Exclusion TRIBAL NOTIFICATION 7/29/2019 3:54 PM EDT Indicate the key issues raised (optional) Yes No Yes No The state has solicited advice from Indian Health Programs and/or Urban Indian Organizations, as required by section 1902(a)(73) of the Social Security Act, and in accordance with the state consultation plan, prior to submission of this SPA. All Indian Health Programs All Urban Indian Organizations All Indian Tribes Access Quality Cost Payment methodology Eligibility

Beneţts Service delivery Other issue

Medicaid State Plan Eligibility Income/Resource Methodologies Eligibility Determinations of Individuals Age 65 or Older or Who Have Blindness or a Disability MEDICAID | Medicaid State Plan | Eligibility | NM2019MS0004O | NM-19-0009 Package Header Package ID NM2019MS0004O Submission Type OŰcial Approval Date 10/18/2019 Superseded SPA ID NM-19-0001 System-Derived SPA ID NM-19-0009 Initial Submission Date 8/1/2019 Eſective Date 7/1/2019 A. Eligibility Determinations of Individuals Who Are Age 65 or Older or Who Have Blindness or a Disability Eligibility determinations of individuals who are age 65 or older or who have blindness or a disability are based on one of the following: The state has an agreement under section 1634 of the Social Security Act for the Social Security Administration to determine Medicaid eligibility of SSI beneţciaries. For all other individuals who seek Medicaid eligibility on the basis of being age 65 or older or having blindness or a disability, the state requires a separate Medicaid application and determines ţnancial eligibility based on SSI income and resource methodologies. The state requires all individuals who seek Medicaid eligibility on the basis of being age 65 or older or having blindness or a disability, including SSI beneţciaries, to ţle a separate Medicaid application, and determines ţnancial eligibility based on SSI income and resource methodologies. The state requires all individuals who seek Medicaid eligibility on the basis of being age 65 or older or having blindness or a disability, including SSI beneţciaries, to ţle a separate Medicaid application, and determines ţnancial eligibility using income and resource methodologies more restrictive than SSI. B. Additional information (optional) 1. SSA Eligibility Determination State (1634 State) 2. State Eligibility Determination (SSI Criteria State) 3. State Eligibility Determination (209(b) State)

Medicaid State Plan Eligibility Income/Resource Methodologies Non-MAGI Methodologies MEDICAID | Medicaid State Plan | Eligibility | NM2019MS0004O | NM-19-0009 Package Header Package ID NM2019MS0004O Submission Type OŰcial Approval Date 10/18/2019 Superseded SPA ID NM-19-0001 User-Entered SPA ID NM-19-0009 Initial Submission Date 8/1/2019 Eſective Date 7/1/2019 The state will apply the methodologies as described below, and consistent with 42 CFR 435.601, 435.602, and 435.831.

A. Basic Financial Methodology 1. The state applies the income and resource methodologies of the SSI program when determining eligibility for a population based on age (65 or older) or having blindness or a disability, with the exceptions described below in B. through G. 2. The state applies the ţnancial methodologies of either the SSI program or the AFDC program in eſect as of July 16, 1996 (whichever is most closely related) when determining eligibility for a population based on age (as a child), pregnancy, or status as a caretaker relative, with the exceptions described below in B. through G. B. Use of Less Restrictive Methodologies 1. The state elects to apply income and/or resources methodologies that are less restrictive than those used under the cash assistance programs, in accordance with 42 CFR 435.601(d). 2. The less restrictive income and resource methodologies are described on the RU for each applicable eligibility group.

Yes No

Non-MAGI Methodologies MEDICAID | Medicaid State Plan | Eligibility | NM2019MS0004O | NM-19-0009 Package Header Package ID NM2019MS0004O Submission Type OŰcial Approval Date 10/18/2019 Superseded SPA ID NM-19-0001 User-Entered SPA ID NM-19-0009 Initial Submission Date 8/1/2019 Eſective Date 7/1/2019 C. Financial Responsibility of Relatives 1. In determining ţnancial eligibility for an individual, the state does not include income and resources from anyone other than the individual's spouse, and for individuals under age 21 or who have blindness or disability, the individual's parent. a.The state includes the income and resources of a spouse or parent only when they are living with the individual in the same household, except as follows: i. In the case of spouses who are age 65 or older or who have blindness or disability and who share the same room in a Medicaid institution, the state: ii. Where applicable, the state determines income and resource eligibility consistent with the spousal impoverishment rules of section 1924 of the Act, as described in the Resource Assessment and Eligibility reviewable unit. b. In the case of individuals under age 21 for whom AFDC is the most closely related cash assistance program, the income and resources of parents and spouses are included only if the individual would have been considered a dependent under the state's approved AFDC state plan in eſect as of July 16, 1996. (1) Considers these couples either as living together or as living separately for the purpose of counting income and resources, whichever is more advantageous to the couple. (2) Considers these couples as living separately for the purpose of counting income and resources.

Non-MAGI Methodologies MEDICAID | Medicaid State Plan | Eligibility | NM2019MS0004O | NM-19-0009 Package Header Package ID NM2019MS0004O Submission Type OŰcial Approval Date 10/18/2019 Superseded SPA ID NM-19-0001 User-Entered SPA ID NM-19-0009 Initial Submission Date 8/1/2019 Eſective Date 7/1/2019 D. Family Size 1. The family size of an individual for whom the SSI income and resource methodologies are used (as described in section A) includes the persons identiţed below: a. The individual applying, or b. If the individual lives together with his or her spouse, the individual applying and the spouse, or c. If the individual lives together with his or her parent(s) and the individual is under 21 or has blindness or a disability, the individual applying and the parent(s). 2. The family size of an individual for whom the AFDC income and resource methodologies are used (as described in section A.), includes the persons who would have been included in the family under the state's July 16, 1996 AFDC state plan, except where the state has elected to use the MAGI-like methodologies (as described in section E). 3. The state deţnes family size for one or more of the following FPL eligibility groups to include others beyond those identiţed in D.1. and D.2. 4. The state uses the same deţnition of family size for the selected FPL eligibility groups. 5. For the selected FPL eligibility groups, family size is deţned as follows: Optional description: Yes No a. Qualiţed Medicare Beneţciaries (described in section 1902(a)(10)(E)(i) of the Act) b. Speciţed Low Income Medicare Beneţciaries (described in section 1902(a)(10)(E)(iii) of the Act) c. Qualifying Individuals (described in section 1902(a)(10)(E)(iv) of the Act) d. Qualiţed Disabled and Working Individuals (described in section 1902(a)(10)(E)(ii) of the Act) e. Age and Disability-Related Poverty Level (described in section 1902(a)(10)(A)(ii)(X) of the Act) f. Work Incentives (described in section 1902(a)(10)(A)(ii)(XIII) of the Act) g. Family Opportunity Act Children with a Disability (described in section 1902(a)(10)(A)(ii)(XIX) of the Act) h. Individuals Receiving State Plan Home and Community-Based Services (described in 42 CFR 435.219) Yes No a. Family is deţned as the individual, the individual's spouse and the individual's children under age 18 living together in the same household. If the individual is a child, the child's parents and siblings under age 18 are also included in the household if living together. b. The state uses another deţnition of family.

Non-MAGI Methodologies MEDICAID | Medicaid State Plan | Eligibility | NM2019MS0004O | NM-19-0009 Package Header Package ID NM2019MS0004O Submission Type OŰcial Approval Date 10/18/2019 Superseded SPA ID NM-19-0001 User-Entered SPA ID NM-19-0009 Initial Submission Date 8/1/2019 Eſective Date 7/1/2019 E. Use of MAGI-like Methodologies 1. The state uses MAGI-like methodologies for one or more populations for whom the most closely related cash assistance program would be the AFDC program in eſect as of July 16, 1996. Yes No

Non-MAGI Methodologies MEDICAID | Medicaid State Plan | Eligibility | NM2019MS0004O | NM-19-0009 Package Header Package ID NM2019MS0004O Submission Type OŰcial Approval Date 10/18/2019 Superseded SPA ID NM-19-0001 User-Entered SPA ID NM-19-0009 Initial Submission Date 8/1/2019 Eſective Date 7/1/2019 F. Countable Income Deductions for the Medically Needy In determining countable income for individuals who are age 65 or older or who have blindness or a disability, the state deducts: 1. Amounts that would be deducted in determining eligibility under SSI. 2. The highest amounts that would be deducted in determining eligibility for optional state supplements if these supplements are paid to all individuals who are receiving SSI or would be eligible for SSI except for their income.

Non-MAGI Methodologies MEDICAID | Medicaid State Plan | Eligibility | NM2019MS0004O | NM-19-0009 Package Header Package ID NM2019MS0004O Submission Type OŰcial Approval Date 10/18/2019 Superseded SPA ID NM-19-0001 User-Entered SPA ID NM-19-0009 Initial Submission Date 8/1/2019 Eſective Date 7/1/2019 G. Additional Information (optional)

Medicaid State Plan Eligibility Optional Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | NM2019MS0004O | NM-19-0009 Package Header Package ID NM2019MS0004O Submission Type OŰcial Approval Date 10/18/2019 Superseded SPA ID NM-19-0001 System-Derived SPA ID NM-19-0009 Initial Submission Date 8/1/2019 Eſective Date 7/1/2019 A. Options for Coverage The state provides Medicaid to speciţed optional groups of individuals. The optional eligibility groups covered in the state plan are (elections made in this screen may not be comprehensive during the transition period from the paper-based state plan to MACPro): Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Optional Coverage of Parents and Other Caretaker Relatives NEW Reasonable Classiţcations of Individuals under Age 21 CONVERTED Children with Non-IV-E Adoption Assistance NEW Independent Foster Care Adolescents CONVERTED Optional Targeted Low Income Children CONVERTED Individuals above 133% FPL under Age 65 APPROVED Individuals Needing Treatment for Breast or Cervical Cancer NEW Individuals Eligible for Family Planning Services CONVERTED Individuals with Tuberculosis NEW Individuals Electing COBRA Continuation Coverage NEW Aged, Blind and Disabled Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Individuals Eligible for but Not Receiving Cash Assistance NEW Yes No

Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Individuals Eligible for Cash Except for Institutionalization APPROVED Individuals Receiving Home and Community- Based Waiver Services under Institutional Rules NEW Optional State Supplement Beneţciaries NEW Individuals in Institutions Eligible under a Special Income Level NEW PACE Participants NEW Individuals Receiving Hospice NEW Children under Age 19 with a Disability NEW Age and Disability- Related Poverty Level NEW Work Incentives APPROVED Ticket to Work Basic NEW Ticket to Work Medical Improvements NEW Family Opportunity Act Children with a Disability NEW Individuals Receiving State Plan Home and Community-Based Services NEW Individuals Receiving State Plan Home and Community-Based Services Who Are Otherwise Eligible for HCBS Waivers NEW

Optional Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | NM2019MS0004O | NM-19-0009 Package Header Package ID NM2019MS0004O Submission Type OŰcial Approval Date 10/18/2019 Superseded SPA ID NM-19-0001 System-Derived SPA ID NM-19-0009 Initial Submission Date 8/1/2019 Eſective Date 7/1/2019 B. Medically Needy Options for Coverage The state provides Medicaid to speciţed groups of individuals who are medically needy. Yes No

Optional Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | NM2019MS0004O | NM-19-0009 Package Header Package ID NM2019MS0004O Submission Type OŰcial Approval Date 10/18/2019 Superseded SPA ID NM-19-0001 System-Derived SPA ID NM-19-0009 Initial Submission Date 8/1/2019 Eſective Date 7/1/2019 C. Additional Information (optional) Approved New Mexico SPA 19-0001 incorrectly indicated that NM had an approved 1915(i) beneţt under its state plan and covered the optional eligibility group described at 42 CFR 435.219. With the submission of 19-0009, the State is making a technical change to MACPro to show that it does not cover the group as well as applying a Census Bureau wages income disregard to its optional Non-MAGI eligibility groups. Eligibility Groups Deselected from Coverage The following eligibility groups were previously covered in the source approved version of the state plan and deselected from coverage as part of this submission package: N/A

Medicaid State Plan Eligibility Eligibility Groups - Options for Coverage Individuals Eligible for Cash Except for Institutionalization MEDICAID | Medicaid State Plan | Eligibility | NM2019MS0004O | NM-19-0009 Individuals who would be eligible for federal cash assistance or an optional state supplement, except for institutionalization. Package Header Package ID NM2019MS0004O Submission Type OŰcial Approval Date 10/18/2019 Superseded SPA ID NM-19-0001 User-Entered SPA ID NM-19-0009 Initial Submission Date 8/1/2019 Eſective Date 7/1/2019 The state covers the optional Individuals Eligible for Cash Except for Institutionalization eligibility group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria:

1. Are in a medical institution.

2. Would meet the eligibility requirements for at least one of the following cash assistance programs, but for the lower income standards used to determine eligibility for institutionalized individuals: a. SSI b. Optional State Supplement c. AFDC

Individuals Eligible for Cash Except for Institutionalization MEDICAID | Medicaid State Plan | Eligibility | NM2019MS0004O | NM-19-0009 Package Header Package ID NM2019MS0004O Submission Type OŰcial Approval Date 10/18/2019 Superseded SPA ID NM-19-0001 User-Entered SPA ID NM-19-0009 Initial Submission Date 8/1/2019 Eſective Date 7/1/2019 B. Individuals Covered 1. The state covers all individuals who meet the characteristics described in section A. Yes No

Individuals Eligible for Cash Except for Institutionalization MEDICAID | Medicaid State Plan | Eligibility | NM2019MS0004O | NM-19-0009 Package Header Package ID NM2019MS0004O Submission Type OŰcial Approval Date 10/18/2019 Superseded SPA ID NM-19-0001 User-Entered SPA ID NM-19-0009 Initial Submission Date 8/1/2019 Eſective Date 7/1/2019 C. Financial Methodologies 1. In calculating household income and resources for individuals who are seeking eligibility on the basis of being age 65 or older or having blindness or disability, SSI methodologies are used. Please refer as necessary to Non-MAGI Methodologies, completed by the state. 3. Less restrictive methodologies are used in calculating countable income. The less restrictive income methodologies are: Description of disregard: Disregard Census Bureau wages for all census activities. 4. Less restrictive methodologies are used in calculating countable resources. Yes No Census Bureau wages are disregarded. Yes No

Individuals Eligible for Cash Except for Institutionalization MEDICAID | Medicaid State Plan | Eligibility | NM2019MS0004O | NM-19-0009 Package Header Package ID NM2019MS0004O Submission Type OŰcial Approval Date 10/18/2019 Superseded SPA ID NM-19-0001 User-Entered SPA ID NM-19-0009 Initial Submission Date 8/1/2019 Eſective Date 7/1/2019 D. Income Standard Used The income standard used is the standard of the most closely related cash assistance program. E. Resource Standard Used The resource standard used is the standard of the most closely related cash assistance program.

Individuals Eligible for Cash Except for Institutionalization MEDICAID | Medicaid State Plan | Eligibility | NM2019MS0004O | NM-19-0009 Package Header Package ID NM2019MS0004O Submission Type OŰcial Approval Date 10/18/2019 Superseded SPA ID NM-19-0001 User-Entered SPA ID NM-19-0009 Initial Submission Date 8/1/2019 Eſective Date 7/1/2019 F. Additional Information (optional)

Eligibility Groups - Options for Coverage Work Incentives MEDICAID | Medicaid State Plan | Eligibility | NM2019MS0004O | NM-19-0009 Individuals with a disability with income below 250% of the FPL, who would qualify for SSI except for earned income. Package Header Package ID NM2019MS0004O Submission Type OŰcial Approval Date 10/18/2019 Superseded SPA ID NM-19-0001 User-Entered SPA ID NM-19-0009 Initial Submission Date 8/1/2019 Eſective Date 7/1/2019 The state covers the optional Work Incentives eligibility group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Have earned income. 2. Meet the SSI deţnition of disability, but for earned income. 3. Meet income and resource standards following a two-step process, which includes: a. Step One - A comparison of family net income to 250% FPL; and b. Step Two - A comparison of individual net income and resources to the SSI standards, excluding earned income.

Work Incentives MEDICAID | Medicaid State Plan | Eligibility | NM2019MS0004O | NM-19-0009 Package Header Package ID NM2019MS0004O Submission Type OŰcial Approval Date 10/18/2019 Superseded SPA ID NM-19-0001 User-Entered SPA ID NM-19-0009 Initial Submission Date 8/1/2019 Eſective Date 7/1/2019 B. Step One Financial Methodologies and Income Test 1. Financial methodologies a. SSI methodologies are used in calculating family income. Please refer as necessary to Non-MAGI Methodologies, completed by the state. b. Less restrictive methodologies are used in calculating countable income. The less restrictive income methodologies are: Name of income type: Description: Work-related expenses for individuals with blindness or a disability after 1/2 remainder of earnings deductions. Disregard work-related expenses for individuals with blindness or a disability after 1/2 remainder of earnings deductions. Census Bureau wages, federal and state tax refunds, and refundable tax credits. Disregard Census Bureau wages + federal and state tax refunds, and refundable tax credits. 2. Income Test Family net income must be less than 250% FPL. Please refer as necessary to Non-MAGI Methodologies for the deţnition of family size. Yes No A speciţed type of income is disregarded:

Work Incentives MEDICAID | Medicaid State Plan | Eligibility | NM2019MS0004O | NM-19-0009 Package Header Package ID NM2019MS0004O Submission Type OŰcial Approval Date 10/18/2019 Superseded SPA ID NM-19-0001 User-Entered SPA ID NM-19-0009 Initial Submission Date 8/1/2019 Eſective Date 7/1/2019 C. Step Two Financial Methodologies and Income/Resource Test 1. Financial methodologies a. SSI methodologies are used in calculating income and resources, except that earned income is not counted. Please refer as necessary to Non-MAGI Methodologies, completed by the state. b. Less restrictive methodologies are used in calculating countable income. The less restrictive income methodologies are: Name of income type: Description: Supplemental Security Income Federal Beneţt Rate Disregard Supplemental Security Income Federal Beneţt Rate c. Less restrictive methodologies are used in calculating countable resources. The less restrictive resource methodologies are: Name of disregard: Description: First $8,000 for an individual and ţrst $13,000 for a couple Disregard ţrst $8,000 for an individual and ţrst $13,000 for a couple. All funds held in retirement funds and accounts, including private retirement accounts such as IRAs and other individual accounts, and employer-sponsored retirement accounts such as 401(k) plans, Keogh plans, and employer pension plans. Disregard all funds held in retirement funds and accounts, including private retirement accounts such as IRAs and other individual accounts, and employer-sponsored retirement accounts such as 401(k) plans, Keogh plans, and employer pension plans. Name of resource type: Description: Federal and state tax refunds and refundable tax credits. Disregard federal and state refunds and refundable tax credits. 2. Income Test For individuals who pass Step One, in Step Two, the individual's unearned income (plus deemed income, if appropriate) must be less than one of the following income standards: Yes No A speciţed type of income is disregarded: Yes No General resource disregard: A speciţed type of resource is disregarded: a. The SSI income standard. b. The income standard of the state supplement program.

3. Resource Test The individual's resources must be less than the SSI resource standard.

Work Incentives MEDICAID | Medicaid State Plan | Eligibility | NM2019MS0004O | NM-19-0009 Package Header Package ID NM2019MS0004O Submission Type OŰcial Approval Date 10/18/2019 Superseded SPA ID NM-19-0001 User-Entered SPA ID NM-19-0009 Initial Submission Date 8/1/2019 Eſective Date 7/1/2019 D. Premiums and Cost Sharing Requirements for premiums and cost sharing for this group are found in the premium and cost sharing sections of the state plan.

Work Incentives MEDICAID | Medicaid State Plan | Eligibility | NM2019MS0004O | NM-19-0009 Package Header Package ID NM2019MS0004O Submission Type OŰcial Approval Date 10/18/2019 Superseded SPA ID NM-19-0001 User-Entered SPA ID NM-19-0009 Initial Submission Date 8/1/2019 Eſective Date 7/1/2019 E. Additional Information (optional)

PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance OŰcer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 10/23/2019 12:02 PM EDT

Table of Contents State/Territory Name: New Mexico State Plan Amendment (SPA) #: 19-0016 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Center for Medicaid & CHIP Services 233 North Michigan Ave., Suite 600 Chicago, Illinois 60601 Financial Management Group Ms. Nicole Comeaux Director Medical Assistance Division New Mexico Human Services Department 2025 South Pacheco Drive P.O. Box 2348 Santa Fe, New Mexico 87504-2348 RE: New Mexico TN#19-0016 Dear Ms. Comeaux: We have reviewed the proposed New Mexico State Plan Amendment (SPA) to Attachment 4.19-B TN#19-0016, which was submitted to the Centers for Medicare & Medicaid Services (CMS) on December 30, 2019. This SPA to establishes a new minimum encounter rate for Federally Qualified Health Centers (FQHCs) based upon the national Medicare Prospective Payment System (PPS) base rate. Additionally, it establishes a new minimum encounter rate for FQHC dental services based on the national average cost of a dental encounter as established by the Health Resources and Services Administration (HRSA) Uniform Data System for 2017. Based upon the information provided by the State, we have approved the amendment with an effective date of October 1, 2019. We are enclosing the approved CMS-179 and a copy of the new state plan page. If you have any additional questions or need further assistance, please contact Tamara Sampson at 214-767-6431 or Tamara.Sampson@cms.hhs.gov. Sincerely, Todd McMillion Director Division of Reimbursement Review Enclosures April 30, 2020

DEPARTMENT OF HEALTHAND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES

FORM APPROVED OMB No. 0938-0193

TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES

2. STATE New Mexico

1. TRANSMITTAL NUMBER 1 9 0 16

3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID)

TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE & MEDICAID SERVICES DEPARTMENT OF HEALTHAND HUMAN SERVICES

4. PROPOSED EFFECTIVE DATE October 1, 2019

5. TYPE OF PLAN MATERIAL (Check One) CO NEW STATE PLAN

LJ AMENDMENT TO BE CONSIDERED AS NEW PLAN

[] AMENDMENT

COMPLETE BLOCKS 6 THRU 10 IF THIS ISAN AMENDMENT (Separate transmittal for each amendment)

6. FEDERAL STATUTE/REGULATION CITATION 42 CFR 447 Subpart F

7. FEDERAL BUDGET IMPACT a. FFY_20.

$3,400,000 b. FFY_21 $3,500,000

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT

Attachment 4.19-B, page 7b

9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (if Applicable)

Attachment 4.19-B, page 7b (NM Amendment 03-002)

10. SUBJECT OF AMENDMENT Federally Qualified Health Center (FQHC) Rates

11. GOVERNOR'S REVIEW (Check One)

OC GOVERNOR'S OFFICE REPORTED NO COMMENT C COMMENTS OF GOVERNOR'S OFFICE ENCLOSED (CD NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

[3] OTHER, AS SPECIFIED Authority delegated to the Medicaid Director

3. EDN. Nicole Comeaux

14. TITLE Director, Medical Assistance Division

15. DATE SUBMITTED . iz|zo0| 201g

> 16. RETURN Gard ry Nicole ‘aux, J.D., M.P.H., Director

Medical Assistance Division P.O. Box 2348 Santa Fe, NM 87504-2348

FOR REGIONAL OFFICE USE ONLY

17. DATE RECEIVED

18. DATE APPROVED 04/30/2020

PLAN APPROVED - ONE COPY ATTACHED

19. EFFECTIVE DATE OF APPROVED MATERIAL

20. SIGNATURE OF REGIONAL OFFICIAL

21. TYPED NAME

Todd MeMillion

22. TITLE Director, Division of Reimbursement Review

23. REMARKS

FORM CMS 179 (07/92)

