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New Mexico Health Care Authority.
[8.100.100.1 NMAC - Rp 8.100.100.1 NMAC, 7/1/2024]
The rule applies to the general public.
[8.100.100.2 NMAC - Rp 8.100.100.2 NMAC, 7/1/2024]
A. Section 27 NMSA 1978 (1992 Repl.) provides for the health care authority to "...adopt, amend and repeal bylaws, rules and regulations…." It also provides for administration of public assistance programs.
B. The income support division (ISD) of the health care authority was created by the secretary under authority granted by Paragraph (3) of Subsection B of Section 9-8-6 NMSA 1978.
C. Section 9-8-1 et seq. NMSA 1978 establishes the health care authority (HCA) as a single, unified department to administer laws and exercise functions relating to health care facility licensure and health care purchasing and regulation.
[8.100.100.3 NMAC - Rp 8.100.100.3 NMAC, 7/1/2024]
Permanent.
[8.100.100.4 NMAC - Rp 8.100.100.4 NMAC, 7/1/2024]
July 1, 2024, unless a different date is cited at the end of a section.
[8.100.100.5 NMAC - Rp 8.100.100.5 NMAC, 7/1/2024]
The objective of these regulations is to provide general policy and procedures for income support division (ISD) administered programs.
[8.100.100.6 NMAC - Rp 8.100.100.6 NMAC, 7/1/2024]
[ RESERVED ]
[8.100.100.7 NMAC - Rp 8.100.100.7 NMAC, 7/1/2024]
The HCA secretary has authority to adopt rules and regulations governing the activities of HCA. These rules and regulations are subject to differing requirements regarding prior notice or hearing. This section details the differing types of rules and requirements relative to promulgation of those rules.
A. Regulations
(1) Internal rules: The HCA secretary has the authority to adopt rules governing the internal operations of the HCA without giving prior notice or opportunity for a hearing
(2) Permanent rules: The secretary approves final rules implementing proposals to adopt, amend or repeal HCA rules and regulations in accordance with the provisions and procedures set forth in Subsections B-F of 8.100.100.8 NMAC.
(3) Interim rulemaking: Under Subsection F of Section 9-8-6 NMSA 1978, the secretary may adopt interim rules where necessary due to reductions in federal funding which do not allow the time necessary to proceed through the regular rule promulgation process. In this process, the secretary must give at least 20 days individual notice of the change but, may then implement on an interim basis until the normal proposed rule publication and hearing process can be carried out. Following that process, the interim rule is superseded by the final rule developed in accordance with the provisions set forth below.
B. Notice of public hearing: A notice of public hearing on the proposed action shall include:
(1) description of the proposed action stated in a manner designed to be easily understood by individuals not knowledgeable in the field of administrative law;
(2) time, place and date of the public hearing on the proposed action, and name of contact person;
(3) manner in which interested individuals may present their views on the proposed action and the cost, if any, to an individual of a copy of the proposed regulations.
C. Publication of notice of public hearing: A public hearing notice is published once, at least 30 days before the hearing date, in at least one newspaper of general circulation in the state.
D. Request for advance notice: Anyone interested in routinely receiving notices of public hearings on HCA proposed rule-making actions may file a written request to be placed on a public notice mailing list. HCA mails copies of hearing notices to all such individuals at least 30 days before the hearing date.
E. Hearing procedures: A hearing is held in accordance with the hearing notice. HCA provides a reasonable opportunity for interested individuals to comment on and state their views regarding the proposed action. The hearing is conducted informally and the rules of evidence do not apply. HCA may, but is not required to, make a verbatim record of the hearing through stenographic notes, tape recording or similar methods.
F. Final decision by the secretary: After a public hearing, the secretary may adopt, change or reject the proposed action. The secretary's decision is delivered in writing, including the reasons for making it and a copy of any rule or regulation adopted or amended. The secretary takes reasonable steps to publicize the final decision but is not required to publish it in a manner other than that required under the State Rules Act unless otherwise required by law.
G. The adoption, amendment or repeal of a rule or regulation under this section is filed and becomes effective in accordance with the provisions of the State Rules Act.
[8.100.100.8 NMAC - Rp 8.100.100.8 NMAC, 7/1/2024]
A. ISD's primary mission is to relieve, minimize or eliminate poverty and to make available certain services for eligible low-income individuals and families through statewide programs of financial assistance, food assistance, and employment assistance and training services.
B. Human dignity and client rights: HCA has a commitment to respect for human dignity. Therefore, all programs are administered in a manner respectful of the dignity and personal privacy and rights of program beneficiaries. Discrimination based on personal judgments of a client's behavior, social status, religion, race, cultural patterns, personality, political beliefs, color, handicap or sex, is a violation of the law and a violation of ISD policy.
[8.100.100.9 NMAC - Rp 8.100.100.9 NMAC, 7/1/2024]
Each assistance program in which eligibility is determined under ISD2 (HCA’s automated eligibility system), the HCA’s eligibility and payment determination and issuance system is referred to as a category of assistance. A two-digit number is assigned to each category indicating the program of assistance. Following is a list of categories, program titles to which they refer, and the type of assistance provided under each. This listing is for informational purposes only.
Category Title Explanation 01 03 04 aid to the aged, blind, and disabled medical - former SSI cases eligible because of the disregard of social security increases received after July, 1977 ( medicaid extension applies only to former SSI recipients). 02 NMW financial and medical 05 general assistance financial - temporary disability 06 non IV-E foster care medical 08 general assistance financial - unrelated children 09 general assistance financial - permanent disability 10 state supplement for residential shelter care financial - medical assistance for these cases is available based on SSI availability 14 refugee foster care medical 17 IV-E adoption subsidy - established in another state medical 19 refugee assistance financial - medical 27 post-NMW medical medical - four months medicaid coverage when NMW closing caused by increased child support 28 transitional medicaid medical - up to 12 months medicaid coverage when NMW closing caused by increased earnings 30 medical assistance for women & children (MAWC) medical - full medicaid coverage for pregnant women 31 medical assistance for women & children medical - twelve months medicaid coverage for newborns 32 medical assistance for women & children medical - for children born after September 30, 1983 33 medical assistance for women & children medical - NMW denied because of deemed income from stepparents, alien sponsors, grandparents or siblings (deemed income is any income of another individual which is counted in determining the recipient’s eligibility) 34 medical assistance for women & children medical - SSI denials because of deemed income from stepparents or alien sponsors 35 medical assistance for women & children medical - medicaid coverage restricted to pregnancy related matters for pregnant women 37 IV-E in-state adoption subsidy medical 39 food stamps food 40 qualified medicare beneficiary (QMB) payment of medicare Part A premium and the coinsurance and deductible amounts on medicare covered services 42 qualified disabled working individuals medical 45 specified low income medicare beneficiary payment of medicare Part B premium for applicants who already have Part A. (state will not pay Part A premium). 46 out-of-state foster care medical - no card issued, services by prior approval only 47 out-of-state adoption subsidy medical - no card issued, services by prior approval only 49 refugee assistance medical medical assistance for the seriously ill 51 aged medical 53 blind medical 54 disabled medical 59 refugee medical assistance (spend down required) medical 66 IV-E foster care medical medical assistance for persons requiring institutional care 81 aged medical 83 blind medical 84 disabled medical 85 emergency assistance for ineligible aliens medical 86 IV-E foster care custody out- of-state medical in-home and community based medicaid waiver programs 90 AIDS medical 91 aged medical 93 blind medical 94 disabled medical 95 medically fragile medical 96 developmentally disabled medical 97 98 99 aged developmentally disabled disabled/blind categories not eligible for federal matching funds under Title XIX. These categories were closed to new approvals effective November, 1989.
[8.100.100.10 NMAC - Rp 8.100.100.10 NMAC, 7/1/2024]
A. NMW:
(1) Purpose: The purpose of the New Mexico works (NMW) program is to improve the quality of life for parents and children by increasing family income, assisting parents to develop the discipline necessary for self-sufficiency and to improve their self-esteem. The further purpose of the program is to increase family income through family employment and child support and by viewing financial assistance as a support service to enable and assist parents to participate in employment.
(2) The program accomplishes this purpose by providing cash assistance, medical assistance, and work program services, including education, job training, and transportation to assist recipients in obtaining and keeping employment that is sufficient to sustain their families thereby ensuring the dignity of those who receive assistance and strengthening families and the families' support for their children.
(3) Legal basis: The New Mexico Works Act assigns responsibility for administration of the New Mexico works program to the health care authority. The governor of the state of New Mexico has designated the HCA as the TANF state agency in the state's biennial TANF block grant plan, pursuant to the requirements of Section 401 of Title IV-A of the federal Social Security Act.
B. General assistance:
(1) Purpose : General assistance (GA) is a limited program providing financial assistance to needy individuals and families who are not eligible for assistance under the New Mexico works program or under the federal supplemental security income (SSI) program. GA payments are made to:
(a) disabled adults who do not qualify for NMW who are not eligible for SSI because their disability is not severe enough;
(b) disabled adults who do not qualify for NMW;
(c) on behalf of children under 18 years of age who would be eligible for NMW except that they are not living with a person who is eligible to receive NMW; and
(d) SSI recipients who reside in licensed adult residential care homes.
(2) Legal basis: Section 27-1-3 NMSA (Repl. 1984) provides that "the state department shall: administer assistance to the needy, blind and otherwise handicapped and general relief."