Instructions on Back

TN No. NM 19-0016 Approval Date __________________ Supersedes TN No. NM 03-002 Effective Date __________________ ATTACHMENT 4.19-B Page 7b Once the base period rate for each FQHC and RHC has been calculated, any claims paid for dates of service on or after January 1, 2001, that were paid an interim rate, will be reprocessed. This reprocessing will adjust the payment on each claim to the PPS base rate amount. d. Updates to PPS base rates: Beginning in Federal Fiscal Year (FFY) 2002, and each year thereafter, each FQHC and RHC payment amount (on a per visit basis) will be increased by the percentage increase in the Medicare Economic Index (MEI) for primary care services. This adjustment to the PPS rate will be effective each October 1. e. Alternative Payment Methodology (APM) An alternative payment methodology will be implemented effective April 1, 2003. This alternative methodology will re-index the PPS rates effective March 31, 2003 by the cumulative percentage difference between the increase in the Medical Care Component of the Consumer Price Index-Urban (CPI-U) for the 12 months in the calendar year 2001 and the increase in the Medicare Economic Index (MEI) effective for calendar year beginning January 1, 2002, and the increase in the Medical Care Component of the CPI-U for the 12 months in calendar year 2002 and the increase in the MEI effective for the calendar year beginning January 1, 2003. The new rates will be effective April 1, 2003. Beginning in Federal Fiscal Year 2021, the Department will calculate the APM by trending the PPS rate by the greater of either the MEI or the CPI-U. Providers must be notified of the APM rate and must agree to receive the APM. This APM will be at least equal to PPS. Dental APM Effective October 1, 2019, an alternative payment methodology will be paid for FQHC dental encounters. The alternative payment methodology is based on the national average cost of a dental encounter as established by the Health Resources and Services Administration (HRSA) Uniform Data system for 2017. Beginning in Federal Fiscal Year 2021, the Department will calculate the dental APM by trending the dental APM effective October 1, 2019 by the greater of either the MEI or the CPI-U. Providers must be notified of the dental APM rate and must agree to receiving the dental APM. The dental APM will be at least equal to PPS. f. Change in Scope of Services Once the PPS rates are determined as outlined in this section, adjustments to those rates will reflect changes in the scope of services will be made upon the written request of the provider and approval by the Medical Assistance Division (MAD). A provider’s request for a PPS rate adjustment due to a change in scope of service must be received no later than 90 days after the provider’s fiscal year end during which the change in scope of service occurred. The provider should notify MAD in advance of any impending changes. The provider will be required to submit data supporting that a change in the scope of service transpired. This documentation will include FQHC and RHC information report and any other supporting documentation considered necessary by MAD or its designee. A minimum of six months should have elapsed since the change in the scope occurred to ensure the change was not temporary and that there is sufficient information upon which to base a rate adjustment. If the change in scope of service occurred in the last six months of a FQHC’s and RHC’s fiscal period, MAD may require the FQHC and RHC to submit and additional information report, covering at least six months since the change in scope of service transpired, to obtain the information necessary to evaluate the request. MAD and/or its designee will review the request and determine if an adjustment to the established PPS rate is merited. The following criteria will be used to evaluate each FQHC request for a rate adjustment due to a change in scope of service. MAD’s final determination will be communicated to the FQHC and RHC in writing. 04-30-20

Table of Contents State/Territory Name: New Mexico State Plan Amendment (SPA) #: 20-0004 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, Maryland 21244-1850 April 2, 2020 Ms. Nicole Comeaux Director Medical Assistance Division New Mexico Human Services Department 2025 South Pacheco Drive P.O. Box 2348 Santa Fe, New Mexico 87504-2348 Re: New Mexico State Plan Amendment (SPA) 20-0004 Dear Director Comeaux: We have reviewed the proposed amendment to add section 7.4 Medicaid Disaster Relief for the COVID-19 National Emergency to your Medicaid state plan, as submitted under transmittal number 20-0004. This amendment proposes to implement temporary policies, which are different from those policies and procedures otherwise applied under your Medicaid state plan, during the period of the Presidential and Secretarial emergency declarations related to the COVID-19 outbreak (or any renewals thereof). On March 13, 2020, the President of the United States issued a proclamation that the COVID-19 outbreak in the United States constitutes a national emergency by the authorities vested in him by the Constitution and the laws of the United States, including sections 201 and 301 of the National Emergencies Act (50 U.S.C. 1601 et seq.), and consistent with section 1135 of the Social Security Act (Act). On March 13, 2020, pursuant to section 1135(b) of the Act, the Secretary of the United States Department of Health and Human Services invoked his authority to waive or modify certain requirements of titles XVIII, XIX, and XXI of the Act as a result of the consequences of the COVID-19 pandemic, to the extent necessary, as determined by the Centers for Medicare & Medicaid Services (CMS), to ensure that sufficient health care items and services are available to meet the needs of individuals enrolled in the respective programs and to ensure that health care providers that furnish such items and services in good faith, but are unable to comply with one or more of such requirements as a result of the COVID-19 pandemic, may be reimbursed for such items and services and exempted from sanctions for such noncompliance, absent any determination of fraud or abuse. This authority took effect as of 6PM Eastern Standard Time on March 15, 2020, with a retroactive effective date of March 1, 2020. The emergency period will terminate, and this state plan provision will no longer be in effect, upon termination of the public health emergency, including any extensions.

The State of New Mexico requested a waiver of public notice requirements applicable to the state plan amendment (SPA) submission process. Public notice for SPAs is required under 42 C.F.R §447.205 for changes in statewide methods and standards for setting Medicaid payment rates, 42 C.F.R. §447.57 for changes to premiums and cost sharing, and 42 C.F.R. §440.386 for changes to ABPs. These requirements help to ensure that the affected public has reasonable opportunity to comment on these SPAs. CMS recognizes that during this public health emergency, New Mexico must act expeditiously to protect and serve the general public. Therefore, under section 1135(b)(5) of the Act, CMS is approving the state’s request to modify these notice requirements applicable to this SPA. The State of New Mexico also requested a waiver to modify the tribal consultation timeline applicable to this SPA submission process. Under section 1135(b)(5) of the Act, CMS is also approving the State of New Mexico’s request for flexibility to modify the timeframes associated with tribal consultation required under section 1902(a)(73) of the Act, including shortening the number of days before submission or conducting consultation after submission of the SPA. These approvals under section 1135 only apply with respect to SPAs that provide or increase beneficiary access to items and services related to COVID-19 (such as cost sharing waivers, payment rate increases, or amendments to ABPs to add services or providers) and that would not restrict or limit payment or services or otherwise burden beneficiaries and providers, and that are temporary, with a specified sunset date that is not later than the last day of the declared COVID- 19 emergency (or any extension thereof). Even though CMS is approving this waiver, we encourage the state to make all relevant information available to the public so they are aware of the changes. We conducted our review of your submittal according to the statutory requirements at section 1902(a) of the Act and implementing regulations. This letter is to inform you that New Mexico’s Medicaid SPA Transmittal Number 20-0004 is approved effective April 1, 2020. Enclosed is a copy of the CMS-179 summary form and the approved state plan pages. Please contact Peter Banks at (415) 744-3782 or by email at Peter.Banks@cms.hhs.gov if you have any questions about this approval. We appreciate the efforts of you and your staff in responding to the needs of the residents of the State of New Mexico and the health care community. Sincerely, Anne Marie Costello Deputy Director Center for Medicaid & CHIP Services Enclosures: Anne M. Costello -S Digitally signed by Anne M. Costello -S Date: 2020.04.24 17 00:16 -04'00'

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES

FORM APPROVED OMB No. 0938-0193

TRANSMITTAL AND NOTICE OF APPROVAL OF

STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES

2. STATE New Mexico

1. TRANSMITTAL NUMBER 2 0 0 O 4

3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID)

TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE & MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES

4. PROPOSED EFFECTIVE DATE April 1, 2020

5. TYPE OF PLAN MATERIAL (Check One) (0 NEw STATE PLAN

(0 AMENDMENT TO BE CONSIDERED AS NEW PLAN

J] AMENDMENT

COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate transmittal for each amendment)

6. FEDERAL STATUTE/REGULATION CITATION SSA Sections 1920, 1920A, 1920C

7. FEDERAL BUDGET IMPACT a. FFY___20 _|

b. FFY___21 $_0

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT

Section 7 — General Provisions, 7.4. Medicaid Disaster Relief for the COVID-19 National Emergency - Pages 80-89

9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (if Applicable)

10. SUBJECT OF AMENDMENT Medicaid Disaster Relief #1

11. GOVERNOR'S REVIEW (Check One)

(J Governor's OFFICE REPORTED NO COMMENT (0 CoMMENTS OF GOVERNOR'S OFFICE ENCLOSED (1 No REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

[X] OTHER, AS SPECIFIED

12. SIGNATURE OF STATE AGENCY OFFICIAL

13. TYPED NAME Nicole Comeaux

14. TITLE Director, Medical Assistance Division

15. DATE SUBMITTED 26, 2020

16. RETURN TO

Nicole Comeaux, J.D., M.P.H., Director Medical Assistance Division

P.O. Box 2348

Santa Fe, NM 87504-2348

FOR REGIONAL OFFICE USE ONLY

17. DATE RECEIVED 3/26/20

18. DATE APPROVED 4/24/20

PLAN APPROVED - ONE COPY ATTACHED

19. EFFECTIVE DATE OF APPROVED MATERIAL 4/1/20

QE EAR hea by anne

M. Costello -S

20. Cie tana le alse lelttt

21. TYPED NAME Anne Marie Costello

Costello -S Date: 2020.04.24 22. TITLE “T7040 U4 00

Deputy Director, Center for Medicaid & CHIP Services

23. REMARKS

FORM CMS-179 (07/92)

Instructions on Back

State/Territory: ___New Mexico__ TN: 20-0004 Supersedes TN: __New _ Approval Date: 4/2ϰ/2020 Effective Date: 4/1/2020 80 Section 7 – General Provisions 7.4. Medicaid Disaster Relief for the COVID-19 National Emergency On March 13, 2020, the President of the United States issued a proclamation that the COVID-19 outbreak in the United States constitutes a national emergency by the authorities vested in him by the Constitution and the laws of the United States, including sections 201 and 301 of the National Emergencies Act (50 U.S.C. 1601 et seq.), and consistent with section 1135 of the Social Security Act (Act). On March 13, 2020, pursuant to section 1135(b) of the Act, the Secretary of the United States Department of Health and Human Services invoked his authority to waive or modify certain requirements of titles XVIII, XIX, and XXI of the Act as a result of the consequences COVID-19 pandemic, to the extent necessary, as determined by the Centers for Medicare & Medicaid Services (CMS), to ensure that sufficient health care items and services are available to meet the needs of individuals enrolled in the respective programs and to ensure that health care providers that furnish such items and services in good faith, but are unable to comply with one or more of such requirements as a result of the COVID-19 pandemic, may be reimbursed for such items and services and exempted from sanctions for such noncompliance, absent any determination of fraud or abuse. This authority took effect as of 6PM Eastern Standard Time on March 15, 2020, with a retroactive effective date of March 1, 2020. The emergency period will terminate, and waivers will no longer be available, upon termination of the public health emergency, including any extensions. The State Medicaid agency (agency) seeks to implement the policies and procedures described below, which are different than the policies and procedures otherwise applied under the Medicaid state plan, during the period of the Presidential and Secretarial emergency declarations related to the COVID-19 outbreak (or any renewals thereof), or for any shorter period described below: Describe shorter period here. NOTE: States may not elect a period longer than the Presidential or Secretarial emergency declaration (or any renewal thereof). States may not propose changes on this template that restrict or limit payment, services, or eligibility, or otherwise burden beneficiaries and providers. Request for Waivers under Section 1135 __X___ The agency seeks the following under section 1135(b)(1)(C) and/or section 1135(b)(5) of the Act: a. _____ SPA submission requirements – the agency requests modification of the requirement to submit the SPA by March 31, 2020, to obtain a SPA effective date during the first calendar quarter of 2020, pursuant to 42 CFR 430.20. b. __X___ Public notice requirements – the agency requests waiver of public notice requirements that would otherwise be applicable to this SPA submission. These requirements may include those specified in 42 CFR 440.386 (Alternative Benefit Plans), 42 CFR 447.57(c) (premiums and cost sharing), and 42 CFR 447.205 (public notice of changes in statewide methods and standards for setting payment rates).

State/Territory: ___New Mexico__ TN: 20-0004 Supersedes TN: __New _ Approval Date: 4/2ϰ/2020 Effective Date: 4/1/2020 81 c. __X___ Tribal consultation requirements – the agency requests modification of tribal consultation timelines specified in [insert name of state] Medicaid state plan, as described below: New Mexico plans to modify the tribal consultation timelines by issuing formal notice to New Mexico’s Indian Nations, Tribes, Pueblos and their health care providers for an opportunity to request a tribal consultation from early April 2020 through early May 2020. Section A – Eligibility 1. _____ The agency furnishes medical assistance to the following optional groups of individuals described in section 1902(a)(10)(A)(ii) or 1902(a)(10)(c) of the Act. This may include the new optional group described at section 1902(a)(10)(A)(ii)(XXIII) and 1902(ss) of the Act providing coverage for uninsured individuals. Include name of the optional eligibility group and applicable income and resource standard. 2. ____ The agency furnishes medical assistance to the following populations of individuals described in section 1902(a)(10)(A)(ii)(XX) of the Act and 42 CFR 435.218: a. ____ All individuals who are described in section 1902(a)(10)(A)(ii)(XX) Income standard: _________ -or-

b. ___ Individuals described in the following categorical populations in section 1905(a) of the Act: Income standard: _________ 3. _____ The agency applies less restrictive financial methodologies to individuals excepted from financial methodologies based on modified adjusted gross income (MAGI) as follows. Less restrictive income methodologies:

State/Territory: ___New Mexico__ TN: 20-0004 Supersedes TN: __New _ Approval Date: 4/2ϰ/2020 Effective Date: 4/1/2020 82 Less restrictive resource methodologies: 4. _____ The agency considers individuals who are evacuated from the state, who leave the state for medical reasons related to the disaster or public health emergency, or who are otherwise absent from the state due to the disaster or public health emergency and who intend to return to the state, to continue to be residents of the state under 42 CFR 435.403(j)(3). 5. _____ The agency provides Medicaid coverage to the following individuals living in the state, who are non-residents: 6. _____ The agency provides for an extension of the reasonable opportunity period for non- citizens declaring to be in a satisfactory immigration status, if the non-citizen is making a good faith effort to resolve any inconsistences or obtain any necessary documentation, or the agency is unable to complete the verification process within the 90-day reasonable opportunity period due to the disaster or public health emergency. Section B – Enrollment 1. _____ The agency elects to allow hospitals to make presumptive eligibility determinations for the following additional state plan populations, or for populations in an approved section 1115 demonstration, in accordance with section 1902(a)(47)(B) of the Act and 42 CFR 435.1110, provided that the agency has determined that the hospital is capable of making such determinations. Please describe the applicable eligibility groups/populations and any changes to reasonable limitations, performance standards or other factors. 2. ____ The agency designates itself as a qualified entity for purposes of making presumptive eligibility determinations described below in accordance with sections 1920, 1920A, 1920B, and 1920C of the Act and 42 CFR Part 435 Subpart L.

State/Territory: ___New Mexico__ TN: 20-0004 Supersedes TN: __New _ Approval Date: 4/2ϰ/2020 Effective Date: 4/1/2020 83 3. __X__ The agency designates the following entities as qualified entities for purposes of making presumptive eligibility determinations or adds additional populations as described below in accordance with sections 1920, 1920A, 1920B, and 1920C of the Act and 42 CFR Part 435 Subpart L. Indicate if any designated entities are permitted to make presumptive eligibility determinations only for specified populations. The following is the list of qualified entities for purposes of making presumptive eligibility (PE) determinations: Furnishes health care items or services covered under the state’s approved state plan and is eligible to receive payments under the plan. Is authorized to determine a child’s eligibility to participate in a Head Start program under the Head Start Act. Is authorized to determine a child’s eligibility to receive childcare services for which financial assistance is provided under the Child Care and Development Block Grant of 1990. Is authorized to determine child’s eligibility to receive assistance under the Special Supplemental Food Program for Women, Infants and Children (WIC) under Section 17 of the Child Nutrition Act of 1966. Is authorized to determine a child’s eligibility under the Medicaid state plan or for child health assistance under CHIP. Is an elementary or secondary school, as defined in section 14101 of the Elementary and Secondary Education Act of 1965. Is an elementary or secondary school operated or supported by the Bureau of Indian Affairs. Is a state or tribal child support enforcement agency under Title IV-D of the Act. Is an organization that provides emergency food and shelter under a grant under the Stewart B. McKinney Homeless Assistance Act. Is a state or tribal office or entity in enrollment in the program under Medicaid, CHIP or title IV-A of the Act. Is an organization that determines eligibility for any assistance or benefits provided under any program of public or assisted housing that receives Federal funds, including the program under section 8 or any other section of the United States Housing Act of 1937 or under the Native American Housing Assistance and Self Determination Act of 1996. Is a health facility operated by the Indian Health Service, a Tribe, or Tribal organization, or an Urban Indian Organization. Correctional Facilities (state prisons\county jails)

State/Territory: ___New Mexico__ TN: 20-0004 Supersedes TN: __New _ Approval Date: 4/2ϰ/2020 Effective Date: 4/1/2020 84 Qualified entities will determine PE for the following MAGI eligibility groups: Parents and other Caretaker Relatives: 1902(a)(10)(A)(i)(I) and 1931(b) and (d) Pregnant Women: 1902(a)(10)(A)(i)(III) and (IV), 1902(a)(10)(A)(ii)(I), (IV) and (IX), 1931(b) and (d), 1920 Infants and Children under Age 19: 1902(a)(10)(A)(i)(III), (IV), (VI) and (VII), 1902(a)(10)(A)(ii)(IV) and (IX), 1931(b) and (d) Individuals below 133% of the FPL: 1902(a)(10)(A)(i)(VIII) Reasonable Classification of Individuals under Age 21: 1902(a)(10)(A)(ii)(I), 1902(a)(10)(A)(ii)(IV) Optional Targeted Low-Income Children: 1902(a)(10)(A)(ii)(XIV), 1905(u)(2)(B) Family Planning: 1902(a)(10)(A)(ii)(XXI) Limitations on allowable PE periods: One PE period is allowed per 12 months. One PE period is allowed per pregnancy. Self-attestation: The agency will accept self-attestation for residency and citizenship, status as a national, and satisfactory immigration status when making a PE determination. 4. _____ The agency adopts a total of _____ months (not to exceed 12 months) continuous eligibility for children under age enter age _____ (not to exceed age 19) regardless of changes in circumstances in accordance with section 1902(e)(12) of the Act and 42 CFR 435.926. 5. _____ The agency conducts redeterminations of eligibility for individuals excepted from MAGI- based financial methodologies under 42 CFR 435.603(j) once every _____ months (not to exceed 12 months) in accordance with 42 CFR 435.916(b). 6. _____ The agency uses the following simplified application(s) to support enrollment in affected areas or for affected individuals (a copy of the simplified application(s) has been submitted to CMS). a. _____ The agency uses a simplified paper application. b. _____ The agency uses a simplified online application. c. _____ The simplified paper or online application is made available for use in call-centers or other telephone applications in affected areas. Section C – Premiums and Cost Sharing 1. __X___ The agency suspends deductibles, copayments, coinsurance, and other cost sharing charges as follows: The State does not currently assess co-pays to beneficiaries under the Medicaid program. The State further attests that it does not intend to impose co-pays upon beneficiaries for COVID-19 related services.

State/Territory: ___New Mexico__ TN: 20-0004 Supersedes TN: __New _ Approval Date: 4/2ϰ/2020 Effective Date: 4/1/2020 85 2. _____ The agency suspends enrollment fees, premiums and similar charges for: a. _____ All beneficiaries b. _____ The following eligibility groups or categorical populations: Please list the applicable eligibility groups or populations. 3. _____ The agency allows waiver of payment of the enrollment fee, premiums and similar charges for undue hardship. Please specify the standard(s) and/or criteria that the state will use to determine undue hardship. Section D – Benefits Benefits: 1. _____ The agency adds the following optional benefits in its state plan (include service descriptions, provider qualifications, and limitations on amount, duration or scope of the benefit): 2. _____ The agency makes the following adjustments to benefits currently covered in the state plan: 3. _____ The agency assures that newly added benefits or adjustments to benefits comply with all applicable statutory requirements, including the statewide requirements found at 1902(a)(1), comparability requirements found at 1902(a)(10)(B), and free choice of provider requirements found at 1902(a)(23). 4. _____ Application to Alternative Benefit Plans (ABP). The state adheres to all ABP provisions in 42 CFR Part 440, Subpart C. This section only applies to states that have an approved ABP(s).

State/Territory: ___New Mexico__ TN: 20-0004 Supersedes TN: __New _ Approval Date: 4/2ϰ/2020 Effective Date: 4/1/2020 86 a. _____ The agency assures that these newly added and/or adjusted benefits will be made available to individuals receiving services under ABPs. b. _____ Individuals receiving services under ABPs will not receive these newly added and/or adjusted benefits, or will only receive the following subset: Please describe. Telehealth: 5. _____ The agency utilizes telehealth in the following manner, which may be different than outlined in the state’s approved state plan: Please describe. Drug Benefit: 6. _____ The agency makes the following adjustments to the day supply or quantity limit for covered outpatient drugs. The agency should only make this modification if its current state plan pages have limits on the amount of medication dispensed. Please describe the change in days or quantities that are allowed for the emergency period and for which drugs. 7. _____ Prior authorization for medications is expanded by automatic renewal without clinical review, or time/quantity extensions. 8. _____ The agency makes the following payment adjustment to the professional dispensing fee when additional costs are incurred by the providers for delivery. States will need to supply documentation to justify the additional fees. Please describe the manner in which professional dispensing fees are adjusted. 9. _____ The agency makes exceptions to their published Preferred Drug List if drug shortages occur. This would include options for covering a brand name drug product that is a multi-source drug if a generic drug option is not available.

State/Territory: ___New Mexico__ TN: 20-0004 Supersedes TN: __New _ Approval Date: 4/2ϰ/2020 Effective Date: 4/1/2020 87 Section E – Payments Optional benefits described in Section D: 1. _____ Newly added benefits described in Section D are paid using the following methodology: a. _____ Published fee schedules – Effective date (enter date of change): _____________ Location (list published location): _____________ b. _____ Other: Describe methodology here. Increases to state plan payment methodologies: 2. _____ The agency increases payment rates for the following services: Please list all that apply. a. _____ Payment increases are targeted based on the following criteria: Please describe criteria. b. Payments are increased through: i. _____ A supplemental payment or add-on within applicable upper payment limits: Please describe. ii. _____ An increase to rates as described below. Rates are increased: _____ Uniformly by the following percentage: _____________

State/Territory: ___New Mexico__ TN: 20-0004 Supersedes TN: __New _ Approval Date: 4/2ϰ/2020 Effective Date: 4/1/2020 88 _____ Through a modification to published fee schedules – Effective date (enter date of change): _____________ Location (list published location): _____________ _____ Up to the Medicare payments for equivalent services. _____ By the following factors: Please describe. Payment for services delivered via telehealth: 3. _____ For the duration of the emergency, the state authorizes payments for telehealth services that: a. _____ Are not otherwise paid under the Medicaid state plan; b. _____ Differ from payments for the same services when provided face to face; c. _____ Differ from current state plan provisions governing reimbursement for telehealth; Describe telehealth payment variation. d. _____ Include payment for ancillary costs associated with the delivery of covered services via telehealth, (if applicable), as follows: i. _____ Ancillary cost associated with the originating site for telehealth is incorporated into fee-for-service rates. ii. _____ Ancillary cost associated with the originating site for telehealth is separately reimbursed as an administrative cost by the state when a Medicaid service is delivered. Other: 4. _____ Other payment changes: Please describe.

State/Territory: ___New Mexico__ TN: 20-0004 Supersedes TN: __New _ Approval Date: 4/2ϰ/2020 Effective Date: 4/1/2020 89 Section F – Post-Eligibility Treatment of Income 1. _____ The state elects to modify the basic personal needs allowance for institutionalized individuals. The basic personal needs allowance is equal to one of the following amounts: a. _____ The individual’s total income b. _____ 300 percent of the SSI federal benefit rate c. _____ Other reasonable amount: _________________ 2. _____ The state elects a new variance to the basic personal needs allowance. (Note: Election of this option is not dependent on a state electing the option described the option in F.1. above.) The state protects amounts exceeding the basic personal needs allowance for individuals who have the following greater personal needs: Please describe the group or groups of individuals with greater needs and the amount(s) protected for each group or groups. Section G – Other Policies and Procedures Differing from Approved Medicaid State Plan /Additional Information PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148 (Expires 03/31/2021). The time required to complete this information collection is estimated to average 1 to 2 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. Your response is required to receive a waiver under Section 1135 of the Social Security Act. All responses are public and will be made available on the CMS web site. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. ***CMS Disclosure*** Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact the Centers for Medicaid & CHIP Services at 410-786-3870.

Table of Contents State/Territory Name: New Mexico State Plan Amendment (SPA) #: 20-0007 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, Maryland 21244-1850 May 1, 2020 Ms. Nicole Comeaux Director Medical Assistance Division New Mexico Human Services Department 2025 South Pacheco Drive P.O. Box 2348 Santa Fe, New Mexico 87504-2348 Re: New Mexio State Plan Amendment (SPA) 20-0007 Dear Ms. Comeaux: We have reviewed the proposed amendment to add section 7.4 Medicaid Disaster Relief for the COVID-19 National Emergency to your Medicaid state plan, as submitted under transmittal number (TN) 20-0007. This amendment proposes to implement temporary policies, which are different from those policies and procedures otherwise applied under your Medicaid state plan, during the period of the Presidential and Secretarial emergency declarations related to the COVID- 19 outbreak (or any renewals thereof). On March 13, 2020, the President of the United States issued a proclamation that the COVID- 19 outbreak in the United States constitutes a national emergency by the authorities vested in him by the Constitution and the laws of the United States, including sections 201 and 301 of the National Emergencies Act (50 U.S.C. 1601 et seq.), and consistent with section 1135 of the Social Security Act (Act). On March 13, 2020, pursuant to section 1135(b) of the Act, the Secretary of the United States Department of Health and Human Services invoked his authority to waive or modify certain requirements of titles XVIII, XIX, and XXI of the Act as a result of the consequences of the COVID-19 pandemic, to the extent necessary, as determined by the Centers for Medicare & Medicaid Services (CMS), to ensure that sufficient health care items and services are available to meet the needs of individuals enrolled in the respective programs and to ensure that health care providers that furnish such items and services in good faith, but are unable to comply with one or more of such requirements as a result of the COVID-19 pandemic, may be reimbursed for such items and services and exempted from sanctions for such noncompliance, absent any determination of fraud or abuse. This authority took effect as of 6PM Eastern Standard Time on March 15, 2020, with a retroactive effective date of March 1, 2020. The emergency period will terminate, and this state plan provision will no longer be in effect, upon termination of the public health emergency, including any extensions. Pursuant to section 1135(b)(5) of the Act, for the period of the public health emergency, CMS is modifying the requirement at 42 C.F.R. 430.20 that the state submit SPAs related to the COVID- 19 public health emergency by the final day of the quarter, to obtain a SPA effective date during

the quarter, enabling SPAs submitted after the last day of the quarter to have an effective date in a previous quarter, but no earlier than the effective date of the public health emergency. The State of New Mexico also requested a waiver of public notice requirements applicable to the SPA submission process. Pursuant to section 1135(b)(1)(C) of the Act, CMS is waiving public notice requirements applicable to the SPA submission process. Public notice for SPAs is required under 42 C.F.R. §447.205 for changes in statewide methods and standards for setting Medicaid payment rates, 42 C.F.R. §447.57 for changes to premiums and cost sharing, and 42 C.F.R. §440.386 for changes to Alternative Benefit Plans (ABPs). Pursuant to section 1135(b)(1)(C), CMS is approving the state’s request to waive these notice requirements otherwise applicable to SPA submissions. The State of New Mexico also requested a waiver to modify the tribal consultation timeline applicable to this SPA submission process. Pursuant to section 1135(b)(5) of the Act, CMS is also allowing states to modify the timeframes associated with tribal consultation required under section 1902(a)(73) of the Act, including shortening the number of days before submission or conducting consultation after submission of the SPA. These waivers or modifications of the requirements related to SPA submission timelines, public notice, and tribal consultation apply only with respect to SPAs that meet the following criteria: (1) the SPA provides or increases beneficiary access to items and services related to COVID-19 (such as by waiving or eliminating cost sharing, increasing payment rates or amending ABPs to add services or providers); (2) the SPA does not restrict or limit payment or services or otherwise burden beneficiaries and providers; and (3) the SPA is temporary, with a specified sunset date that is not later than the last day of the declared COVID-19 public health emergency (or any extension thereof). We nonetheless encourage states to make all relevant information about the SPA available to the public so they are aware of the changes. We conducted our review of your submittal according to the statutory requirements at section 1902(a) of the Act and implementing regulations. This letter is to inform you that New Mexico’s Medicaid SPA Transmittal Number 20-0007 is approved effective March 18, 2020. 7KLV 63$ LV LQ DGGLWLRQ WR 'LVDVWHU 5HOLHI 63$V DSSURYHG RQ $SULO   DQG 0D\   DQG GRHV QRW VXSHUVHGH DQ\WKLQJ DSSURYHG LQ WKRVH 63$V Enclosed is a copy of the CMS-179 summary form and the approved state plan pages. Please contact Peter Banks at (415) 744-3782 or by email at Peter.Banks@cms.hhs.gov if you have any questions about this approval. We appreciate the efforts of you and your staff in responding to the needs of the residents of the State of New Mexico and the health care community. Sincerely, Anne Marie Costello Deputy Director Center for Medicaid & CHIP Services Enclosures Anne M. Costello -S Digitally signed by Anne M. Costello -S Date: 2020.05.13 12:53:21 -04'00'

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES

FORM APPROVED OMB No. 0938-0193

TRANSMITTAL AND NOTICE OF APPROVAL OF

STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES

2. STATE New Mexico

1. TRANSMITTAL NUMBER 2 0 0 O 7

3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID)

TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE & MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES

4. PROPOSED EFFECTIVE DATE March 18, 2020

5. TYPE OF PLAN MATERIAL (Check One) (0 NEw STATE PLAN

(0 AMENDMENT TO BE CONSIDERED AS NEW PLAN

J] AMENDMENT

COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate transmittal for each amendment)

6. FEDERAL STATUTE/REGULATION CITATION 1902(a)(10)(A)(ii)(XXIII), 1902(a)(47)(B)

7. FEDERAL BUDGET IMPACT a. FFY20 $9,920,000 b. FFY21 $0

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT

Section 7 — General Provisions, 7.4. Medicaid Disaster Relief for the COVID-19 National Emergency, Pages 100-108

9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (if Applicable)

10. SUBJECT OF AMENDMENT Medicaid Disaster Relief #3

11. GOVERNOR'S REVIEW (Check One)

(J Governor's OFFICE REPORTED NO COMMENT (0 CoMMENTS OF GOVERNOR'S OFFICE ENCLOSED (1 No REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

[X] OTHER, AS SPECIFIED

‘ =“

13. TYPED NAME Nicole Comeaux

14. TITLE Director, Medical Assistance Division

15. DATE SUBMITTED Apri

7

16. RETURN TO

Nicole Comeaux, J.D., M.P.H., Director Medical Assistance Division

P.O. Box 2348

Santa Fe, NM 87504-2348

FOR REGIONAL OFFICE USE ONLY

17. DATE RECEIVED April 21, 2020

18. DATE APPROVED May 13, 2020

PLAN APPROVED - ONE COPY ATTACHED

19. EFFECTIVE DATE OF APPROVED MATERIAL March 18, 2020

DIDFF+@isby Anne

M. Costello -S

20. SIGNATURE QE REGIONA Costello -S 3S. uira.

21. TYPED NAME Anne Marie Costello

22. TITLE Deputy Director

Center for Medicaid & CHIP Services

23. REMARKS

FORM CMS-179 (07/92)

Instructions on Back

State/Territory: New Mexico TN: 20-0007 Supersedes TN: NEW Approval Date: 5/1ϯ/2020 Effective Date: 3/18/2020 100 This SPA is in addition to Disaster Relief SPAs 20-0004 approved on April 24, 2020 and 20-0005 approved on May 7, 2020. This SPA does not supersede anything approved in the previous SPAs. Section 7 – General Provisions 7.4. Medicaid Disaster Relief for the COVID-19 National Emergency On March 13, 2020, the President of the United States issued a proclamation that the COVID-19 outbreak in the United States constitutes a national emergency by the authorities vested in him by the Constitution and the laws of the United States, including sections 201 and 301 of the National Emergencies Act (50 U.S.C. 1601 et seq.), and consistent with section 1135 of the Social Security Act (Act). On March 13, 2020, pursuant to section 1135(b) of the Act, the Secretary of the United States Department of Health and Human Services invoked his authority to waive or modify certain requirements of titles XVIII, XIX, and XXI of the Act as a result of the consequences COVID-19 pandemic, to the extent necessary, as determined by the Centers for Medicare & Medicaid Services (CMS), to ensure that sufficient health care items and services are available to meet the needs of individuals enrolled in the respective programs and to ensure that health care providers that furnish such items and services in good faith, but are unable to comply with one or more of such requirements as a result of the COVID-19 pandemic, may be reimbursed for such items and services and exempted from sanctions for such noncompliance, absent any determination of fraud or abuse. This authority took effect as of 6PM Eastern Standard Time on March 15, 2020, with a retroactive effective date of March 1, 2020. The emergency period will terminate, and waivers will no longer be available, upon termination of the public health emergency, including any extensions. The State Medicaid agency (agency) seeks to implement the policies and procedures described below, which are different than the policies and procedures otherwise applied under the Medicaid state plan, during the period of the Presidential and Secretarial emergency declarations related to the COVID-19 outbreak (or any renewals thereof), or for any shorter period described below: Describe shorter period here. NOTE: States may not elect a period longer than the Presidential or Secretarial emergency declaration (or any renewal thereof). States may not propose changes on this template that restrict or limit payment, services, or eligibility, or otherwise burden beneficiaries and providers. Request for Waivers under Section 1135 __X___ The agency seeks the following under section 1135(b)(1)(C) and/or section 1135(b)(5) of the Act: a. __X___ SPA submission requirements – the agency requests modification of the requirement to submit the SPA by March 31, 2020, to obtain a SPA effective date during the first calendar quarter of 2020, pursuant to 42 CFR 430.20. b. __X___ Public notice requirements – the agency requests waiver of public notice requirements that would otherwise be applicable to this SPA submission. These requirements may include those specified in 42 CFR 440.386 (Alternative Benefit Plans), 42 CFR 447.57(c) (premiums and cost sharing), and 42 CFR 447.205 (public notice of changes in statewide methods and standards for setting payment rates).

State/Territory: New Mexico TN: 20-0007 Supersedes TN: NEW Approval Date: 5/1ϯ/2020 Effective Date: 3/18/2020 101 This SPA is in addition to Disaster Relief SPAs 20-0004 approved on April 24, 2020 and 20-0005 approved on May 7, 2020. This SPA does not supersede anything approved in the previous SPAs. c. __X___ Tribal consultation requirements – the agency requests modification of tribal consultation timelines specified in [insert name of state] Medicaid state plan, as described below: New Mexico plans to modify the tribal consultation timelines by issuing formal notice to New Mexico’s Indian Nations, Tribes, Pueblos and their health care providers for an opportunity to request a tribal consultation from mid-April through mid-May 2020. Section A – Eligibility 1. __X___ The agency furnishes medical assistance to the following optional groups of individuals described in section 1902(a)(10)(A)(ii) or 1902(a)(10)(c) of the Act. This may include the new optional group described at section 1902(a)(10)(A)(ii)(XXIII) and 1902(ss) of the Act providing coverage for uninsured individuals. COVID-19 testing group at 1902(a)(10)(A)(ii)(XXIII) of the Act 2. _____ The agency furnishes medical assistance to the following populations of individuals described in section 1902(a)(10)(A)(ii)(XX) of the Act and 42 CFR 435.218: a. _____ All individuals who are described in section 1905(a)(10)(A)(ii)(XX) Income standard: _____________ -or-

b. _____ Individuals described in the following categorical populations in section 1905(a) of the Act: Income standard: _____________ 3. _____ The agency applies less restrictive financial methodologies to individuals excepted from financial methodologies based on modified adjusted gross income (MAGI) as follows. Less restrictive income methodologies:

State/Territory: New Mexico TN: 20-0007 Supersedes TN: NEW Approval Date: 5/1ϯ/2020 Effective Date: 3/18/2020 102 This SPA is in addition to Disaster Relief SPAs 20-0004 approved on April 24, 2020 and 20-0005 approved on May 7, 2020. This SPA does not supersede anything approved in the previous SPAs. Less restrictive resource methodologies: 4. _____ The agency considers individuals who are evacuated from the state, who leave the state for medical reasons related to the disaster or public health emergency, or who are otherwise absent from the state due to the disaster or public health emergency and who intend to return to the state, to continue to be residents of the state under 42 CFR 435.403(j)(3). 5. _____ The agency provides Medicaid coverage to the following individuals living in the state, who are non-residents: 6. _____ The agency provides for an extension of the reasonable opportunity period for non- citizens declaring to be in a satisfactory immigration status, if the non-citizen is making a good faith effort to resolve any inconsistences or obtain any necessary documentation, or the agency is unable to complete the verification process within the 90-day reasonable opportunity period due to the disaster or public health emergency. Section B – Enrollment 1. __X__ The agency elects to allow hospitals to make presumptive eligibility determinations for the following additional state plan populations, or for populations in an approved section 1115 demonstration, in accordance with section 1902(a)(47)(B) of the Act and 42 CFR 435.1110, provided that the agency has determined that the hospital is capable of making such determinations. COVID-19 testing group at 1902(a)(10)(A)(ii)(XXIII) of the Act Limitations on allowable presumptive eligibility (PE) periods: One PE period for the duration of the emergency for the COVID-19 testing group. Self-attestation: The agency will accept self-attestation of residency and citizenship, status as a national, and satisfactory immigration status when making a PE determination.

State/Territory: New Mexico TN: 20-0007 Supersedes TN: NEW Approval Date: 5/1ϯ/2020 Effective Date: 3/18/2020 103 This SPA is in addition to Disaster Relief SPAs 20-0004 approved on April 24, 2020 and 20-0005 approved on May 7, 2020. This SPA does not supersede anything approved in the previous SPAs. 2. ____ The agency designates itself as a qualified entity for purposes of making presumptive eligibility determinations described below in accordance with sections 1920, 1920A, 1920B, and 1920C of the Act and 42 CFR Part 435 Subpart L. 3. _____ The agency designates the following entities as qualified entities for purposes of making presumptive eligibility determinations or adds additional populations as described below in accordance with sections 1920, 1920A, 1920B, and 1920C of the Act and 42 CFR Part 435 Subpart L. Indicate if any designated entities are permitted to make presumptive eligibility determinations only for specified populations. 4. _____ The agency adopts a total of _____ months (not to exceed 12 months) continuous eligibility for children under age enter age _____ (not to exceed age 19) regardless of changes in circumstances in accordance with section 1902(e)(12) of the Act and 42 CFR 435.926. 5. _____ The agency conducts redeterminations of eligibility for individuals excepted from MAGI- based financial methodologies under 42 CFR 435.603(j) once every _____ months (not to exceed 12 months) in accordance with 42 CFR 435.916(b). 6. _____ The agency uses the following simplified application(s) to support enrollment in affected areas or for affected individuals (a copy of the simplified application(s) has been submitted to CMS). a. _____ The agency uses a simplified paper application. b. _____ The agency uses a simplified online application. c. _____ The simplified paper or online application is made available for use in call-centers or other telephone applications in affected areas. Section C – Premiums and Cost Sharing 1. _____ The agency suspends deductibles, copayments, coinsurance, and other cost sharing charges as follows: Please describe whether the state suspends all cost sharing or suspends only specified deductibles, copayments, coinsurance, or other cost sharing charges for specified items and services or for specified eligibility groups consistent with 42 CFR 447.52(d) or for specified income levels consistent with 42 CFR 447.52(g). 2. _____ The agency suspends enrollment fees, premiums and similar charges for: a. _____ All beneficiaries b. _____ The following eligibility groups or categorical populations:

State/Territory: New Mexico TN: 20-0007 Supersedes TN: NEW Approval Date: 5/1ϯ/2020 Effective Date: 3/18/2020 104 This SPA is in addition to Disaster Relief SPAs 20-0004 approved on April 24, 2020 and 20-0005 approved on May 7, 2020. This SPA does not supersede anything approved in the previous SPAs. Please list the applicable eligibility groups or populations. 3. _____ The agency allows waiver of payment of the enrollment fee, premiums and similar charges for undue hardship. Please specify the standard(s) and/or criteria that the state will use to determine undue hardship. Section D – Benefits Benefits: 1. _____ The agency adds the following optional benefits in its state plan (include service descriptions, provider qualifications, and limitations on amount, duration or scope of the benefit): 2. _____ The agency makes the following adjustments to benefits currently covered in the state plan: 3. _____ The agency assures that newly added benefits or adjustments to benefits comply with all applicable statutory requirements, including the statewideness requirements found at 1902(a)(1), comparability requirements found at 1902(a)(10)(B), and free choice of provider requirements found at 1902(a)(23). 4. _____ Application to Alternative Benefit Plans (ABP). The state adheres to all ABP provisions in 42 CFR Part 440, Subpart C. This section only applies to states that have an approved ABP(s). a. _____ The agency assures that these newly added and/or adjusted benefits will be made available to individuals receiving services under ABPs. b. _____ Individuals receiving services under ABPs will not receive these newly added and/or adjusted benefits, or will only receive the following subset:

State/Territory: New Mexico TN: 20-0007 Supersedes TN: NEW Approval Date: 5/1ϯ/2020 Effective Date: 3/18/2020 105 This SPA is in addition to Disaster Relief SPAs 20-0004 approved on April 24, 2020 and 20-0005 approved on May 7, 2020. This SPA does not supersede anything approved in the previous SPAs. Please describe. Telehealth: 5. _____ The agency utilizes telehealth in the following manner, which may be different than outlined in the state’s approved state plan: Please describe. Drug Benefit: 6. _____ The agency makes the following adjustments to the day supply or quantity limit for covered outpatient drugs. The agency should only make this modification if its current state plan pages have limits on the amount of medication dispensed. Please describe the change in days or quantities that are allowed for the emergency period and for which drugs. 7. _____ Prior authorization for medications is expanded by automatic renewal without clinical review, or time/quantity extensions. 8. _____ The agency makes the following payment adjustment to the professional dispensing fee when additional costs are incurred by the providers for delivery. States will need to supply documentation to justify the additional fees. Please describe the manner in which professional dispensing fees are adjusted. 9. _____ The agency makes exceptions to their published Preferred Drug List if drug shortages occur. This would include options for covering a brand name drug product that is a multi-source drug if a generic drug option is not available. Section E – Payments Optional benefits described in Section D: 1. _____ Newly added benefits described in Section D are paid using the following methodology:

State/Territory: New Mexico TN: 20-0007 Supersedes TN: NEW Approval Date: 5/1ϯ/2020 Effective Date: 3/18/2020 106 This SPA is in addition to Disaster Relief SPAs 20-0004 approved on April 24, 2020 and 20-0005 approved on May 7, 2020. This SPA does not supersede anything approved in the previous SPAs. a. _____ Published fee schedules – Effective date (enter date of change): _____________ Location (list published location): _____________ b. _____ Other: Describe methodology here. Increases to state plan payment methodologies: 2. _____ The agency increases payment rates for the following services: a. _____ Payment increases are targeted based on the following criteria: b. Payments are increased through: i. _____ A supplemental payment or add-on within applicable upper payment limits: ii. _____ An increase to rates as described below. Rates are increased: _____ Uniformly by the following percentage: _____ Through a modification to published fee schedules – Effective date (enter date of change): _____________ Location (list published location): _____________ _____ Up to the Medicare payments for equivalent services.

State/Territory: New Mexico TN: 20-0007 Supersedes TN: NEW Approval Date: 5/1ϯ/2020 Effective Date: 3/18/2020 107 This SPA is in addition to Disaster Relief SPAs 20-0004 approved on April 24, 2020 and 20-0005 approved on May 7, 2020. This SPA does not supersede anything approved in the previous SPAs. _____ By the following factors: Please describe. Payment for services delivered via telehealth: 3. _____ For the duration of the emergency, the state authorizes payments for telehealth services that: a. _____ Are not otherwise paid under the Medicaid state plan; b. _____ Differ from payments for the same services when provided face to face; c. _____ Differ from current state plan provisions governing reimbursement for telehealth; Describe telehealth payment variation. d. _____ Include payment for ancillary costs associated with the delivery of covered services via telehealth, (if applicable), as follows: i. _____ Ancillary cost associated with the originating site for telehealth is incorporated into fee-for-service rates. ii. _____ Ancillary cost associated with the originating site for telehealth is separately reimbursed as an administrative cost by the state when a Medicaid service is delivered. Other: 4. _____ Other payment changes: Section F – Post-Eligibility Treatment of Income 1. _____ The state elects to modify the basic personal needs allowance for institutionalized individuals. The basic personal needs allowance is equal to one of the following amounts: a. _____ The individual’s total income b. _____ 300 percent of the SSI federal benefit rate c. _____ Other reasonable amount: _________________

State/Territory: New Mexico TN: 20-0007 Supersedes TN: NEW Approval Date: 5/1ϯ/2020 Effective Date: 3/18/2020 108 This SPA is in addition to Disaster Relief SPAs 20-0004 approved on April 24, 2020 and 20-0005 approved on May 7, 2020. This SPA does not supersede anything approved in the previous SPAs. 2. _____ The state elects a new variance to the basic personal needs allowance. (Note: Election of this option is not dependent on a state electing the option described the option in F.1. above.) The state protects amounts exceeding the basic personal needs allowance for individuals who have the following greater personal needs: Please describe the group or groups of individuals with greater needs and the amount(s) protected for each group or groups. Section G – Other Policies and Procedures Differing from Approved Medicaid State Plan /Additional Information PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148 (Expires 03/31/2021). The time required to complete this information collection is estimated to average 1 to 2 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. Your response is required to receive a waiver under Section 1135 of the Social Security Act. All responses are public and will be made available on the CMS web site. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. ***CMS Disclosure*** Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact the Centers for Medicaid & CHIP Services at 410-786-3870.

Table of Contents State/Territory Name: New Mexico State Plan Amendment (SPA) #: 19-0012 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Center for Medicaid & CHIP Services 233 North Michigan Ave., Suite 600 Chicago, Illinois 60601 Financial Management Group Ms. Nicole Comeaux Director Medical Assistance Division P.O. Box 2348 Santa Fe, NM 87504-2348 RE: TN 19-0012 Dear Ms. Comeaux: We have reviewed the proposed New Mexico Name State Plan Amendment (SPA) to Attachment 4.19-B 19-0012, which was submitted to the Centers for Medicare & Medicaid Services (CMS) on September 30, 2019. This plan amendment increases the payment rate for Evaluation and Management (E&M) office visits. Based upon the information provided by the State, we have approved the amendment with an effective date of July 1, 2019. We are enclosing the approved CMS-179 and a copy of the new state plan page. If you have any additional questions or need further assistance, please contact Tom Couch at 208-861-9838 or Thomas.Couch@cms.hhs.gov . Sincerely, Todd McMillion Acting Director Division of Reimbursement Review Enclosures Cc: Jennifer Vigil April 3, 2020

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES

TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES

FORM APPROVED OMB No. 0996-0193 1. TRANSMITTAL NUMBER 2. STATE 19 _ 0 12 New Mexico

3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID)

TO; REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE & MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES

4, PROPOSED EFFECTIVE DATE July 1, 2019

5. TYPE OF PLAN MATERIAL (Check One) (1 NEw STATE PLAN 1 AMENDMENT TO BE CONS

|IDERED AS NEW PLAN I) AMENOMENT

COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate transmittal for each amendment)

6. FEDERAL STATUTE/REGULATION CITATION

7. FEDERAL BUDGET IMPACT

42 CFR 447 Subpart F a FFY_19 $978,125 . b. FFY_.20 ——.. $ 3.912500

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (if Applicable)

Attachment 4.19-B, page 2

Attachment 4.19-B, page 2 (NM SPA 18-0004)

10. SUBJECT OF AMENDMENT Fee Schedule Pricing Changes

41. GOVERNOR'S REVIEW (Check One)

CJ GOVERNOR'S OFFICE REPORTED NO COMMENT C1 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED (1 NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

[XJ OTHER, AS SPECIFIED Authority delegated to the Medicaid Director

> 13. TYPED

Nicole Comeaux 14. TITLE

16. RETURN TO

Nicole Comeau, J.D., M.P.H., Director Medical Assistance Division

P.O. Box 2348

Santa Fe, NM 87504-2348

Director, Medical Assistance Division 15, DATE SUBMITTED September 30, 2019 FOR REGIONAL O} USE ONLY 17. DATE RECEIVED 18. DATE APPROVED 4/03/2020

PLAN APPROVED - ONE COPY ATTACHED

19. EFFECTIVE DATE OF APPROVED MATERIAL

20. SIGNATURE " ee ™ (~

7/1/2019 21. TYPED NAME 22. TITLE .

Todd McMillion Acting Director, Division of Reimbursement Review 23. REMARKS

FORM CMS-179 (07/92)

Instructions on Back

Supersedes TN No. ___NM 18-0004 __ Effective Date _

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE OF NEW MEXICO AND STANDARDS FOR ESTABLISHING PAYMENT RATES --OTHER TYPES OF CARE

Attachment 4.19-B Page 2 The average commercial rates are determined by:

i, Calculating a commercial payment to charge ratio for all services paid to the eligible providers by commercial insurers using the providers’ claims- specific data from the most currently available fiscal year period.

ii. Multiplying the Medicaid charges by the commercial payment to charge ratio to establish the estimated commercial payments to be made for these services; and

iii. Subtracting the interim Medicaid payments already made for these services to establish the supplemental payment amount.

a. Providers eligible under Part (a) of this section will be paid on an interim claims-specific basis through the Department’s claims processing system using the methodology outlined elsewhere in this state plan. The supplemental payment, which represents final payment for services, will be made on a quarterly basis subject to available claims data.

A. Medical and Dental Services

Medical and dental services are reimbursed on a fee schedule basis and include physicians, dentists, radiologists, and radiological facilities, licensed treatment and diagnostic centers and family planning clinics, podiatrists, optometrists, certified nurse midwives and certified nurse practitioners working under the direction of a physician. Transitional care, chronic care management, and personal care services are also included with this fee schedule.

Preventive services provided to alternative benefit plan recipients not otherwise covered under standard Medicaid benefits are also reimbursed using this methodology including annual preventive care physicals, expanded nutritional and dietary counseling, and expanded skin cancer and tobacco use counseling, Electroconvulsive therapy services provided to alternative benefit plan recipients not otherwise covered under standard Medicaid benefits are paid at the Medicare fee schedule rate.

Services rendered under the supervision of one of the above providers are paid at the fee schedule rate for the supervising provider when the service is performed by one of the following: a dietician; clinical pharmacist; physician assistant; dental hygienist; nurse; certified nurse practitioner; or, clinical nurse specialist.

Except as otherwise noted in the state plan both governmental and private providers are paid the same. The agency’s medical fee schedule rates were updated July 1, 2019 for services provided on or after that date. All rates are published at http://www.hsd.state.nm.us/providers/fee- schedules.aspx Notice of changes to rates will be made as required by 42 CFR 447.205.

TNNo, 19-0012 Approval Date _ 04/03/20

07/01/19

Table of Contents State/Territory Name: New Mexico State Plan Amendment (SPA) #: 20-0019 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, MD 21244-1850 Financial Management Group Ms. Nicole Comeaux, J.D., M.P.H., Director Medical Assistance Division P.O. Box 2348 Santa Fe, NM 87504-2348 RE: New Mexico State Plan Amendment (SPA) 20-0019 Dear Ms. Comeaux: We have reviewed the proposed amendment to Attachment 4.19-A of your Medicaid state plan submitted under transmittal number (TN) 20-0019 effective for services on or after July 1, 2020. The SPA increases the number of FTEs for the states GME program which will provide access to care in more rural areas of the state. Both public and private hospitals will be allowed to participate. We conducted our review of your submittal according to the statutory requirements at sections 1902(a)(2), 1902(a)(13), 1902(a)(30), 1903(a), and 1923 of the Social Security Act and the regulations at 42 CFR 447 Subpart C. We hereby inform you that Medicaid State plan amendment 20-0019 is approved effective July 1, 2020. We are enclosing the CMS-179 and the amended plan pages. If you have any questions, please call Tom Caughey at (517) 487-8598. Sincerely, Rory Howe Acting Director Enclosure For May 25, 2021

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES

FORM APPROVED OMB No. 0938-0193

TRANSMITTAL AND NOTICE OF APPROVAL OF

STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES

7. TRANSMITTAL NUMBER 2. STATE 20-019 New Mexico 3, PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID)

TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE & MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES

4. PROPOSED EFFECTIVE DATE July 1, 2020

5. TYPE OF PLAN MATERIAL (Check One) (1 NEW STATE PLAN

(J AMENDMENT TO BE CONSIDERED AS NEW PLAN

AMENDMENT

COMPLETE BLOCKS 6 THRU 10 IF THIS IS ANAMENDMENT (Separate transmittal for each amendment)

6. FEDERAL STATUTE/REGULATION CITATION

7. FEDERAI DGET IMPACT

42 CFR 413.75 a. FFY. 1,272,089 b. FFY_21 $ 5,686,036 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (if Applicable)

Attachment 4.19-A pgs. 21, 21A, 21B, 21C

Same TN 16-008

10. SUBJECT OF AMENDMENT

Graduate Medical Education (GME) Program

11. GOVERNOR'S REVIEW (Check One)

CJ GoveRNor’s OFFICE REPORTED NO COMMENT (J COMMENTS OF GOVERNOR'S OFFICE ENCLOSED (1 NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

OTHER, AS SPECIFIED

1 AGENCY OFFICIAL

13. TYPED NAME Nicole Comeaux

14. TITLE ; ; . Director, Medical Assistance Division

15. DATE SUBMITTED September 30, 2020

16. RETURN TO

Nicole Comeaux, J.D., M.P.H., Director Medical Assistance Division

P.O. Box 2348

Santa Fe, NM 87504-2348

FOR REGIONAL OFFICE USE ONLY

17. DATE RECEIVED September 30, 2020

18. DATE APPROVED 5/25/21

PLAN APPROVED - ONE COPY ATTACHED

19. EFFECTIVE DATE OF APPROVED MATERIAL July 1, 2020

20. SIGNATURE OF REGIONAL OFFICIAL For

21. TYPED NAME

Rory Howe

22. TITLE

Acting Director, Financial Management Group

23. REMARKS

FORM CMS-179 (07/92)

Instructions on Back

TN No. 20-0019 Supersedes TN. No. 16-008 Approval Date _____________ Effective Date July 1, 2020_ ATTACHMENT 4.19-A Page 21 8. Indirect Medical Education (IME) Adjustment Effective July 1, 2020, each acute care hospital that qualifies as a teaching hospital will receive an indirect medical education (IME) payment adjustment which covers the increase operating or patient care costs that are associated with approved intern and resident programs. a. In order to qualify as a teaching hospital and be deemed eligible for an IME adjustment, the hospital must: 1) Be licensed by the State of New Mexico; and 2) Be reimbursed on a DRG basis under the plan; and 3) Have 125 or more full time equivalent (FTE) residents enrolled in approved teaching programs or operate one or more nationally-accredited residency programs. b. Determination of a hospital’s eligibility for an IME adjustment will be done annually by the state, as of the first day of the provider’s fiscal year. If a hospital meets the qualifications for an IME adjustment after the start of its fiscal year, it will be deemed eligible for the IME adjustment beginning on the first day of the quarter after the date the qualifications were met. c. The IME payment amount is determined by multiplying DRG operating payments, which are DRG payments and outlier payments, by the IME adjustment factor computed by the following formula: 1.89*((1+R)'405-1) Where R equals the number of approved full-time equivalent (FTE) residents divided by the number of available beds (excluding nursery and neonatal bassinets). FTE residents are counted in accordance with 42 CFR 412.105(f) except that the limits on the total number of FTE residents in 412.105(f)(l)(iv) shall not apply. For purposes of this paragraph, DRG operating payments include the estimated average per discharge amount that would otherwise have been paid for Medicaid managed care enrollees if those persons had not been enrolled in managed care. d. Quarterly IME payments will be made to qualifying hospitals at the end of each quarter. Prior to the end of each quarter, the provider will submit to the Department’s audit agent the information necessary to make the calculation, i.e. number of beds, number of estimated residents for the quarter, and the Medicaid DRG amount. After review and adjustment, if necessary, the audit agent will notify the Department of the amount due to/from the provider for the applicable quarter. Final settlement of the IME adjustment amount will be made through the cost report; that is, the number of beds, residents, and DRG amounts used in the quarterly calculation will be adjusted to the actual numbers shown on the provider’s cost report for those quarters. 5/25/21

TN No. 20-0019 Supersedes TN. No. 16-008 ATTACHMENT 4.19-A Page 21A 9. Payment for Direct Graduate Medical Education (GME) The purpose of this Direct Graduate Medical Education plan is to incentivize Primary Care and General Psychiatry to address the state’s primary care shortage. Payments for Direct Graduate Medical Education in Accreditation Council of Graduate Medical Education (ACGME)-accredited programs will be directed to four (4) categories of providers including the State Academic Medical Center, Hospitals, Federally Qualified Health Centers (FQHCs) and Rural Health Centers (RHCs) that support the cost of resident training. a. Eligibility: To be claimed in the calculation for Medicaid GME reimbursement, a resident must be participating in an ACGME approved medical residency, as defined by Medicare in 42 CFR 413.75(b). With regard to categorizing residents, as described in paragraph 2 of this section, the manner of counting and weighting resident FTEs will be the same as is used by Medicare in 42 CFR 413.79 except that the number of FTE residents shall not be subject to the FTE resident cap described in 413.79(b)(2). 1) For a hospital to qualify for Medicaid GME payments, a hospital must be licensed by the state of New Mexico, be currently enrolled as a Medicaid provider, must have achieved a Medicaid inpatient utilization rate of 5 percent or greater during its most recently concluded fiscal year, and participate in the costs of a nationally accredited residency program either directly or under contract with an ACGME- accredited program. 2) For FQHCs and RHCs to qualify for Medicaid GME payments, the FQHC/RHC must be licensed by the state of New Mexico, be currently enrolled as a Medicaid provider, must have achieved a Medicaid utilization rate of 35 percent or greater of total payor mix during its most recently completed state fiscal year, and participate in the costs of a nationally accredited residency program either directly or under contract with an ACGME-accredited program. b. Approved resident FTEs are categorized as follows for GME payment: 1) Primary Care (meaning Family Medicine, General internal Medicine, General Pediatrics, and General Psychiatry) resident. 2) Other approved resident. Any resident specialty not meeting the criteria in Items b.1, above. c. Payments: 1) Payments will be made quarterly to qualifying entities, at a rate determined by the number of full-time-equivalent (FTE) residents in Primary Care, General Psychiatry and Other specialty training as defined below, who worked at the respective facility during the quarter for which GME payments are requested and Approval Date ____________ Effective Date July 1, 2020_ 5/25/21

TN No. 20-0019 Supersedes TN. No. 16-008 ATTACHMENT 4.19-A Page 21B subject to the total resident FTE described below. 2) Existing GME Positions i. GME payment amount per current resident FTE; the annual Medicaid payment amount per resident FTE in state fiscal year 2021 for 510 FTE residents counted as of the end of state fiscal year 2019 is as follows: • Primary Care and General Psychiatry resident $50,000 • Other resident $50,000 ii. The per resident amounts will be inflated for state fiscal years beginning on or after July 1, 2021 using the annual inflation update factor described in paragraph e.1. 3) Expansion GME payment amount per resident FTE i. Expansion positions are new ACGME-approved positions that begin training on or after July 1, 2020; ii. The annual Medicaid payment amount per resident FTE beginning with state fiscal year 2021 is as follows: • Primary Care and General Psychiatry resident $100,000 • Other resident $50,000 iii. “Other” resident FTE will be equal to or less than the number of eligible new/expanded Primary Care and Psychiatric Residents in any prior fiscal year. iv. The total number of expansion residents of hospitals, FQHCs and RHCs will be limited to the number of Primary Care and Psychiatric resident FTEs approved in the annually updated state GME Expansion Strategic plan and shall not exceed 101. • SFY 2021 - 2 FTE • SFY 2022 - 21 FTE • SFY 2023 - 31 FTE • SFY 2024 - 32 FTE • SFY 2025 - 15 FTE • Each year after shall be limited by 10 FTE per year or as determined by the Secretary of HSD v. The annual Medicaid payment amount per resident FTE as set forth in paragraph c.3(ii) above is contingent upon the certification of each participating GME program director that increased GME funding will go directly to the GME program. d. State Academic Medical Center: 1) The State Academic Medical Center shall provide the state share of the general fund needed to support its number of GME FTEs through an intergovernmental transfer (IGT). FTEs for the State Academic Medical Center shall only be limited by the IGT the State Academic Medical Center makes available. Approval Date ___________ Effective Date July 1, 2020_ 5/25/21

TN No. 20-0019 Supersedes TN. No. 16-008 ATTACHMENT 4.19-A Page 21C 2) The State Academic Hospital shall receive the annual Medicaid payment amount in paragraph c.3(ii) per resident FTE in state fiscal year 2021 and each subsequent year. The per resident amount for residents counted as of the end of state fiscal year 2019 is described in paragraph c.2(i). e. Annual Inflation Update Factor: 1) The per resident amounts specified in paragraph c.1 will be inflated for state fiscal years beginning on or after July 1, 2021 using the annual inflation update factor directed by CMS. 2) The Department at its discretion and budget availability will update the per resident GME amounts for inflation using the global inflation factor as directed by CMS. f. Reporting and payment schedule: 1) GME payment eligible entities will count the number of residents working according to the specification in this part during each fiscal year (July 1 through June 30) and will report this information to the Department by December 31. Counts will represent the weighted average number of residents who were employed by the eligible entity during the specified 12-month period. Eligible entities may also add to this count any FTEs associated with newly approved residency programs that will be implemented on or before the start of the prospective GME payment year, to the extent that these FTEs are not already reflected in the weighted average counts of the preceding year. To illustrate, resident FTE amounts would be counted from 07/01/18 - 06/30/19 for the payment year 07/01/20 - 06/30/21. The Department may require eligible entities to provide documentation necessary to support the summary counts provided. 2) The Department will establish the amount payable to each eligible entity for the prospective payment period that will begin each July 1. 3) The annual amount payable to each hospital is divided into four equal payments. These payments will be made by the Department on or about the start of each prospective payment quarter. 4) Should a facility not report timely with the accurate resident information as required in paragraph 1, above, it will still be entitled to receive payment for any quarter yet remaining in the prospective payment year, after acceptable information has been submitted. 5) FQHC/RHC will provide a copy of the most recently submitted HRSA, Bureau of Primary Health Care, Uniform Data System (UDS) for the most recent state fiscal year (July 1 through June 30) and will report this information to the Department by December 31. Approval Date ____________ Effective Date July 1, 2020_ 5/25/21

Table of Contents State/Territory Name: New Mexico State Plan Amendment (SPA) #: 21-0005 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

4/20/2021 Medicaid State Plan Print View https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwXRmZtl2LIcjf-vAMo-BtAWpTgO6QfW7sfytGJjTskhdvPqCEg8Oq3… 1/38 Records / Submission Packages - View All NM - Submission Package - NM2019MS0009O - (NM-21-0005) - Health Homes CMS-10434 OMB 0938-1188 Package Information Package ID NM2019MS0009O Program Name MIGRATED_HH.CareLink NM SPA ID NM-21-0005 Version Number 1 Submitted By Donna Lopez Package Disposition Priority Code P2 Submission Type OŰcial State NM Region Dallas, TX Package Status Approved Submission Date 2/15/2021 Approval Date 4/15/2021 12:03 PM EDT Summary Reviewable Units Versions Correspondence Log Compare Doc Change Report Analyst Notes Review Assessment Report Approval Letter Transaction Logs News Related Actions

4/20/2021 Medicaid State Plan Print View https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwXRmZtl2LIcjf-vAMo-BtAWpTgO6QfW7sfytGJjTskhdvPqCEg8Oq3… 2/38 DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Medicaid and CHIP Operations Group (MCOG) 601 E. 12th St. Room 355 Kansas City, MO 64105 Center for Medicaid & CHIP Services April 15, 2021 Nicole Comeaux Director NM Human Services Department, Medical Assistance Division PO Box 2348 2025 S. Pacheco Street Santa Fe, NM 87504 Re: Approval of State Plan Amendment NM-21-0005 Dear Ms. Comeaux, On February 15, 2021, the Centers for Medicare and Medicaid Services (CMS) received New Mexico State Plan Amendment (SPA) NM-21-0005 to add substance use disorder (SUD) as an additional eligibility criterion for Health Home services. We approve New Mexico State Plan Amendment (SPA) NM-21-0005 with an eſective date of January 01, 2021. For payments made to Health Homes providers for Health Homes participants who newly qualify based on the Health Homes program’s additional condition coverage under this amendment, a medical assistance percentage (FMAP) rate of 90% applies to such payments for 8 quarters from the eſective date of this SPA. The FMAP rate for payments made to health homes providers will return to the state's published FMAP rate at the end of the enhanced match period.

As a reminder, please use the designated category of service Line 43 on the CMS-64 form to report health homes services expenditures for enrollees with chronic conditions. If you have any questions regarding this amendment, please contact Peter Banks at peter.banks@cms.hhs.gov. Sincerely, James G. Scott Director, Division of Program Operations Center for Medicaid & CHIP Services Submission - Summary MEDICAID | Medicaid State Plan | Health Homes | NM2019MS0009O | NM-21-0005 | MIGRATED_HH.CareLink NM Package Header Package ID NM2019MS0009O Submission Type OŰcial Approval Date 4/15/2021 Superseded SPA ID N/A SPA ID NM-21-0005 Initial Submission Date 2/15/2021 Eſective Date N/A State Information State/Territory Name: New Mexico Medicaid Agency Name: NM Human Services Department, Medical Assistance Division Submission Component State Plan Amendment Medicaid CHIP

4/20/2021 Medicaid State Plan Print View https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwXRmZtl2LIcjf-vAMo-BtAWpTgO6QfW7sfytGJjTskhdvPqCEg8Oq3… 3/38 Submission - Summary MEDICAID | Medicaid State Plan | Health Homes | NM2019MS0009O | NM-21-0005 | MIGRATED_HH.CareLink NM Package Header Package ID NM2019MS0009O Submission Type OŰcial Approval Date 4/15/2021 Superseded SPA ID N/A SPA ID NM-21-0005 Initial Submission Date 2/15/2021 Eſective Date N/A SPA ID and Eſective Date SPA ID NM-21-0005 Reviewable Unit Proposed Eſective Date Superseded SPA ID Health Homes Intro 1/1/2021 18-002 Health Homes Population and Enrollment Criteria 1/1/2021 18-002 Health Homes Providers 1/1/2021 18-002 Health Homes Payment Methodologies 1/1/2021 18-002 Health Homes Services 1/1/2021 18-002 Health Homes Monitoring, Quality Measurement and Evaluation 1/1/2021 18-002

4/20/2021 Medicaid State Plan Print View https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwXRmZtl2LIcjf-vAMo-BtAWpTgO6QfW7sfytGJjTskhdvPqCEg8Oq3… 4/38 Submission - Summary MEDICAID | Medicaid State Plan | Health Homes | NM2019MS0009O | NM-21-0005 | MIGRATED_HH.CareLink NM Package Header Package ID NM2019MS0009O Submission Type OŰcial Approval Date 4/15/2021 Superseded SPA ID N/A SPA ID NM-21-0005 Initial Submission Date 2/15/2021 Eſective Date N/A Executive Summary Summary Description Including Goals and Objectives In April 2016 New Mexico Human Services Department (HSD), with CMS approval, initiated the CareLink New Mexico Health Home Program (CLNM HH) to provide coordinated care in two rural New Mexico counties. In April 2018, CMS approved the expansion of Health Home services in eight additional counties, including rural and urban counties and a Native American Pueblo (SPA ID NM-18-0002, approved by CMS on 7/3/2018). Health Homes (HH) are designed to serve individuals with chronic conditions in the categories of serious mental illness for adults (SMI) and severe emotional disturbance (SED) for children and adolescents. The expansion included a high-ţdelity wraparound model with two providers for New Mexico’s most vulnerable youth. The HH delivery model provides for enhanced care coordination and integration of primary, acute, behavioral health, long-term care services and social supports. It also includes comprehensive care management, health promotion, disease management, risk prevention, comprehensive transitional care, peer and family supports, and referrals for community and social services and supports.

HSD would like to add substance use disorder (SUD) as an additional eligibility criterion for HH services. This addition is in keeping with New Mexico’s Centennial Care 2.0 1115 Medicaid Demonstration extension application, approved by CMS in December 2018. That demonstration project (11W-00285/6) included the addition of SUD services to allow the state to better address opioid use disorder and other SUD.

As noted in the SUD Implementation Plan proposal for the demonstration waiver, New Mexico has made progress in slowing overdose trends, however New Mexico continues to rank ţrst in the nation for alcohol-related deaths, and third in suicide. Adding SUD eligibility criteria to Health Homes aligns with existing goals of HH and support the State’s eſorts to: 1. Increase rates of identiţcation, initiation and engagement in treatment for Opioid Use Disorder (OUD) and other SUD; 2. Increase adherence to retention in treatment for OUD and other SUD; 3. Reduce overdose deaths, particularly those due to opioids; 4. Reduce utilization of emergency departments and inpatient hospital settings for OUD and other SUD treatment where the utilization is preventable or medically inappropriate through improved access to other continuum of care services; 5. Fewer readmissions to the same or higher level of care where readmission is preventable or medically inappropriate for OUD and other SUD; 6. Improved care coordination and transitions between levels of care. 7. Increase provision of medically appropriate interventions. Levels of care for the continuum of services are based on the American Society of Addiction Medicine (ASAM) recommendations. Federal Budget Impact and Statute/Regulation Citation Federal Budget Impact Federal Fiscal Year Amount First 2021 $1483369 Second 2022 $1978062 Federal Statute / Regulation Citation Section 2703 (P.L. 111-148, ACA) Supporting documentation of budget impact is uploaded (optional). Name Date Created No items available

4/20/2021 Medicaid State Plan Print View https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwXRmZtl2LIcjf-vAMo-BtAWpTgO6QfW7sfytGJjTskhdvPqCEg8Oq3… 5/38 Submission - Summary MEDICAID | Medicaid State Plan | Health Homes | NM2019MS0009O | NM-21-0005 | MIGRATED_HH.CareLink NM Package Header Package ID NM2019MS0009O Submission Type OŰcial Approval Date 4/15/2021 Superseded SPA ID N/A SPA ID NM-21-0005 Initial Submission Date 2/15/2021 Eſective Date N/A Governor's OŰce Review No comment Comments received No response within 45 days Other

4/20/2021 Medicaid State Plan Print View https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwXRmZtl2LIcjf-vAMo-BtAWpTgO6QfW7sfytGJjTskhdvPqCEg8Oq3… 6/38 Submission - Public Notice/Process MEDICAID | Medicaid State Plan | Health Homes | NM2019MS0009O | NM-21-0005 | MIGRATED_HH.CareLink NM Package Header Package ID NM2019MS0009O Submission Type OŰcial Approval Date 4/15/2021 Superseded SPA ID N/A SPA ID NM-21-0005 Initial Submission Date 2/15/2021 Eſective Date N/A Name of Health Homes Program MIGRATED_HH.CareLink NM Upload copies of public notices and other documents used Name Date Created 20-0001 Health Homes SUD aŰdavit Alb Journal 12/3/2020 4:42 PM EST 20-0001 Health Homes SUD aŰdavit LCSN 12/3/2020 4:42 PM EST Public notice was provided due to proposed changes in methods and standards for setting payment rates for services, pursuant to 42 CFR 447.205.

4/20/2021 Medicaid State Plan Print View https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwXRmZtl2LIcjf-vAMo-BtAWpTgO6QfW7sfytGJjTskhdvPqCEg8Oq3… 7/38 Submission - Tribal Input MEDICAID | Medicaid State Plan | Health Homes | NM2019MS0009O | NM-21-0005 | MIGRATED_HH.CareLink NM Package Header Package ID NM2019MS0009O Submission Type OŰcial Approval Date 4/15/2021 Superseded SPA ID N/A SPA ID NM-21-0005 Initial Submission Date 2/15/2021 Eſective Date N/A Name of Health Homes Program: MIGRATED_HH.CareLink NM One or more Indian Health Programs or Urban Indian Organizations furnish health care services in this state This state plan amendment is likely to have a direct eſect on Indians, Indian Health Programs or Urban Indian Organizations, as described in the state consultation plan. Complete the following information regarding any solicitation of advice and/or tribal consultation conducted with respect to this submission: Solicitation of advice and/or Tribal consultation was conducted in the following manner: Date of solicitation/consultation: Method of solicitation/consultation: 4/14/2020 Website posting and email notiţcation Date of solicitation/consultation: Method of solicitation/consultation: 4/14/2020 Website posting and email notiţcation States are not required to consult with Indian tribal governments, but if such consultation was conducted voluntarily, provide information about such consultation below: Date of consultation: Method of consultation: 4/14/2020 Website posting and email notiţcation The state must upload copies of documents that support the solicitation of advice in accordance with statutory requirements, including any notices sent to Indian Health Programs and/or Urban Indian Organizations, as well as attendee lists if face-to-face meetings were held. Also upload documents with comments received from Indian Health Programs or Urban Indian Organizations and the state's responses to any issues raised. Alternatively indicate the key issues and summarize any comments received below and describe how the state incorporated them into the design of its program. Name Date Created 20-0001 Health Homes SUD TN 20-08 12/3/2020 4:57 PM EST Indicate the key issues raised (optional) Yes No Yes No The state has solicited advice from Indian Health Programs and/or Urban Indian Organizations, as required by section 1902(a)(73) of the Social Security Act, and in accordance with the state consultation plan, prior to submission of this SPA. All Indian Health Programs All Urban Indian Organizations All Indian Tribes Access Quality Cost

4/20/2021 Medicaid State Plan Print View https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwXRmZtl2LIcjf-vAMo-BtAWpTgO6QfW7sfytGJjTskhdvPqCEg8Oq3… 8/38 Payment methodology Eligibility Beneţts Service delivery Other issue

4/20/2021 Medicaid State Plan Print View https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwXRmZtl2LIcjf-vAMo-BtAWpTgO6QfW7sfytGJjTskhdvPqCEg8Oq3… 9/38 Submission - Other Comment MEDICAID | Medicaid State Plan | Health Homes | NM2019MS0009O | NM-21-0005 | MIGRATED_HH.CareLink NM Package Header Package ID NM2019MS0009O Submission Type OŰcial Approval Date 4/15/2021 Superseded SPA ID N/A SPA ID NM-21-0005 Initial Submission Date 2/15/2021 Eſective Date N/A SAMHSA Consultation Name of Health Homes Program MIGRATED_HH.CareLink NM Date of consultation 2/11/2021 The State provides assurance that it has consulted and coordinated with the Substance Abuse and Mental Health Services Administration (SAMHSA) in addressing issues regarding the prevention and treatment of mental illness and substance abuse among eligible individuals with chronic conditions.

4/20/2021 Medicaid State Plan Print View https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwXRmZtl2LIcjf-vAMo-BtAWpTgO6QfW7sfytGJjTskhdvPqCEg8Oq… 10/38 Health Homes Intro MEDICAID | Medicaid State Plan | Health Homes | NM2019MS0009O | NM-21-0005 | MIGRATED_HH.CareLink NM Package Header Package ID NM2019MS0009O Submission Type OŰcial Approval Date 4/15/2021 Superseded SPA ID 18-002 User-Entered SPA ID NM-21-0005 Initial Submission Date 2/15/2021 Eſective Date 1/1/2021 Program Authority 1945 of the Social Security Act The state elects to implement the Health Homes state plan option under Section 1945 of the Social Security Act. Name of Health Homes Program MIGRATED_HH.CareLink NM Executive Summary Provide an executive summary of this Health Homes program including the goals and objectives of the program, the population, providers, services and service delivery model used In April 2016 New Mexico Human Services Department (HSD), with CMS approval, initiated the CareLink New Mexico Health Home Program (CLNM HH) to provide coordinated care in two rural New Mexico counties. In April 2018, CMS approved the expansion of Health Home services in eight additional counties, including rural and urban counties and a Native American Pueblo (SPA ID NM-18-0002, approved by CMS on 7/3/2018). Health Homes (HH) are designed to serve individuals with chronic conditions in the categories of serious mental illness for adults (SMI) and severe emotional disturbance (SED) for children and adolescents. The expansion included a high-ţdelity wraparound model with two providers for New Mexico’s most vulnerable youth. The Health Home delivery model provides for enhanced care coordination and integration of primary, acute, behavioral health, long-term care services and social supports. It also includes comprehensive care management, health promotion, disease management, risk prevention, comprehensive transitional care, peer and family supports, and referrals for community and social services and supports.

HSD would like to add substance use disorder (SUD) as an additional eligibility criterion for HH services. This addition is in keeping with New Mexico’s Centennial Care 2.0 1115 Medicaid Demonstration extension application, approved by CMS in December 2018. That demonstration project (11W-00285/6) included the addition of SUD services to allow the state to better address opioid use disorder and other SUD. As noted in the SUD Implementation Plan proposal for the demonstration waiver, New Mexico has made progress in slowing overdose trends, however New Mexico continues to rank ţrst in the nation for alcohol-related deaths, and third in suicide. Adding SUD eligibility criteria to Health Homes aligns with existing goals of HH and support the State’s eſorts to: 1. Increase rates of identiţcation, initiation and engagement in treatment for OUD and other SUD; 2. Increase adherence to retention in treatment for OUD and other SUD; 3. Reduce overdose deaths, particularly those due to opioids; 4. Reduce utilization of emergency departments and inpatient hospital settings for OUD and other SUD treatment where the utilization is preventable or medically inappropriate through improved access to other continuum of care services; 5. Fewer readmissions to the same or higher level of care where readmission is preventable or medically inappropriate for OUD and other SUD; 6. Improved care coordination and transitions between levels of care. 7. Increase provision of medically appropriate interventions. Levels of care for the continuum of services are based on the American Society of Addiction Medicine (ASAM) recommendations. General Assurances The state provides assurance that eligible individuals will be given a free choice of Health Homes providers. The states provides assurance that it will not prevent individuals who are dually eligible for Medicare and Medicaid from receiving Health Homes services. The state provides assurance that hospitals participating under the state plan or a waiver of such plan will be instructed to establish procedures for referring eligible individuals with chronic conditions who seek or need treatment in a hospital emergency department to designated Health Homes providers. The state provides assurance that FMAP for Health Homes services shall be 90% for the ţrst eight ţscal quarters from the eſective date of the SPA. After the ţrst eight quarters, expenditures will be claimed at the regular matching rate. The state provides assurance that it will have the systems in place so that only one 8-quarter period of enhanced FMAP for each health homes enrollee will be claimed. The state provides assurance that there will be no duplication of services and payment for similar services provided under other Medicaid authorities.

4/20/2021 Medicaid State Plan Print View https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwXRmZtl2LIcjf-vAMo-BtAWpTgO6QfW7sfytGJjTskhdvPqCEg8Oq… 11/38 Health Homes Population and Enrollment Criteria MEDICAID | Medicaid State Plan | Health Homes | NM2019MS0009O | NM-21-0005 | MIGRATED_HH.CareLink NM Package Header Package ID NM2019MS0009O Submission Type OŰcial Approval Date 4/15/2021 Superseded SPA ID 18-002 User-Entered SPA ID NM-21-0005 Initial Submission Date 2/15/2021 Eſective Date 1/1/2021 Categories of Individuals and Populations Provided Health Homes Services The state will make Health Homes services available to the following categories of Medicaid participants Categorically Needy (Mandatory and Options for Coverage) Eligibility Groups Medically Needy Eligibility Groups

4/20/2021 Medicaid State Plan Print View https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwXRmZtl2LIcjf-vAMo-BtAWpTgO6QfW7sfytGJjTskhdvPqCEg8Oq… 12/38 Health Homes Population and Enrollment Criteria MEDICAID | Medicaid State Plan | Health Homes | NM2019MS0009O | NM-21-0005 | MIGRATED_HH.CareLink NM Package Header Package ID NM2019MS0009O Submission Type OŰcial Approval Date 4/15/2021 Superseded SPA ID 18-002 User-Entered SPA ID NM-21-0005 Initial Submission Date 2/15/2021 Eſective Date 1/1/2021 Population Criteria The state elects to oſer Health Homes services to individuals with: Specify the criteria for a serious and persistent mental health condition: The existing SMI and SED criteria were developed and approved by the Behavioral Health Collaborative, a statutorily-created body that includes 15 cabinet-level agencies as well as the Governor’s oŰce. The addition of OUD and other SUD for eligibility for HH services is in accordance with the “Program Description and Implementation” described in the 1115 continuation waiver. The state is also implementing initiatives to improve existing SUD services. SUD diagnosis criteria for children and adolescents are included in the “Criteria for Severe Emotional Disturbance Determination” approved by the Behavioral Health Collaborative described above and found in Attachment A; SUD criteria align with the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, described as follows: a diagnosis of substance use disorder is based on evidence of impaired control, social impairment, risky use, and pharmacological criteria. The term “SUD-eligible individual” means an individual who satisţes all of the following: 1. Is an eligible individual with chronic conditions; 2. Is an individual with a substance use disorder; 3. Has not previously received HH services under any other State plan amendment approved for New Mexico.

All HH providers have been serving adults and children with SMI, SED, and co- occurring diagnoses. Two or more chronic conditions One chronic condition and the risk of developing another One serious and persistent mental health condition

4/20/2021 Medicaid State Plan Print View https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwXRmZtl2LIcjf-vAMo-BtAWpTgO6QfW7sfytGJjTskhdvPqCEg8Oq… 13/38 Health Homes Population and Enrollment Criteria MEDICAID | Medicaid State Plan | Health Homes | NM2019MS0009O | NM-21-0005 | MIGRATED_HH.CareLink NM Package Header Package ID NM2019MS0009O Submission Type OŰcial Approval Date 4/15/2021 Superseded SPA ID 18-002 User-Entered SPA ID NM-21-0005 Initial Submission Date 2/15/2021 Eſective Date 1/1/2021 Enrollment of Participants Participation in a Health Homes is voluntary. Indicate the method the state will use to enroll eligible Medicaid individuals into a Health Home: Describe the process used: Enrollment in CLNM Health Homes is voluntary. Members must aŰrmatively agree to opt in to the Health Home program by signing the opt-in form, which is retained in members’ records. Members are asked to remain in the HH program for one year unless they meet criteria for opting out sooner.

Potentially eligible beneţciaries, both Managed Care and Fee for Service, are identiţed by Health Home providers through their own electronic health records and community outreach based on partners, referral networks, and practitioners providing primary and behavioral health care services, as well as SUD screening and treatment services.

Historical claims data are used to identify eligible individuals based on SUD diagnoses and Medicaid eligibility. The State will send letters to all eligible fee- for-service beneţciaries and MCO will send letters to all eligible managed care beneţciaries meeting SUD diagnoses. The letter describes the opportunity to enroll in a CLNM HH and advises beneţciaries to contact the HH in their area or wait for the HH to contact them. In addition, new Centennial Care managed care members will be referred by MCO when deemed eligible.

The exception to this process relates to beneţciaries for High-Fidelity Wraparound. Eligibility for this level of care coordination requires an SED diagnosis as well as other criteria that are not identiţable in claims data nor known to MCO. Since SED diagnosis criteria includes “Substance-Related and Addictive Disorders,” individuals enrolled in HH through Wraparound are not speciţcally addressed in this SPA.

Opt-In to Health Homes provider Referral and assignment to Health Homes provider with opt-out Other (describe)

4/20/2021 Medicaid State Plan Print View https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwXRmZtl2LIcjf-vAMo-BtAWpTgO6QfW7sfytGJjTskhdvPqCEg8Oq… 14/38 Health Homes Providers MEDICAID | Medicaid State Plan | Health Homes | NM2019MS0009O | NM-21-0005 | MIGRATED_HH.CareLink NM Package Header Package ID NM2019MS0009O Submission Type OŰcial Approval Date 4/15/2021 Superseded SPA ID 18-002 User-Entered SPA ID NM-21-0005 Initial Submission Date 2/15/2021 Eſective Date 1/1/2021 Types of Health Homes Providers Indicate the Health Homes Designated Providers the state includes in its program and the provider qualiţcations and standards Describe the Provider Qualiţcations and Standards Each CareLink NM Health Home must meet the following criteria. Criteria apply to all HH providers, regardless of provider type: 1. Registered Medicaid Provider in the State of New Mexico; 2. Have Comprehensive Community Support Services (CCSS) Certiţcation from the State of New Mexico as deţned in NMAC Supplement 17-06; 3. Meet the State standards and requirements as a Behavioral Health Organization; 4. Employ the following staſ: • CareLink NM Health Home Director • Health Promotion Coordinator • Care Manager(s)/Care Coordinator(s) • Community Liaison • Clinical Supervisor(s) • Certiţed Peer Support Workers and/or Certiţed Family Peer Support Workers • Medical Consultant • Psychiatric Consultant • Other optional staſ may include but is not limited to: pharmacist, nutritionist, nurse, physical therapist or exercise specialist, traditional practitioners, licensed alcohol and drug abuse counselors (LADAC) and certiţed alcohol and drug abuse counselors (CADC); 5. Demonstrate the ability to meet all data collection, quality and reporting requirements described in this SPA and others as deţned by the State; 6. Be approved by New Mexico Human Services Department through the application process; 7. Be able to provide primary care services for adults and children or have a MOA with at least one primary care practice in the area that serves children and one that serves adults; 8. Have established member referral protocols with area hospitals, residential treatment facilities, specialty providers, schools, and other community resources; 9. Be able to provide Naloxone for in-agency use; 10. Provide Medication-Assisted Treatment (MAT) or have a MOA with a MAT provider; 11. If providing or referring to MAT, services must be accompanied by a provision for or referral to counseling services and behavioral therapy; 12. Provide Intensive Outpatient services or have a MOA with at least one IOP provider.

The provider is required to maintain the following care coordination ratios for all CLNM HH members. The range of ratios of care coordinators to members is dependent on severity of case, as follows, with a recommended average of 1:61: Lowest level: 1:51-100 Higher level: 1:30-50

Describe the Provider Qualiţcations and Standards Each CareLink NM Health Home must meet the following: 1. Registered Medicaid Provider in the State of New Mexico; 2. Have Comprehensive Community Support Services (CCSS) Certiţcation from the State of New Mexico as deţned in NMAC Supplement 17-06; Designated Providers Physicians Clinical Practices or Clinical Group Practices Rural Health Clinics

4/20/2021 Medicaid State Plan Print View https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwXRmZtl2LIcjf-vAMo-BtAWpTgO6QfW7sfytGJjTskhdvPqCEg8Oq… 15/38 3. Meet the State standards and requirements as a Behavioral Health Organization; 4. Employ the following staſ: • CareLink NM Health Home Director • Health Promotion Coordinator • Care Managers/Care Coordinator(s) • Community Liaison • Clinical Supervisor(s) • Certiţed Peer Support Workers • Certiţed Family Peer Support Workers • Medical Consultant • Psychiatric Consultant • Other optional staſ may include but is not limited to: pharmacist, nutritionist, nurse, physical therapist or exercise specialist, traditional practitioners, licensed alcohol and drug abuse counselors (LADAC) and certiţed alcohol and drug abuse counselors (CADC); 5. Demonstrate the ability to meet all data collection, quality and reporting requirements described in this SPA, and others as deţned by the State; 6. Be approved by New Mexico Human Services Department through the application process; 7. Be able to provide primary care services for adults and children or have a MOA with at least one primary care practice in the area that serves children and one that serves adults; 8. Have established member referral protocols with area hospitals, residential treatment facilities, specialty providers, schools, and other community resources. 9. Be able to provide Naloxone for in-agency use; 10. Provide Medication-Assisted Treatment or have a MOA with a MAT provider; 11. If providing or referring to MAT, services must be accompanied by a provision for or referral to counseling services and behavioral therapy; 12. Provide Intensive Outpatient services or have a MOA with at least one IOP provider.

The provider is required to maintain the following care coordination ratios for all CLNM HH members. The range of ratios of care coordinators to members is dependent on severity of case, as follows, with a recommended average of 1:61: Lowest level: 1:51-100 Higher level: 1:30-50

Describe the Provider Qualiţcations and Standards Each CareLink NM Health Home must meet the following: 1. Registered Medicaid Provider in the State of New Mexico; 2. Have Comprehensive Community Support Services (CCSS) Certiţcation from the State of New Mexico as deţned in NMAC Supplement 17-06; 3. Meet the State standards and requirements as a Behavioral Health Organization; 4. Employ the following staſ: • CareLink NM Health Home Director • Health Promotion Coordinator • Care Managers/Care Coordinator(s) • Community Liaison • Clinical Supervisor(s) • Certiţed Peer Support Workers • Certiţed Family Peer Support Workers • Medical Consultant • Psychiatric Consultant • Other optional staſ may include but is not limited to: pharmacist, nutritionist, nurse, physical therapist or exercise specialist, traditional practitioners, licensed alcohol and drug abuse counselors (LADAC) and certiţed alcohol and drug abuse counselors (CADC); 5. Demonstrate the ability to meet all data collection, quality and reporting requirements described in this SPA, and others as deţned by the State; 6. Be approved by New Mexico Human Services Department through the application process; 7. Be able to provide primary care services for adults and children or have a MOA with at least one primary care practice in the area that serves children and one that serves adults; 8. Have established member referral protocols with area hospitals, residential treatment facilities, specialty providers, schools, and other community resources; 9. Be able to provide Naloxone for in-agency use; 10. Provide Medication-Assisted Treatment or have a MOA with a MAT provider; 11. If providing or referring to MAT, services must be accompanied by a provision for or referral to counseling services and behavioral therapy; Community Health Centers Community Mental Health Centers

4/20/2021 Medicaid State Plan Print View https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwXRmZtl2LIcjf-vAMo-BtAWpTgO6QfW7sfytGJjTskhdvPqCEg8Oq… 16/38 12. Provide Intensive Outpatient services or have a MOA with at least one IOP provider.

The provider is required to maintain the following care coordination ratios for all CLNM HH members. The range of ratios of care coordinators to members is dependent on severity of case, as follows, with a recommended average of 1:61: Lowest level: 1:51-100 Higher level: 1:30-50

Describe the Provider Qualiţcations and Standards Each CareLink NM Health Home must meet the following: 1. Registered Medicaid Provider in the State of New Mexico; 2. Have Comprehensive Community Support Services (CCSS) Certiţcation from the State of New Mexico as deţned in NMAC Supplement 17-06; 3. Meet the State standards and requirements as a Behavioral Health Organization; 4. Employ the following staſ: • CareLink NM Health Home Director • Health Promotion Coordinator • Care Managers/Care Coordinator(s) • Community Liaison • Clinical Supervisor(s) • Certiţed Peer Support Workers • Certiţed Family Peer Support Workers • Medical Consultant • Psychiatric Consultant • Other optional staſ may include but is not limited to: pharmacist, nutritionist, nurse, physical therapist or exercise specialist, traditional practitioners, licensed alcohol and drug abuse counselors (LADAC) and certiţed alcohol and drug abuse counselors (CADC); 5. Be approved by New Mexico Human Services Department through the application process; 6. Be able to provide primary care services for adults and children or have a MOA with at least one primary care practice in the area that serves children and one that serves adults; 7. Have established member referral protocols with area hospitals, residential treatment facilities, specialty providers, schools, and other community resources; 8. Be able to provide Naloxone for in-agency use; 9. Provide Medication-Assisted Treatment or have a MOA with a MAT provider; 10. If providing or referring to MAT, services must be accompanied by a provision for or referral to counseling services and behavioral therapy; 11. Provide Intensive Outpatient services or have a MOA with at least one IOP provider.

The provider is required to maintain the following care coordination ratios for all CLNM HH members. The range of ratios of care coordinators to members is dependent on severity of case, as follows, with a recommended average of 1:61: Lowest level: 1:51-100 Higher level: 1:30-50

Describe the Provider Qualiţcations and Standards Each CareLink NM Health Home must meet the following: 1. Registered Medicaid Provider in the State of New Mexico; 2. Have Comprehensive Community Support Services (CCSS) Certiţcation from the State of New Mexico as deţned in NMAC Supplement 17-06; 3. Meet the State standards and requirements as a Behavioral Health Organization; 4. Employ the following staſ: • CareLink NM Health Home Director • Health Promotion Coordinator • Care Managers/Care Coordinator(s) • Community Liaison • Clinical Supervisor(s) • Certiţed Peer Support Workers • Certiţed Family Peer Support Workers • Medical Consultant • Psychiatric Consultant • Other optional staſ may include but is not limited to: pharmacist, Home Health Agencies Case Management Agencies Community/Behavioral Health Agencies Federally Qualiţed Health Centers (FQHC)

4/20/2021 Medicaid State Plan Print View https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwXRmZtl2LIcjf-vAMo-BtAWpTgO6QfW7sfytGJjTskhdvPqCEg8Oq… 17/38 nutritionist, nurse, physical therapist or exercise specialist, traditional practitioners, licensed alcohol and drug abuse counselors (LADAC) and certiţed alcohol and drug abuse counselors (CADC); 5. Demonstrate the ability to meet all data collection, quality and reporting requirements described in this SPA, and others as deţned by the State; 6. Be approved by New Mexico Human Services Department through the application process; 7. Be able to provide primary care services for adults and children or have a MOA with at least one primary care practice in the area that serves children and one that serves adults; 8. Have established member referral protocols with area hospitals, residential treatment facilities, specialty providers, schools, and other community resources; 9. Be able to provide Naloxone for in-agency use; 10. Provide Medication-assisted Treatment or have a MOA with a MAT provider; 11. If providing or referring to MAT, services must be accompanied by a provision for or referral to counseling services and behavioral therapy; 12. Provide Intensive Outpatient services or have a MOA with at least one IOP provider.

The provider is required to maintain the following care coordination ratios for all CLNM HH members. The range of ratios of care coordinators to members is dependent on severity of case, as follows, with a recommended average of 1:61: Lowest level: 1:51-100 Higher level: 1:30-50 Provider Type Description IHS or Tribal 638 Clinics Each CareLink NM Health Home must meet the following: 1. Registered Medicaid Provider in the State of New Mexico; 2. Have Comprehensive Community Support Services (CCSS) Certiţcation from the State of New Mexico as deţned in NMAC Supplement 17-06; 3. Meet the State standards and requirements as a Behavioral Health Organization; 4. Employ the following staſ: • CareLink NM Health Home Director • Health Promotion Coordinator • Care Managers/Care Coordinator(s), including a care coordinator to serve the SUD population • Community Liaison • Clinical Supervisor(s) • Certiţed Peer Support Workers • Certiţed Family Peer Support Workers • Medical Consultant • Psychiatric Consultant • Other optional staſ may include but is not limited to: pharmacist, nutritionist, nurse, physical therapist or exercise specialist, traditional practitioners, licensed alcohol and drug abuse counselors (LADAC) and certiţed alcohol and drug abuse counselors (CADC); 5. Demonstrate the ability to meet all data collection, quality and reporting requirements described in this SPA, and others as deţned by the State; 6. Be approved by New Mexico Human Services Department through the application process; 7. Be able to provide primary care services for adults and children or have a MOA with at Other (Specify)

4/20/2021 Medicaid State Plan Print View https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwXRmZtl2LIcjf-vAMo-BtAWpTgO6QfW7sfytGJjTskhdvPqCEg8Oq… 18/38 Provider Type Description least one primary care practice in the area that serves children and one that serves adults; 8. Have established member referral protocols with area hospitals, residential treatment facilities, specialty providers, schools, and other community resources; 9. Be able to provide Naloxone for in-agency use; 10. Provide Medication-Assisted Treatment or have a MOA with a MAT provider; 11. If providing or referring to MAT, services must be accompanied by a provision for or referral to counseling services and behavioral therapy; 12. Provide Intensive Outpatient services or have a MOA with at least one IOP provider.

The provider is required to maintain the following care coordination ratios for all CLNM HH members. The range of ratios of care coordinators to members is dependent on severity of case, as follows, with a recommended average of 1:61: Lowest level: 1:51-100 Higher level: 1:30-50

Kewa Pueblo Health Corporation, the State’s Tribal 638 HH provider, serves only Native Americans, but serves all Tribal members. Provider Infrastructure Describe the infrastructure of provider arrangements for Health Home Services The CareLink NM Health Homes serve as the lead entity and have memoranda of agreement (MOA) with partnering primary care practices (adult and child), local hospitals, residential treatment centers, IOP, and MAT service providers, and other specialty providers. The MOA describe standards and protocols for communication, collaboration, referral, follow-up, and other information necessary to eſectively deliver services without duplication. An example is a behavioral health entity that has a MOA with a primary care physician or a MAT provider. Centennial Care MCOs are required to contract with all Health Homes to ensure continuity of care and support to MCO members in receiving Health Home services, including members with dual eligibility. This process includes HH establishing MOA with a variety of providers to ensure a suŰcient number of primary care providers are available for each MCO. MOA are not required if the partner providing primary care is part of the same organization operating in the same or another location. Supports for Health Homes Providers Describe the methods by which the state will support providers of Health Homes services in addressing the following components 1. Provide quality-driven, cost-eſective, culturally appropriate, and person- and family- centered Health Homes services 2. Coordinate and provide access to high quality health care services informed by evidence-based clinical practice guidelines 3. Coordinate and provide access to preventive and health promotion services, including prevention of mental illness and substance use disorders 4. Coordinate and provide access to mental health and substance abuse services 5. Coordinate and provide access to comprehensive care management, care coordination, and transitional care across settings. Transitional care includes appropriate follow-up from inpatient to other settings, such as participation in discharge planning and facilitating transfer from a pediatric to an adult system of health care 6. Coordinate and provide access to chronic disease management, including self-management support to individuals and their families 7. Coordinate and provide access to individual and family supports, including referral to community, social support, and recovery services 8. Coordinate and provide access to long-term care supports and services 9. Develop a person-centered care plan for each individual that coordinates and integrates all of his or her clinical and non-clinical health-care related needs and services 10. Demonstrate a capacity to use health information technology to link services, facilitate communication among team members and between the health team and individual and family caregivers, and provide feedback to practices, as feasible and appropriate 11. Establish a continuous quality improvement program, and collect and report on data that permits an evaluation of increased coordination of care and chronic disease management on individual-level clinical outcomes, experience of care outcomes, and quality of care outcomes at the population level Description The Health Home project team is comprised of the Director of BHSD, an experienced behavioral health clinician, an information technology professional, a registered nurse who leads the Quality Division of HSD, an experienced behavioral health project manager, a Native American liaison, the Behavioral Health Teams of Health Care Professionals Health Teams

4/20/2021 Medicaid State Plan Print View https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwXRmZtl2LIcjf-vAMo-BtAWpTgO6QfW7sfytGJjTskhdvPqCEg8Oq… 19/38 Director from New Mexico’s Children, Youth and Families Department’s Behavioral Health Dept., and assistance from the University of New Mexico’s Department of Psychiatry’s psychiatrist. Before Health Home providers began delivering services for the SMI- and SED-target population, the team developed and delivered training programs for a year to ensure providers were prepared to deliver services, including the following: 1. A collective learning platform for shared information exchange on relevant topics with the participation of all CLNM providers and access to extensive resource documents. Programming for the eight in-person day long sessions included: • Areas of responsibility to determine ţt: CLNM population; staŰng; care coordination levels; use of IT; services; reimbursement; application process; • The six core services; Peer and Family Support Specialist Programming; High Fidelity Wraparound for children/youth; CLNM policies; • Developing memorandums of agreement; review of evaluation criteria & quality reporting; and population health management; • Trauma informed care: historical trauma & adult trauma; trauma in children; • Collaboration with the Centennial Care MCOs; nursing facility level of care; • Cost reporting, membership forecasting, and the development of the PMPMs; • Review of CLNM information technology: i) BHSD STAR: registration/activation; assessment; service plan; service tracking; referrals; quality reporting; ii) Prism Risk Management system; iii) Emergency Department Information Exchange (EDIE); iv) Billing and start up IT activities; • Readiness criteria and preparing for the onsite review; • A training speciţcally on care coordination is currently in development; • New trainings are being developed for Health Home providers to address speciţc needs of SUD-eligible members. Trainings for evidence-based and promising practice programs and services will include (but are not limited to) the following: Naloxone use and overdose prevention to include awareness of polysubstance use, harm reduction, SBIRT, and Seeking Safety. Additional trainings for those agencies who wish to implement Intensive Outpatient services within their agency will be provided.

For providers interested in delivering Medication Assisted Treatment, New Mexico Project ECHO’s Behavioral Health and Addiction program is a robust system developed and sponsored by the University of New Mexico to connect community providers with specialists at centers of excellence in real-time collaborative sessions. The ECHO program partners with the State’s MCO and delivers trainings covering a wide range of behavioral health issues, include MAT. Providers may also present speciţc cases to the team’s addiction specialists for consultation. Attachment B is an announcement from Project ECHO for a health care provider training on opioid services. 2. A Steering Committee comprised of HSD management, MCO management (including medical directors), CYFD Behavioral Health Department management, a Native American Liaison, and University of New Mexico Psychiatry department to oversee the application, administration, oversight, and policy development of the Health Home program and providers. The Steering Committee oſers operational support through members’ respective organizations; 3. The Children, Youth and Families Department provides the required training for certiţed Family Peer Support Workers. The OŰce of Peer Recovery and Engagement at BHSD provides required training for Certiţed Peer Support Workers; 4. An Operations Committee composed of CLNM providers, MCO representatives, State Information Technology department, and the CLNM project team to confer on operational and IT issues, and to work within the relevant organizations to resolve issues and improve processes.

Other Health Homes Provider Standards The state's requirements and expectations for Health Homes providers are as follows 1. Registered Medicaid Provider in the State of New Mexico; 2. Have Comprehensive Community Support Services (CCSS) Certiţcation from the State of New Mexico; 3. Meet the State standards and requirements as a Behavioral Health Organization; 4. Employ the following: a) Health Home Director with three years’ experience with the Health Home population ; b ) Health Promotion Coordinator - Relevant bachelors level degree, experience developing and delivering curriculum; c) Care Coordinator - Licensed as a registered nurse or behavioral health practitioner, or have a Bachelor's or Master’s level degree and two years of experience or as approved through waiver by HSD; d) Community Liaison - multilingual and experienced with resources in the local community including family and caregiver support services; e) Clinical Supervisor(s) – independently licensed professional who has experience with adults and children; f) Peer Support Workers – certiţed by the State; g) Family Peer Support Workers – certiţed by the State; h) physical health consultant, either MD, DO, CNP or CNS; and i) Psychiatric Consultant, MD or DO Board certiţed in psychiatry. Either the consulting MD/PCP or the consulting psychiatrist must have the ability to consult with an addiction specialist or UNM’s Project ECHO, which connects community providers with specialists at centers of excellence in real-time collaborative sessions; 5. Demonstrate the ability to meet all data collection, quality and reporting requirements described in this SPA; 6. The Health Home must be approved by New Mexico through the Health Home application process; 7. The Health Home must have the ability to provide primary care services for adults and children or have a MOA with at least one primary care practice in the area that serves children and one that serves adults; 8. The CareLink NM Health Home must have established member referral protocols with area hospitals and residential treatment facilities.

Name Date Created Attachment A - SMI Criteria Checklist 11/19/2019 12:18 PM EST Attachment B - Project ECHO Opioid Recruitment Flyer 11/19/2019 12:18 PM EST Health Homes Payment Methodologies MEDICAID | Medicaid State Plan | Health Homes | NM2019MS0009O | NM-21-0005 | MIGRATED_HH.CareLink NM Package Header Package ID NM2019MS0009O Submission Type OŰcial Approval Date 4/15/2021 Superseded SPA ID 18-002 User-Entered SPA ID NM-21-0005 Initial Submission Date 2/15/2021 Eſective Date 1/1/2021

4/20/2021 Medicaid State Plan Print View https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwXRmZtl2LIcjf-vAMo-BtAWpTgO6QfW7sfytGJjTskhdvPqCEg8Oq… 20/38 Payment Methodology The State's Health Homes payment methodology will contain the following features Describe below Cost analysis Describe below Cost analysis Describe any variations in payment based on provider qualiţcations, individual care needs, or the intensity of the services provided Described below Fee for Service Individual Rates Per Service Per Member, Per Month Rates Fee for Service Rates based on Severity of each individual's chronic conditions Capabilities of the team of health care professionals, designated provider, or health team Other Comprehensive Methodology Included in the Plan Fee for Service Rates based on Severity of each individual's chronic conditions Capabilities of the team of health care professionals, designated provider, or health team Other Incentive Payment Reimbursement PCCM (description included in Service Delivery section) Risk Based Managed Care (description included in Service Delivery section) Alternative models of payment, other than Fee for Service or PMPM payments (describe below)

4/20/2021 Medicaid State Plan Print View https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwXRmZtl2LIcjf-vAMo-BtAWpTgO6QfW7sfytGJjTskhdvPqCEg8Oq… 21/38 Health Homes Payment Methodologies MEDICAID | Medicaid State Plan | Health Homes | NM2019MS0009O | NM-21-0005 | MIGRATED_HH.CareLink NM Package Header Package ID NM2019MS0009O Submission Type OŰcial Approval Date 4/15/2021 Superseded SPA ID 18-002 User-Entered SPA ID NM-21-0005 Initial Submission Date 2/15/2021 Eſective Date 1/1/2021 Agency Rates Describe the rates used FFS Rates included in plan Comprehensive methodology included in plan The agency rates are set as of the following date and are eſective for services provided on or after that date

4/20/2021 Medicaid State Plan Print View https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwXRmZtl2LIcjf-vAMo-BtAWpTgO6QfW7sfytGJjTskhdvPqCEg8Oq… 22/38 Health Homes Payment Methodologies MEDICAID | Medicaid State Plan | Health Homes | NM2019MS0009O | NM-21-0005 | MIGRATED_HH.CareLink NM Package Header Package ID NM2019MS0009O Submission Type OŰcial Approval Date 4/15/2021 Superseded SPA ID 18-002 User-Entered SPA ID NM-21-0005 Initial Submission Date 2/15/2021 Eſective Date 1/1/2021 Rate Development Provide a comprehensive description in the SPA of the manner in which rates were set 1. In the SPA please provide the cost data and assumptions that were used to develop each of the rates 2. Please identify the reimbursable unit(s) of service 3. Please describe the minimum level of activities that the state agency requires for providers to receive payment per the deţned unit 4. Please describe the state's standards and process required for service documentation, and 5. Please describe in the SPA the procedures for reviewing and rebasing the rates, including the frequency with which the state will review the rates, and the factors that will be reviewed by the state in order to understand if the rates are economic and eŰcient and suŰcient to ensure quality services. Comprehensive Description To support Health Homes, a per member per month (PMPM) care management cost was developed separately for each provider based on modeling estimated enrollment, staſ salaries and beneţts, and administrative costs providers incurred during the ţrst two enrollment phases. The PMPM included an allowance for a 5% per annum dropout rate. The initial enrollment periods for SMI and SED members have been completed; enrollment for members with SUD will not be a phased enrollment, and PMPM will not be recalculated to include this additional criterion. The State anticipates that the addition of the SUD criterion, and any additional staſ required to serve these members and maintain care ratios, will not raise enrollment beyond the initial projections used to calculate existing PMPM. Thus, PMPM and staŰng ramp-up projections will not be recalculated for this additional eligibility criterion.

The following sections address the key elements considered in calculating PMPM costs approved in SPA NM-18-0002:

Enrollment Development The Health Homes approved by the State and the counties they are serving are shown in Table I of Attachment C - Health Homes Payment Methodologies.

1. Each Health Home was asked to develop projections for two separate enrollment phases by month. Projections for the ţrst phase were based upon the number of SMI/SED members providers were already serving. Projections for the second phase were based on the number of individuals within a county with SMI/SED diagnoses that HH projected they could enroll (based upon claims data) through outreach eſorts. Outreach included eſorts by Health Home staſ, establishing referral networks in the community, and referrals made by MCOs. For the addition of SUD, Health Homes were asked to project the number of clients they serve with SUD diagnoses that are not members of the Health Home program, and the number of clients they anticipate enrolling through referral networks; 2. Additional data used is based on members identiţed through claims data in each of the existing HH counties. Criteria for claims data follows: • Primary diagnosis in the SUD spectrum; • Full Medicaid eligibility; • Residence in a county served by a Health Home; • Not enrolled in a Health Home.

Attachment C, Table 3 shows the enrollment estimates for each Health Home for members with SUD diagnoses.

Health Home Salaries, Beneţts and Overhead Development The PMPM costs for each Health Home were driven by the number of full-time equivalent employees needed to manage the care of the enrolled members, their job classiţcations, and member enrollment projections. Salary and beneţt costs used in projections were developed by each Health Home using publicly available sources for similar job classiţcations and the Health Home staŰng qualiţcations. This methodology was approved in SPA NM-18-002. As noted above, the State does not anticipate the addition of SUD criterion to aſect staŰng projections and PMPM already developed.

Health Home Operational Staſ The required operational staſ will not be changed for the inclusion of SUD criteria, and includes a Health Home director, community liaison, health promotion coordinator, medical consultant, and psychiatric consultant. The addition of SUD will require that either the medical or psychiatric consultant be an addiction specialist or be able to consult with an addiction specialist, or UNM Project ECHO, which connects community providers with specialists at centers of excellence in real-time collaborative sessions. Following are staſ required for Health Homes, with necessary qualiţcations and job descriptions.

Health Home Director The Health Home Director is responsible for the day-to-day Health Home operations; the job description is modeled after a clinical operations manager. The Director’s responsibilities include overall service oversight, ţnancial performance, and quality management. The Director may have an advanced degree with three years’ experience with the Health Home population (members with SMI/SED/SUD diagnoses).

Community Liaison The community liaison coordinates, organizes and plans programs that promote the Health Home with potential members and with health care and specialty providers, including treatment centers and substance abuse counselors, within the community to foster relationships and build referral networks. They develop memoranda of agreements with other providers, oversee referral relationships, and are a resource to care coordinators. Community liaison staſ have developed

4/20/2021 Medicaid State Plan Print View https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwXRmZtl2LIcjf-vAMo-BtAWpTgO6QfW7sfytGJjTskhdvPqCEg8Oq… 23/38 relationships with agencies and individuals rendering SUD treatment services, such as residential treatment centers, MAT and IOP service providers, and will continue outreach eſorts in their communities.

Health Promotion Coordinator The health promotion coordinator designs and implements health education and disease management programs for the improvement and maintenance of health conditions and prevalent morbidities. They are knowledgeable about the prevention of common risk behaviors and stay abreast of changes in health care technology and best practices to keep educational materials current. Coordinators can provide education on the use of Naloxone and overdose prevention and harm reduction.

Consultant - Physical Health Consultant The consulting clinician will be available to the care team on a consulting basis for issues related to member physical health conditions. The physical health consultant must be able to consult with an addiction specialist or a specialist through UNM’s Project ECHO.

Consultant – Psychiatrist The consulting psychiatrist will be available to the care team on a consulting basis for issues related to member mental health or substance use. The Psychiatric Consultant must have the ability to consult with an addiction specialist or UNM’s Project ECHO.

Care Coordination Staſ The care coordination staſ includes care manager supervisors, care coordinators, and peer and family support workers.

Care Coordinators Care coordination staŰng ratios are calculated using 1:51-100 for lower severity members and 1:30-50 for members with higher severity with a recommended average of 1:61. An average of 65% of current Health Home members have lower severity, and 35% higher severity. Qualiţcations for care coordinators include: a registered nurse with two years of behavioral health care experience, behavioral health clinicians, or a person holding a bachelor’s degree and having two years relevant healthcare experience. Care coordinators develop and oversee a member’s comprehensive care management and the planning and coordination of all physical, behavioral, and support services.

Peer and Family Support Staſ Peer and family support staſ have lived experience with SMI, SED, and/or SUD or have been a parent, spouse, sibling, or signiţcant other of one who has one or more of these conditions. Peer staſ work with members to increase empowerment and hope, increase social functioning, increase community engagement, help members navigate treatment and support systems, help improve quality of life, and decrease self-stigma. They support family members in dealing with member behaviors, navigating systems, and supporting family resilience.

Supervisors Supervisors provide supervision and serve as a clinical review resource for care coordination staſ, community liaisons, health promotion coordinators, and peer support staſ. The target ratio of supervisor to staſ is 1:8. Supervisors are independently-licensed behavioral health practitioners who have direct service experience in working with adult and child populations.

Administrative Costs The ţnal component in cost development was an allowance for administrative expenses associated with Health Homes’ operations and staŰng costs. Administrative expenses include rent, utilities, phone, computers, equipment, claims support, internet services, trainings, continuing education, promotions, insurance, oŰce supplies, travel, and other indirect costs that may be required to visit members in their homes or other health care settings. Health Homes provided estimates as a percentage of salaries of Health Home staſ or as estimated dollar amounts.

Projection of PMPM Rates PMPM cost modeling was completed based on assumptions about enrollment, staſ salary and beneţts, and administrative overhead as developed by the Health Homes. Tables for projected costs and PMPM rates for Health Home services were included in SPA NM-18-0002 and rates were approved by CMS. The State does not anticipate the addition of SUD to eligibility criteria to impact the staŰng or PMPM rates of Health Homes.

A Health Home provider must deliver at least one of the six core services to a member within a month to bill the PMPM; selecting one of these six services in the BHSDStar service tracking system triggers the payment. Service activities are tracked through the BHSDStar system developed speciţcally for Health Homes. Each of the six core services has a list of activities that may be rendered for a provider to bill for the service. Management reports are available in the Star system for Health Homes and the State to track utilization and compliance with Health Home policy and expectations. Quality indicators that do not require claims data may also be derived from the system. Process and outcome criteria are categorized by the ţve goals of the program.

Based on tracking the six core services through the Star system, claims are submitted to the State’s MMIS system. Rules for submission are as follows: 1. For reimbursement of the PMPM, the G9001 or G9003 code must be billed with one other service code (HCPCS code); 2. Codes for the six services are billed at $0.01 but will pay $0.00; 3. All service codes are billed with the actual dates of service and accurate time units; 4. FQHC provider types billing other services using a UB claim form and a revenue code bill the CLNM codes on a CMS 1500 claim form using HCPCS codes. FQHC obtained a new NPI and facility ID to bill Health Home services; 5. IHS and Tribal 638 facilities bill other services using the OMB rate and bill CLNM codes on a CMS 1500 claim for using HCPCS codes.

Health Home services are available to the following categories of Medicaid participants: individuals with SMI, SED, or SUD receiving services in the counties listed in Attachment C - Tables in this SPA who are fee-for service or managed care Medicaid beneţciaries.

4/20/2021 Medicaid State Plan Print View https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwXRmZtl2LIcjf-vAMo-BtAWpTgO6QfW7sfytGJjTskhdvPqCEg8Oq… 24/38 Health Homes Payment Methodologies MEDICAID | Medicaid State Plan | Health Homes | NM2019MS0009O | NM-21-0005 | MIGRATED_HH.CareLink NM Package Header Package ID NM2019MS0009O Submission Type OŰcial Approval Date 4/15/2021 Superseded SPA ID 18-002 User-Entered SPA ID NM-21-0005 Initial Submission Date 2/15/2021 Eſective Date 1/1/2021 Assurances Describe below how non- duplication of payment will be achieved Under managed care, MCO make monthly payments to Health Homes for enrolled members. Although the PMPM was developed based on staŰng and administrative costs of the Health Home, current capitated rates paid by the State to MCOs include care coordination or case management activities as the primary function under the federal authority under which Centennial Care operates. Health Home care coordination activities are similar in scope to Centennial Care coordination activities factored into the current MCO capitated rate. Currently under managed care, members assessed with SUD, SMI or SED diagnoses are assigned to the most intensive levels of care coordination. To ensure there is no duplication of payment, Health Home PMPM payment is evaluated against care coordination funding included in the capitated rated. The State monitors payments between the MCO and the Health Homes by evaluating encounter data submitted by MCO as well as MCO Health Home reporting. Optional Supporting Material Upload Name Date Created Attachment C - Tables 11/19/2019 6:31 PM EST The State provides assurance that it will ensure non-duplication of payment for services similar to Health Homes services that are oſered/covered under a diſerent statutory authority, such as 1915(c) waivers or targeted case management. The state has developed payment methodologies and rates that are consistent with section 1902(a)(30)(A). The State provides assurance that all governmental and private providers are reimbursed according to the same rate schedule, unless otherwise described above. The State provides assurance that it shall reimburse providers directly, except when there are employment or contractual arrangements consistent with section 1902(a)(32).

4/20/2021 Medicaid State Plan Print View https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwXRmZtl2LIcjf-vAMo-BtAWpTgO6QfW7sfytGJjTskhdvPqCEg8Oq… 25/38 Health Homes Services MEDICAID | Medicaid State Plan | Health Homes | NM2019MS0009O | NM-21-0005 | MIGRATED_HH.CareLink NM Package Header Package ID NM2019MS0009O Submission Type OŰcial Approval Date 4/15/2021 Superseded SPA ID 18-002 User-Entered SPA ID NM-21-0005 Initial Submission Date 2/15/2021 Eſective Date 1/1/2021 Service Deţnitions Provide the state's deţnitions of the following Health Homes services and the speciţc activities performed under each service Comprehensive Care Management Deţnition Comprehensive Care Management comprises the CLNM comprehensive needs assessment (CNA) and the development of an individualized service plan with active participation from the Health Home member, family, caregivers and the Health Home team, and providing care coordination for members' physical and behavioral health, long-term care, and social needs.

The Health Home Comprehensive Needs Assessment The provider agency is responsible for conducting the CNA to determine a member’s needs related to physical and behavioral health, long-term care, social and community support resources and family supports. The CNA: 1. Provides all the required data elements speciţed in the HSD authorized CNA; 2. Assesses preliminary risk conditions and health needs, including alcohol and drug abuse and opioid use; 3. Uses data from the risk management system to help determine care coordination levels; 4. Requires outreach to potential CLNM members within 14 calendar days of receipt of a referral; 5. Must document that a provider contacted and/or met with a member to at least begin assessment within the mandated 14-day timeframe; 6. May conduct face-to-face meetings in a member’s home. If the member is homeless, the meeting may be held at a mutually agreed upon location; 7. Need not be completed during the ţrst visit if using the Treat First model. The member may be enrolled in Health Homes and assigned care coordination level eight (pending CNA completion) until a diagnosis of SUD, SMI or SED is determined and accepted by the member. The CNA may be completed over the course of four appointments; when completed, the care coordination level is updated.

The Health Home Service Plan The service plan maps a member’s path toward self-management of physical and behavioral health conditions and is speciţcally designed to help members meet needs and achieve goals. The Service Plan is intended to be updated frequently to reŤect identiţed needs, communicate services a member will receive, and serve as a shared plan for the member, their family or representative, and service providers. The plan is intended to be supplemented by treatment plans developed by practitioners. The service plan: 1. Requires active participation from members, family, caregivers, and team members; 2. Requires consultation with interdisciplinary team experts, primary care provider, specialists, behavioral health providers, MAT and IOP providers, and other participants involved in a member’s care; 3. Identiţes additional recommended health screenings; 4. Addresses long-term and physical, behavioral, and social health needs; 5. Is organized around a member’s goals, preferences and optimal clinical outcomes, including self-management. The plan includes as many short- and long- term goals as needed; 6. Speciţes treatment and wellness supports that bridge behavioral health and primary care; 7. Includes a backup plan that addresses situations that may arise if a member’s providers are unavailable, and provides contact information for people and agencies where the member may seek support. This is primarily for members receiving home- and community-based services where there is a nursing facility level of care (NFLOC) determination. There is no required template; 8. Includes a crisis/emergency plan listing steps a member and/or representative will take that diſer from the standard emergency protocol in the event of an emergency. These are individualized plans; 9. Is shared with members and their providers; 10. Is updated with status and plan changes.

Comprehensive care management services must also include: 1. Assignment of Health Home team roles and responsibilities; 2. Development of treatment guidelines for teams to follow across risk levels or health conditions; 3. Oversight of the implementation of the Health Home service plan which bridges treatment and wellness support across behavioral health, primary care and social health supports; 4. Monitoring of individual health status and service use to determine adherence to or variance from treatment guidelines; 5. Development and dissemination of reports that indicate progress toward meeting outcomes for client satisfaction, health status, service delivery and costs.

Describe how Health Information Technology will be used to link this service in a comprehensive approach across the care continuum BHSDStar web-based data collection tools are used for this project. Registration and activation modules to support care management include the level of care deemed most appropriate for the member. The CNA requires screenings for alcohol abuse and asks members about alcohol and opioid use, general drug use and substance abuse treatments, as well as clinical risk assessments and comprehensive history and information gathering over the course of four appointments. The Star system includes a service plan which is developed with members, inclusive of short- and long-term goals, service requirements, and expected outcomes. Systems were developed to be used on touch screen laptops or tablets for in-home or community use. BHSDStar helps Health Home providers support members, and Care Coordinators identify unmet needs, gaps in care, required clinical protocols, case management, medical and behavioral health services, and social determinants of health.

Through a contract with HSD, CLNM providers have access to analytics from the Predictive Risk Intelligence System (PRISM) owned by Spectrum Informatics, LLC. PRISM data provide insights to CLNM providers related to utilization history for behavioral and physical health services, medication history, hospitalizations and ED use. The system utilizes state-of-the-art predictive modeling to identify patients at greatest risk of high future medical costs or hospitalization. Care

4/20/2021 Medicaid State Plan Print View https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwXRmZtl2LIcjf-vAMo-BtAWpTgO6QfW7sfytGJjTskhdvPqCEg8Oq… 26/38 Coordinators access this system while determining a member’s care coordination level and developing a service plan and can gain new insights as case management evolves.

HSD has contracted with PreManage Emergency Department Information Exchange (EDIE), and Health Homes receive notiţcations from participating hospitals when a member has been admitted on an in- or outpatient basis. Care coordinators may be contacted by email, text, or telephone when a member has been admitted to a hospital for services and are able to reach out to members for needed services, including updates to service plans. Approximately 90% of New Mexico hospitals participate in the EDIE program.

Health Homes utilize telehealth services to help support members, and University of New Mexico’s Project ECHO to attend training sessions hosted by medical and behavioral health professionals. Seminars support continuing education for all professional levels of providers. In addition to regularly hosted seminars, Project ECHO connects community providers with specialists at centers of excellence in real-time collaborative sessions where providers may consult on speciţc cases.

Scope of service The service can be provided by the following provider types Description See Other Description See Other Description See Other Description See Other Description See Other Description See Other Provider Type Description Behavioral Health Professionals or Specialists Nurse Practitioner Nurse Care Coordinators Nurses Medical Specialists Physicians Physician's Assistants Pharmacists Social Workers Doctors of Chiropractic Licensed Complementary and alternative Medicine Practitioners Dieticians Nutritionists Other (specify)

4/20/2021 Medicaid State Plan Print View https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwXRmZtl2LIcjf-vAMo-BtAWpTgO6QfW7sfytGJjTskhdvPqCEg8Oq… 27/38 Provider Type Description Health Home Provider Team 1. Care Coordinator who is a Regulation and Licensing Department (RLD) licensed behavioral health practitioner or holds a human services bachelor’s or master’s level degree and has two years of behavioral health experience, or is a registered nurse with behavioral health experience, or is approved through the Health Home Steering Committee. A Care Coordinator develops and oversees a CLNM member’s comprehensive care management, including the planning and coordination of all physical, behavioral, and support services; 2. Supervisor of the care coordinators, community liaison, health promotion coordinator, family and peer support workers, and any other clinical staſ, who is an independently licensed behavioral health practitioner. The Supervisor must have direct experience in working with both adult and child populations; 3. A Certiţed Peer Support Worker (CPSW) or Family Peer Support Worker (FPSW) who holds certiţcation from the New Mexico Credentialing Board for Behavioral Health Professionals. CPSW have successfully navigated their personal behavioral health experiences and are willing to support peers in their recovery process; 4. A Certiţed Family Support Worker (CFSW) who holds a certiţcation from the New Mexico Credentialing Board for Behavioral Health Professionals as a CFSW. CFSW have successfully navigated their personal behavioral health experiences and are willing to support peers in their recovery process; 5. A Health Promotion Coordinator who assures that disease management and risk prevention programs or referrals to outside programs are available based on speciţc needs of members; 6. A Community Liaison who builds a network of community resources and makes recommendation for resources outside of the Health Home to meet the needs of individual members; 7. Optional Health Home multidisciplinary team participants: • Nutritionist • Medication assisted treatment providers • Intensive outpatient providers • Exercise Specialist • Pharmacist • Doctors of Chiropractic • Licensed complementary and alternative medicine practitioners.

Only Health Home-designated providers are paid for Health Home services; all non-Health Home services will continue to be paid to participating Medicaid providers in accordance with the Medicaid State Plan. Care Coordination Deţnition Care Coordination activities are conducted by care coordinators with members, their identiţed supports, medical and behavioral health providers and community providers. Care is coordinated across care settings to implement individualized service plans and to coordinate appropriate linkages, referrals, and follow-up. Care coordination promotes integration and cooperation among service providers and reinforces treatment strategies that support members’ eſorts to better understand and actively self-manage his or her health conditions. Care coordinators’ activities include, but are not limited to: 1. Outreach and engagement of Health Home members; 2. Communication with members, their family or representative, other providers and team members, including face-to-face visits to address health and safety concerns; 3. Ensuring members and their identiţed supports have access to medical, behavioral health, pharmacology, age-appropriate resiliency and recovery support services, and natural and community supports; 4. Ensuring that services are integrated and compatible as identiţed in the service plan; 5. Coordinating primary, specialty, and transitional health care from nursing homes, ED, hospitals and residential treatment facilities; 6. Making referrals, assisting in scheduling appointments, and conducting follow-up monitoring; 7. Developing self-management care plans with members; 8. Delivering health education plans tailored to a member’s speciţc conditions; 9. Conducting a face-to-face in-home visit within two weeks of a NFLOC determination; 10. Coordinating with a MCO care coordinator when a member has a NFLOC determination. Describe how Health Information Technology will be used to link this service in a comprehensive approach across the care continuum The BHSD Star web based system is available to the Health Home team, the MCOs, and outside providers that are part of a member’s integrated care team. Both the assessment and service plan are constantly updated with new information and progress toward achieving outcomes. Critical risks such as suicidality, uncontrolled substance use, and pregnancy are highlighted on the home page for quick reference. A reminder system speciţc to each care coordinator’s activities for the coming week are both automatic based on policy, or entered by the care coordinator based on activities paramount for the member condition.

An Emergency Department Information Exchange (EDIE PreManage) system is available to the Health Home, and automatically sends notiţcations in real-time to the Health Home as a patient presents at the ED to give immediate perspective on the patient. The content of the notiţcation is speciţc to the ED including ED visit history, and other valuable clinical and social history information. Currently 90% of New Mexico hospitals are engaged with this system, and others are in process. The Health Homes all have 24 hour call lines, and can specify other modes of real time communication. Scope of service The service can be provided by the following provider types Behavioral Health Professionals or Specialists

4/20/2021 Medicaid State Plan Print View https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwXRmZtl2LIcjf-vAMo-BtAWpTgO6QfW7sfytGJjTskhdvPqCEg8Oq… 28/38 Description See Other Provider Type Description Behavioral Health Care Coordinator See Other CareLink NM Provider Team • Care Coordinator who is a Regulation and Licensing Department (RLD) licensed behavioral health practitioner, or holds a human services bachelor’s level or master’s level degree and has two years of behavioral health experience, or is a registered nurse with behavioral health experience, or is approved through the Health Home Steering Committee. A Care Coordinator develops and oversees a CLNM Member’s comprehensive care management, including the planning and coordination of all physical, behavioral, and support services. • A Supervisor of the care coordinators, community liaison, health promotion coordinator, family and peer support workers, and any other clinical staſ, who is an independently licensed behavioral health practitioner or behavioral health nurse practitioner or behavioral health clinical nurse specialist as described in 8.321.2 NMAC. The Supervisor must have direct experience in working with both adult and child populations • A Certiţed Peer Support Worker (CPSW) or Certiţed Family Peer Support Worker (CFPSW) who holds certiţcation from the New Mexico Credentialing Board for Behavioral Health Professions. The CPSW and/or CFPSW has successfully remediated his or her own behavioral health experiences and is willing to assist his or her peers in their recovery/support process.

Only CareLink NM Health Home designated providers will be paid for the Health Home services, all non-health home services will continue to be paid to participating Medicaid providers in accordance with the Medicaid State Plan. Health Promotion Deţnition Prevention and health promotion services are intended to prevent and reduce health risks and provide interventions to promote healthy lifestyles. Examples of prevention and health promotion services include supports for: substance use prevention and/or reduction, harm reduction, resiliency and recovery, independent living, smoking prevention and cessation, HIV/AIDS prevention and early intervention, STD prevention and early intervention, family planning and pregnancy support, chronic disease management, nutritional counseling, obesity reduction and prevention, and improving social networks. Health promotion activities assist Health Home members to participate in the implementation of both their treatment and medical services plans, and place strong emphasis on person-centered empowerment to understand and self-manage chronic health conditions. Health promotion activities include, but are not limited to: • Use of member-level, clinical data to deliver speciţc health promotion activities to support self-care needs and goals. Some data are available from New Mexico’s data warehouse, from provider's electronic health records, and from assessment data in BHSDStar; • Development of disease management and self-management plans with members; • Delivery of health education speciţc to a member’s health conditions; • Education of members about the importance of immunizations and screenings for general health conditions; • Development and delivery of health-promoting lifestyle programs and interventions for topics such as substance use prevention and/or reduction, resiliency and recovery, independent living, family planning and pregnancy support, parenting, and life skills. • Use of evidence-based, evidence-informed, best emerging and/or promising practices for prevention, health promotion, and disease management programs and interventions; • Use of evidence-based, evidence-informed, best emerging and/or promising practices curricula that integrate physical and behavioral health concepts and meet the needs of the population served; • Providing classes or counseling, either in a group or individual setting; • Increasing the use of proactive health promotion and self-management activities; • Tracking success of prevention, health promotion, and disease management programs and interventions, as well as identifying areas of improvement. Describe how Health Information Technology will be used to link this service in a comprehensive approach across the care continuum Nurse Practitioner Nurse Care Coordinators Nurses Medical Specialists Physicians Physician's Assistants Pharmacists Social Workers Doctors of Chiropractic Licensed Complementary and alternative Medicine Practitioners Dieticians Nutritionists Other (specify)

4/20/2021 Medicaid State Plan Print View https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwXRmZtl2LIcjf-vAMo-BtAWpTgO6QfW7sfytGJjTskhdvPqCEg8Oq… 29/38 Curricula for the predominant comorbidities within each county have been developed for chronic conditions prevalent within counties. The most prevalent conditions have been identiţed using the Elixhauser comorbidity analysis of 31 common diagnoses. (See Attachment D for a sample). Online curricula are available through a MCO for the most prevalent chronic conditions that Health Home may use with members or for members to access directly. BHSDStar service tracking is used to track all counseling and health promotions activities provided to members. Each Health Home provider is able to determine which staſ members may access member records in BHSDStar, enabling designated team members to follow- up on members’ health status, needs, and services. Scope of service The service can be provided by the following provider types Description See Other Description See Other Description See Other Description See Other Description See Other Description See Other Description See Other Provider Type Description Behavioral Health Professionals or Specialists Nurse Practitioner Nurse Care Coordinators Nurses Medical Specialists Physicians Physician's Assistants Pharmacists Social Workers Doctors of Chiropractic Licensed Complementary and alternative Medicine Practitioners Dieticians Nutritionists Other (specify)

4/20/2021 Medicaid State Plan Print View https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwXRmZtl2LIcjf-vAMo-BtAWpTgO6QfW7sfytGJjTskhdvPqCEg8Oq… 30/38 Provider Type Description Health Home Provider Team 1. Health Promotion Coordinator with a bachelor’s level degree in a human or health services ţeld and experience in developing and delivering curricula. The Health Promotion Coordinator manages health promotion and risk prevention services and resources appropriate for the Health Home population. Typical programs include substance use prevention and cessation, psychotropic medication management, nutritional counseling and weight management, and diabetes care. This role also explores and manages relationships with outside providers such as the New Mexico Department of Health and MCO for additional referral opportunities not available in the Health Home. The Health Promotion Coordinator is part of the multi- disciplinary treatment team and ensures required services are available within the Health Home or through referral; 2. Care Coordinator who is a Regulation and Licensing Department (RLD) licensed behavioral health practitioner or holds a human services bachelor’s level or master’s level degree and has two years of behavioral health experience, or is a registered nurse with behavioral health experience, or is approved through the Health Home Steering Committee. A Care Coordinator develops and oversees a member’s comprehensive care management, including the planning and coordination of all physical, behavioral, and support services; 3. A Supervisor of the care coordinators, community liaison, health promotion coordinator, family and peer support workers, and any other clinical staſ, who is an independently licensed behavioral health practitioner as described in 8.321.2 NMAC. The Supervisor must have direct experience in working with both adult and child populations; 4. A Certiţed Peer Support Worker (CPSW) or Family Peer Support Worker (FPSW) who holds certiţcation from the New Mexico Credentialing Board for Behavioral Health Professionals. CPSW and FPSW have successfully navigated their personal behavioral health experiences and are willing to support peers in their recovery process.

Only Health Home-designated providers are paid for Health Home services; all non-Health Home services will continue to be paid to participating Medicaid providers in accordance with the Medicaid State Plan. Comprehensive Transitional Care from Inpatient to Other Settings (including appropriate follow-up) Deţnition Health Home staſ are responsible for taking a lead role in transitional care. Comprehensive transitional care focuses on the movement within diſerent levels of care, settings, or situations. Comprehensive transitional care is bidirectional, intended to help members shift from levels of care such as ED services, residential treatment centers, and inpatient hospitalization to outpatient services. Transitional services help reduce barriers to timely access, inappropriate hospitalizations, and time in residential treatment centers (RTC). Health Home staſ work with staſ in RTC to ensure discharge plans are in place and members continue to adhere to treatment goals and receive appropriate recovery supports. Transitional services help to interrupt patterns of frequent ED use and prevent gaps in services which could result in (re)admission to a higher level of care or a longer stay at an unnecessarily higher level of care. Providers of transitional services should be mindful of a member’s transition from childhood to adulthood to ensure service plans incorporate a member’s shift from pediatric to adult providers, and address issues such as independent living arrangements. Health Homes proactively work with members reaching the age of majority to ensure appropriate supports and services are in place in the member’s plan to assist in the successful transition to adulthood. Comprehensive transitional care activities include, but are not limited to: • Supporting the use of proactive health promotion and self-management; • Participating in all discharge and transitional planning activities to ensure members have appropriate medications and adhere to medication schedules; • Coordinating with physicians, nurses, social workers, discharge planners, pharmacists, Indian Health Services (IHS), Tribal programs, RTC staſ, MAT providers, and others to continue implementing or modifying the service plan as needed; • Implementing appropriate services and supports to reduce use of hospital ED, domestic violence and other shelters, and residential treatment centers. Services should also support decreased hospital admissions and readmissions, and involvement with State agencies such as Juvenile Justice, Protective Services, and Corrections; • Coordinating with members as they change levels of care or providers within the same level of care to ensure timely access to indicated services and supports; • Sharing critical planning and transition documents with all providers involved with an individual’s care via web-based tools, secure email or hard copy; • Facilitating critical transitions from child to adult providers, or to long-term services and supports. Describe how Health Information Technology will be used to link this service in a comprehensive approach across the care continuum BHSDStar service tracking includes a section for comprehensive transitional care which identiţes the type of facility to or from which a member transitions. It also documents Care Coordinator involvement in the planning. Medication reconciliation during transitions and discharge planning are both reported through BHSDStar. Star also tracks seven- and 30- day follow-up visits through the State’s claims system, and these data are included in quality reporting. Each Health Home provider can determine which staſ members may access member records in BHSDStar, enabling all designated team members to follow-up on members’ health status, needs, and services. PRISM, a risk management application based on 15 months of rolling claims data aſords Health Home providers data on utilization history for behavioral and physical health, prescriptions, ED use and hospitalizations. Health Homes subscribe to the EDIE (PreManage) system and receive real-time notiţcations for members being admitted to the hospital. Notiţcations include hospital visit history and other valuable clinical information. Approximately 90% of New Mexico hospitals are engaged with this system, thus serving most New Mexico providers. Scope of service The service can be provided by the following provider types Description Behavioral Health Professionals or Specialists

4/20/2021 Medicaid State Plan Print View https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwXRmZtl2LIcjf-vAMo-BtAWpTgO6QfW7sfytGJjTskhdvPqCEg8Oq… 31/38 See Other Description See Other Provider Type Description Health Home Provider Team 1. Care Coordinator who is a Regulation and Licensing Department (RLD) licensed behavioral health practitioner or holds a human services bachelor’s- or master’s-level degree and has two years of behavioral health experience, or is a registered nurse with behavioral health experience, or is approved through the Health Home Steering Committee. A Care Coordinator develops and oversees a Health Home member’s comprehensive care management, including the planning and coordination of all physical, behavioral, and support services; 2. Community liaison who is bilingual and speaks a language used by most non-English speaking members, and who is experienced with the resources in the member’s local community. The community liaison identiţes, connects, and engages with community services, resources, and providers and works with care coordinators to connect members to needed community services, resources and practitioners; 3. A Certiţed Peer Support Worker (CPSW) or Family Peer Support Worker (FPSW) who holds certiţcation from the New Mexico Credentialing Board for Behavioral Health Professionals; 4. Physical Health Consultant who is a physician licensed to practice medicine (MD) or osteopathy (DO) as described in 8.310.3 NMAC; 5. A Psychiatric Consultant who is a physician licensed to practice medicine (MD) or osteopathy (DO) and is board-eligible or board-certiţed in psychiatry as described in 8.321.2 NMAC; and 6. A clinical nurse specialist (CNS) or a certiţed nurse practitioner (CNP) licensed by the New Mexico board of nursing and certiţed in psychiatric nursing by a national nursing organization, to include the groups they form, who can furnish services to adults or children as his or her certiţcation permits as described in 8.321.2 NMAC.

Only Health Home-designated providers are paid for Health Home services; all non-Health Home services will continue to be paid to participating Medicaid providers in accordance with the Medicaid State Plan.

Individual and Family Support (which includes authorized representatives) Deţnition Individual and family support services reduce barriers to Health Home members’ care coordination, increase skills and engagement, and improve health outcomes. Services also increase health and medication literacy, enhance one’s ability to self-manage care, promote peer and family involvement and support, improve access to education and employment supports, and support recovery and resiliency. Individual and family support activities include, but are not limited to: • Supporting a member and their family in recovery and resiliency goals; • Supporting families in their knowledge of a member’s disease and possible side eſects of medication and treatments; • Enhancing the abilities of members and their support systems to manage care and live safely in the community; • Teaching members and families self-advocacy skills and how to navigate systems; • Providing peer support services; • Assisting members in obtaining and adhering to medication schedules and other prescribed treatments; • Assisting members in accessing self-help activities and services; • Arranging for transportation to medically-necessary services; • Identifying resources to support individuals in attaining their highest level of health and functionality within their families and communities; • Assessing impacts of a member’s behaviors on families and assisting in obtaining respite services as needed. Nurse Practitioner Nurse Care Coordinators Nurses Medical Specialists Physicians Physician's Assistants Pharmacists Social Workers Doctors of Chiropractic Licensed Complementary and alternative Medicine Practitioners Dieticians Nutritionists Other (specify)

4/20/2021 Medicaid State Plan Print View https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwXRmZtl2LIcjf-vAMo-BtAWpTgO6QfW7sfytGJjTskhdvPqCEg8Oq… 32/38 Describe how Health Information Technology will be used to link this service in a comprehensive approach across the care continuum The following activities are included in BHSDStar service tracking system under “Individual/Family Support” from which reporting measures can be collected: • Supported the member in recovery & resiliency goals; • Supported the family in the members recovery & resiliency goals; • Conducted family education on member’s chronic condition; • Identiţed community services; • Arranged respite services; • Arranged family/legal representative meetings; • Peer support contact; • Educated on client rights. Each Health Home provider can determine which staſ members may access member records in BHSDStar, enabling all designated team members to follow-up on members’ health status, needs, and services. Scope of service The service can be provided by the following provider types Description See Other Description See Other Description See Other Description See Other Description See Other Provider Type Description Behavioral Health Professionals or Specialists Nurse Practitioner Nurse Care Coordinators Nurses Medical Specialists Physicians Physician's Assistants Pharmacists Social Workers Doctors of Chiropractic Licensed Complementary and alternative Medicine Practitioners Dieticians Nutritionists Other (specify)

4/20/2021 Medicaid State Plan Print View https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwXRmZtl2LIcjf-vAMo-BtAWpTgO6QfW7sfytGJjTskhdvPqCEg8Oq… 33/38 Provider Type Description Health Home Provider Team • Health Promotion Coordinator with a bachelor’s level degree in a human or health services ţeld and experience in developing curriculum and curriculum delivery. The Health Promotion Coordinator manages health promotion services and resources appropriate for a Health Home member such as interventions related to substance use prevention and cessation, nutritional counseling, and parenting classes; • Care Coordinator who is a Regulation and Licensing Department (RLD) licensed behavioral health practitioner or holds a human services bachelor’s level or master’s level degree and has two years of behavioral health experience, or is a registered nurse with behavioral health experience, or is approved through the Health Home Steering Committee. A Care Coordinator develops and oversees a Health Home member’s comprehensive care management, including the planning and coordination of all physical, behavioral, and support services; • Supervisor of the care coordinators, community liaison, health promotion coordinator, family and peer support workers, and any other clinical staſ, who is an independently licensed behavioral health practitioner as described in 8.321.2 NMAC. The Supervisor must have direct experience in working with both adult and child populations; • Certiţed Peer Support Worker (CPSW) or Family Peer Support Worker (FPSW) who holds certiţcation from the New Mexico Credentialing Board for Behavioral Health Professionals. CPSW and FPSW have successfully navigated his or her personal behavioral health experiences and is willing to support peers in the recovery process; • Community liaison who is bilingual and speaks a language used by most non-English speaking members, and who is experienced with resources in the member’s local community. The community liaison identiţes, connects, and engages with community services, resources, and providers and works with care coordinators to connect members to needed community services, resources and practitioners.

Only Health Home-designated providers are paid for Health Home services; all non-Health Home services will continue to be paid to participating Medicaid providers in accordance with the Medicaid State Plan. Referral to Community and Social Support Services Deţnition Referrals to community and social support services help overcome access and service barriers, increase self-management skills, and improve overall health. Providers identify available and eſective community-based resources and actively link and manage appropriate referrals. Linkages support the personal needs of members and are consistent with the service plan. Community and social support service referral activities include, but are not limited to: • Identifying and partnering with community-based and telehealth resources such as medical and behavioral health care, durable medical equipment (DME), legal services, housing, educational and employment supports, recovery and treatment plan goal supports, entitlements and beneţts, social integration and skill building, transportation, wellness and health promotion services, specialized support groups, substance use prevention and treatment, and culturally-speciţc programs such as veterans’ or IHS and Tribal services; • Developing referral and communication protocols as outlined in MOA; • Making referrals and assisting members to establish and maintain eligibility for services; • Conţrming members’ and providers’ encounters and post-referral follow-up. Describe how Health Information Technology will be used to link this service in a comprehensive approach across the care continuum The BHSDStar service tracking system includes a section entitled “Referral to Community & Social Support Services” from which reporting measures can be collected. The activities within this section are: • Evaluate care needs for ancillary support • Legal contact made • Educational contact made • Identiţed and/or arranged housing contact • Utilities paid or contact • Religious contact made • Food contact made • Clothing contact made Each Health Home provider can determine which staſ members may access member records in BHSDStar, enabling all designated team members to follow-up on members’ health status, needs, and services. Health Homes use telehealth services to link members to service providers not available within the member’s community.

Scope of service The service can be provided by the following provider types Description See other Description Behavioral Health Professionals or Specialists Nurse Practitioner Nurse Care Coordinators Nurses

4/20/2021 Medicaid State Plan Print View https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwXRmZtl2LIcjf-vAMo-BtAWpTgO6QfW7sfytGJjTskhdvPqCEg8Oq… 34/38 See other Description See other Description See other Provider Type Description Health Home Provider Team members • Care Coordinator who is a Regulation and Licensing Department (RLD) licensed behavioral health practitioner or holds a human services bachelor’s level or master’s level degree and has two years of behavioral health experience, or is a registered nurse with behavioral health experience, or is approved through the Health Home Steering Committee. A Care Coordinator develops and oversees a Health Home member’s comprehensive care management, including the planning and coordination of all physical, behavioral, and support services; • A Supervisor of the care coordinators, community liaison, health promotion coordinator, family and peer support workers, and any other clinical staſ, who is an independently licensed behavioral health practitioner as described in 8.321.2 NMAC. The Supervisor must have direct experience in working with both adult and child populations; • Certiţed Peer Support Worker (CPSW) or Family Peer Support Worker (FPSW) who holds certiţcation from the New Mexico Credentialing Board for Behavioral Health Professionals; • A Community Liaison who is bilingual and speaks a language which is utilized by a majority of non-English speaking Health Home members, and who is experienced with the resources in the member’s local community. The community liaison identiţes, connects, and engages with community services, resources, and providers. The community liaison works with the Health Home care coordinator to connect and integrate the Health Home member to needed community services, resources and practitioners.

Only Health Home-designated providers are paid for Health Home services; all non-Health Home services will continue to be paid to participating Medicaid providers in accordance with the Medicaid State Plan. Medical Specialists Physicians Physician's Assistants Pharmacists Social Workers Doctors of Chiropractic Licensed Complementary and alternative Medicine Practitioners Dieticians Nutritionists Other (specify)

4/20/2021 Medicaid State Plan Print View https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwXRmZtl2LIcjf-vAMo-BtAWpTgO6QfW7sfytGJjTskhdvPqCEg8Oq… 35/38 Health Homes Services MEDICAID | Medicaid State Plan | Health Homes | NM2019MS0009O | NM-21-0005 | MIGRATED_HH.CareLink NM Package Header Package ID NM2019MS0009O Submission Type OŰcial Approval Date 4/15/2021 Superseded SPA ID 18-002 User-Entered SPA ID NM-21-0005 Initial Submission Date 2/15/2021 Eſective Date 1/1/2021 Health Homes Patient Flow Describe the patient Ťow through the state's Health Homes system. Submit with the state plan amendment Ťow-charts of the typical process a Health Homes individual would encounter Comorbidity data and the patient Ťow system are unchanged from the submission and approval of SPA NM-18-0002. The patient Ťow diagram is attached. Please see Attachment E for Patient Flowchart. Name Date Created Attachment D - Sample County Comorbidity Data 11/19/2019 12:23 PM EST Attachment E - CLNM Patient Flow 11/19/2019 12:23 PM EST

4/20/2021 Medicaid State Plan Print View https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwXRmZtl2LIcjf-vAMo-BtAWpTgO6QfW7sfytGJjTskhdvPqCEg8Oq… 36/38 Health Homes Monitoring, Quality Measurement and Evaluation MEDICAID | Medicaid State Plan | Health Homes | NM2019MS0009O | NM-21-0005 | MIGRATED_HH.CareLink NM Package Header Package ID NM2019MS0009O Submission Type OŰcial Approval Date 4/15/2021 Superseded SPA ID 18-002 User-Entered SPA ID NM-21-0005 Initial Submission Date 2/15/2021 Eſective Date 1/1/2021 Monitoring Describe the state's methodology for calculating cost saving (and report cost savings annually in Quality Measure Report). Include savings that result from improved coordination of care and chronic disease management achieved through the Health Homes Program, including data sources and measurement speciţcations, as well as any savings associated with dual eligibles, and if Medicare data was available to the state to utilize in arriving at its cost-savings estimates The State identiţes people who aŰrmatively enroll in a Health Home. For these individuals, we are examining total claims costs from our MMIS data warehouse for the two years preceding Health Home enrollment and comparing them to total costs after enrollment in Health Home. We are categorizing those costs by (1) those for which we ultimately expect to realize savings, such as emergency department visits, inpatient admissions, and residential treatment; and (2) all other outpatient and pharmaceutical costs we expect to initially increase. We will also analyze cost data by contrasting those with fewer than three comorbid conditions with those with three or more comorbid conditions. A third contrast will examine costs for those with a substance use disorder compared to those without a SUD diagnosis. Describe how the state will use health information technology in providing Health Homes services and to improve service delivery and coordination across the care continuum (including the use of wireless patient technology to improve coordination and management of care and patient adherence to recommendations made by their provider) 1. CLNM Health Home providers are using certiţed Electronic Health Records (EHR) for the Health Home program. These systems provide the most current technology to both oŰce and ţeld staſ; 2. Designated providers are required to work within the BHSDStar system designed speciţcally for collecting data for Health Homes members. 3. Health Home providers use the EDIE system to receive notiţcations when members are admitted to hospitals; 4. Health Home providers use the PRISM risk management system to help inform member’s health, medication, and hospital usage history and diagnoses; 5. Providers, particularly those in rural areas, use telehealth services. 6. Providers may access University of New Mexico’s Project ECHO program to connect with specialists at centers of excellence in real-time collaborative sessions. Health Home providers may also access Project ECHO training and educational seminars; 7. All Health Home providers have participated in operational initiatives planning and problem-solving initiatives with HSD and MCO to integrate systems data and resolve issues.

4/20/2021 Medicaid State Plan Print View https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwXRmZtl2LIcjf-vAMo-BtAWpTgO6QfW7sfytGJjTskhdvPqCEg8Oq… 37/38 Health Homes Monitoring, Quality Measurement and Evaluation MEDICAID | Medicaid State Plan | Health Homes | NM2019MS0009O | NM-21-0005 | MIGRATED_HH.CareLink NM Package Header Package ID NM2019MS0009O Submission Type OŰcial Approval Date 4/15/2021 Superseded SPA ID 18-002 User-Entered SPA ID NM-21-0005 Initial Submission Date 2/15/2021 Eſective Date 1/1/2021 Quality Measurement and Evaluation The state provides assurance that all Health Homes providers report to the state on all applicable quality measures as a condition of receiving payment from the state The state provides assurance that it will identify measureable goals for its Health Homes model and intervention and also identify quality measures related to each goal to measure its success in achieving the goals The state provides assurance that it will report to CMS information submitted by Health Homes providers to inform evaluations, as well as Reports to Congress as described in Section 2703(b) of the Aſordable Care Act and as described by CMS The state provides assurance that it will track avoidable hospital readmissions and report annually in the Quality Measures report

4/20/2021 Medicaid State Plan Print View https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwXRmZtl2LIcjf-vAMo-BtAWpTgO6QfW7sfytGJjTskhdvPqCEg8Oq… 38/38 PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format deţned by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reŤects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in eſorts to boost program integrity eſorts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance OŰcer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 4/20/2021 12:39 PM EDT

Table of Contents State/Territory Name: New Mexico State Plan Amendment (SPA) #: 22-0016 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 601 E. 12th St., Room 355 Kansas City, Missouri 64106 Medicaid and CHIP Operations Group September 22, 2022 Ms. Nicole Comeaux Director Medical Assistance Division New Mexico Human Services Department 2025 South Pacheco Drive P.O. Box 2348 Santa Fe, New Mexico 87504-2348 Re: New Mexico State Plan Amendment (SPA) 22-0016

Dear Ms. Comeaux:

The Centers for Medicare & Medicaid Services (CMS) reviewed your Medicaid State Plan Amendment (SPA) submitted under transmittal number (TN) 22-0016. This amendment proposes to implement changes to state plan limits on amounts for necessary medical or remedial care to comply with 42 CFR 435.725(c)(4).

We conducted our review of your submittal according to statutory requirements in Title XIX of the Social Security Act and implementing regulations 42 CFR 435.725(c)(4). This letter is to inform you that New Mexico Medicaid SPA 22-0016 was approved on September 22, 2022, with an effective date of December 1, 2022.

If you have any questions, please contact Peter Banks at (415) 744-3782 or via email at Peter.Banks@cms.hhs.gov. Sincerely,

James G. Scott, Director Division of Program Operations cc: - Nicole Comeaux - Valerie Tapia - Donna Lopez

DEPARTMENT OF HEALTH ANDHUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB No. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES 1. TRANSMITTAL NUMBER 2. STATE 3. PROGRAM IDENTIFICATION: TITLE OF THE SOCIAL SECURITY ACT TO: CENTER DIRECTOR CENTERS FOR MEDICAID & CHIP SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES 4. PROPOSED EFFECTIVE DATE 5. FEDERAL STATUTE/REGULATION CITATION 6. FEDERAL BUDGET IMPACT (Amounts in WHOLE dollars) a. FFY $ b. FFY $ 7. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT GOVERNOR’S OFFICE REPORTED NO COMMENT OTHER, AS SPECIFIED: COMMENTS OF GOVERNOR’S OFFICE ENCLOSED NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 11. SIGNATURE OF STATE AGENCY OFFICIAL 15. RETURN TO 12. TYPED NAME 13. TITLE 14. DATE SUBMITTED FOR CMS USE ONLY 16. DATE RECEIVED 17. DATE APPROVED PLAN APPROVED - ONE COPY ATTACHED 18. EFFECTIVE DATE OF APPROVED MATERIAL 19. SIGN OVING OFFICIAL 20. TYPED NAME OF APPROVING OFFICIAL 21. TITLE OF APPROVING OFFICIAL 22. REMARKS FORM CMS-179 (09/24) Instructions on Back PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable) SUBJECT OF AMENDMENT GOVERNOR’S REVIEW (Check One)

SUPPLEMENT 3 to ATTACHMENT 2.6-A

Page 1 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: New Mexico REASONABLE LIMITS ON AMOUNTS FOR NECESSARY MEDICAL OR REMEDIAL CARE NOT COVERED UNDER MEDICAID

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. 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 “Professional Providers, Services, and Reimbursement”, even if such practitioner is not a Medicaid provider. 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 the New Mexico Administrative Code “Resource Standards” section (or a prorated amount of this figure, for unpaid nursing facility services that are for less than a full month). The deduction for medical and remedial care expenses that were incurred as the result of a transfer penalty period is limited to zero. 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. 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.

TN No. 22-0016

Approval Date: 9/22/2022 Supersedes TN No. 93-12 Effective Date: 12/1/2022

Table of Contents State/Territory Name: New Mexico State Plan Amendment (SPA) #: 23-0005 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

Records / Submission Packages - View All

NM - Submission Package - NM2023MS00020 - (NM-23-0005) - Eligibility

Summary Reviewable Units Versions Correspondence Log

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Department of Health & Human Services Centers for Medicare & Medicaid Services

601 E. 12th St., Room 355

Kansas City, MO 64106

Center for Medicaid & CHIP Services March 22, 2024

Dana Flannery

Medicaid Director, NM Human Services Department

NM Human Services Department, Medical Assistance Division 2025 South Pacheco Drive

P.O. Box 2348

Santa Fe, NM 87504

Re: Approval of State Plan Amendment NM-23-0005

Dear Dana Flannery,

Approval

RAI Transaction Logs News. Related Actions v

CMS

CENTERS FOR MEDICARE & MEDICAID SERVICES

On March 10, 2023, the Centers for Medicare and Medicaid Services (CMS) received New Mexico State Plan Amendment (SPA) NM-23-0005, in which the state proposed to adopt the changes to the eligibility rules for the Former Foster Care Children eligibility group, as enacted by the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act, Pub. L. No. 115-217, section 1002.

We approve New Mexico State Plan Amendment (SPA) NM-23-0005 with an effective date(s) of January 01, 2023.

If you have any questions regarding this amendment, please contact Dana Brown at Dana.Brown@cms.hhs.gov.

Sincerely, James G. Scott Director

Center for Medicaid & CHIP Services

Records / Submission Packages - View All

NM - Submission Package - NM2023MS00020 - (NM-23-0005) - Eligibility

Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter RAI Transaction Logs News. Related Actions v

CMS-10434 OMB 0938-1188

Submission - Summary

MEDICAID | Medicaid State Plan | Eligibility | NM2023MS00020 | NM-23-0005

Package Header

Package ID NM2023MS00020 SPAID NM-23-0005 Submission Type Official Initial Submission Date 3/10/2023 Approval Date 03/22/2024 Effective Date N/A

Superseded SPAID N/A

State Information

State/Territory Name: New Mexico Medicaid Agency Name: NM Human Services Department, Medical Assistance Division

Submission Component

State Plan Amendment Medicaid CHIP

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | NM2023MS00020 | NM-23-0005 Package Header Package ID NM2023MS00020 Submission Type Official Approval Date 03/22/2024 Superseded SPAID N/A

SPA ID and Effective Date

SPAID NM-23-0005

Reviewable Unit Proposed Effective Date Mandatory Eligibility Groups 1/1/2023 Former Foster Care Children 1/1/2023

Page Number of the Superseded Plan Section or Attachment (If Applicable):

SPAID NM-23-0005 Initial Submission Date 3/10/2023

Effective Date N/A

Superseded SPA ID NM-22-0013

NM-17-0005

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | NM2023MS00020 | NM-23-0005 Package Header

Package ID NM2023MS00020 SPAID NM-23-0005 Submission Type Official Initial Submission Date 3/10/2023 Approval Date 03/22/2024 Effective Date N/A

Superseded SPAID N/A

Executive Summary

Summary Description Including Effective January 1, 2023, changes are being made to the Former Foster Care Children (FFCC) group to comply with changes Goals and Objectives made to Section 1002(a) of the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for

Patients and Communities (SUPPORT) Act. One change mandates that eligibility for the FFCC group be allowed for. individuals who age out of foster care from another state than where they currently live. New Mexico already allows coverage for FFCC group individuals who age out of foster care from another state through an 1115 Waiver. New Mexico will continue to include individuals who aged out of foster care from another state prior to January 1, 2023 through the 1115 Waiver; the new State Plan change applies only to individuals who aged out of foster care from another state on or after January 1, 2023. A second change of the SUPPORT Act provides that individuals who meet the eligibility requirements of the FFCC group may be enrolled in that group, even if they meet the eligibility requirements for another mandatory group, as long as they are not actually enrolled in such group.

Federal Budget Impact and Statute/Regulation Citation

Federal Budget Impact

Federal Fiscal Year Amount First 2023 $0 Second 2024 $0

Federal Statute / Regulation Citation

Statute: 1902(a)(10)(A)(i)(IX); Section 1002(a)(2) of the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (Pub. L. No. 115-271) Regulation: 42 CFR 435.150

Supporting documentation of budget impact is uploaded (optional).

Name Date Created

No items available

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | NM2023MS00020 | NM-23-0005 Package Header Package ID NM2023MS00020 Submission Type Official Approval Date 03/22/2024 Superseded SPAID N/A

Governor's Office Review

No comment

Comments received

No response within 45 days Other

SPAID NM-23-0005 Initial Submission Date 3/10/2023

Effective Date N/A

PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state's program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

This view was generated on 3/22/2024 2:28 PM EDT

Records / Submission Packages - View All

NM - Submission Package - NM2023MS00020 - (NM-23-0005) - Eligibility

Summary Reviewable Units Versions Correspondence Log Analyst Notes — Approval Letter RAI Transaction Logs News Related A v

CMS-10434 OMB 0938-1188

Medicaid State Plan Eligibility Mandatory Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | NM2023MS00020 | NM-23-0005 Package Header Package ID NM2023MS00020 SPAID NM-23-0005 Submission Type Official Initial Submission Date 3/10/2023 Approval Date 03/22/2024 Effective Date 1/1/2023 Superseded SPAID NM-22-0013

System-Derived

Mandatory Coverage A. The state provides Medicaid to mandatory groups of individuals. The mandatory groups covered are:

Families and Adults

Include RU In Package Included in Another e Submission Package

Eligibility Group Name Covered In State Plan Source Type @

Infants and Children under Age 19 Cc O CONVERTED Parents and Other

Caretaker Relatives CONVERTED

Pregnant Women APPROVED

Deemed Newborns NEW

Children with Title IV-E Adoption Assistance, Foster Care or Guardianship Care

NEW

Former Foster Care Children APPROVED Transitional Medical NEW Assistance

Extended Medicaid due to Spousal Support Collections

NEW

(o] [el fe) fe) le fe} be fe nM O00 0 080

Aged, Blind and Disabled

Include RU In Package Included in Another e Submission Package

Cc O NEW O NEW c O NEW

Eligibility Group Name Covered In State Plan Source Type @

SSI Beneficiaries

Closed Eligibility Groups

Individuals Deemed To Be Receiving SSI

[e] [e} fe) Mn

Eligibility Group Name

Working Individuals under 1619(b)

Qualified Medicare Beneficiaries

Qualified Disabled and Working Individuals

Specified Low Income Medicare Beneficiaries

Qualifying Individuals

Covered In State Plan

Include RU In Package e

Included in Another Submission Package

O