C. Food stamps:
(1) Purpose: The food stamp program is designed to promote the general welfare and to safeguard the health and well-being of the nation's population by raising the levels of nutrition among low-income households.
(2) Section 2 of the Food Stamp Act of 1977 states, in part: Congress hereby finds that the limited food purchasing power of low-income households contributes to hunger and malnutrition among members of such households. To alleviate such hunger and malnutrition, a food stamp program is herein authorized which will permit low-income households to obtain a more nutritious diet through normal channels of trade by increasing food purchasing power to all eligible households who apply for participation.
(3) Legal basis: The food stamp program is authorized by the Food Stamp Act of 1977 as amended (7 U. S. C. 2011 et seq.). Regulations issued pursuant to the act are contained in 7 CFR Parts 270-282. state authority for administering the food stamp program is contained in Chapter 27 NMSA, 1978. Administration by HCA, including its authority to issue regulations, is governed by Chapter 9, Article 8 NMSA (Repl. 1983).
D. Refugee resettlement program:
(1) Purpose: The purpose of the refugee resettlement program (RRP) is to help refugees, political asylees and entrants, regardless of national origin, achieve economic self-sufficiency as quickly as possible. The purposes of the program are accomplished through financial and medical assistance while support services are provided to help refugees acclimate to American society, learn English and get a job. Federal legislation gives eligible refugees and their dependents financial and medical assistance through one hundred percent federal reimbursement to states, including administrative costs, for the first 18 months after entry into the United States.
(2) Legal basis: The refugee resettlement program (RRP) is authorized under Title IV of the Immigration and Nationality Act of 1980. The act designates the U.S. department of health and human services as the federal administering agency. RRP program regulations are issued by DHHS in the Code of Federal Regulations Title 45, Part 400, supplemented by administrative and program instructions issued by the federal department from time to time. By Executive Order No. 80-62, dated 10/1/1981, the governor of the state of New Mexico has designated HCA as the single state agency responsible for administering the program in New Mexico.
E. Medical assistance programs:
(1) Medicaid:
(a) Purpose: Medicaid is a federally matched program that makes certain essential health care services available to eligible New Mexico residents who otherwise would not have the financial resources to obtain them. With certain exceptions, medicaid benefits are provided through “ salud !”, the HCA's medicaid managed care program.
(b) Eligible individuals include:
( i ) families who meet New Mexico's AFDC requirements as it existed, or is considered to have existed, on July 16, 1996, as amended;
(ii) individuals who have been NMW recipients and are in transition to self-support due to employment, child support, or both;
(iii) pregnant women who meet income and resource requirements for the state's AFDC program as it existed, or is considered to have existed on July 16, 1996, as amended (full-coverage medicaid );
(iv) children under 19 years of age whose income is below one hundred eighty-five percent of federal poverty levels;
(v) pregnant women with income below one hundred eighty-five percent of federal income poverty levels (for pregnancy-related services);
(vi) recipients of assistance under the federal SSI program and those who have lost their SSI eligibility because of cost-of-living increases in Title II benefits;
(vii) aged, blind, and disabled individuals in institutions who meet all standards for SSI except income;
(viii) individuals who meet all standards for institutional care but can be cared for at home;
(ix) qualified medicare beneficiaries (QMBs), qualified disabled working individuals (QDs),
(x) and specified low income medicare beneficiaries (SLIMBs), limited coverage for medicare beneficiaries; and
(xi) certain foster children in the custody of the state.
(c) Legal basis: HCA is the single state agency designated to administer the New Mexico Title XIX medicaid program in accordance with 42 CFR 431.10, single state agency. State authority is provided by Section 27-2-12 NMSA 1978 (Repl. 1984). Title XIX of the Social Security Act and United States department of health and human services rules establish the requirements for state plans for medical assistance.
(2) Special medical needs:
(a) Purpose: The special medical needs program for seriously ill individuals is an entirely state-funded medical assistance program for individuals who suffer serious illnesses. Individuals applying under this program must be eligible according to New Mexico statutes and HCA policy. No new recipients are being added to this category.
(b) Legal basis: State authority for administering the special medical needs program is contained in Sections 27-4-1 to 27-4-5 NMSA 1978 (Repl. 1984).
(3) Medical assistance to refugees
(a) Purpose: This program operates in accordance with the provisions of the medicaid program but is at present one hundred percent funded by the federal government. Medical assistance is provided to individuals and families qualifying for assistance under the refugee resettlement program.
(b) Legal basis: State authority for administering the medical assistance to refugees program is contained in Section 27-2-12 NMSA 1978 (Repl. 1984).
(4) Waivers for in-home care: The New Mexico department of health, under waivers from DHHS, provides certain in-home care services as an alternative to institutionalization. These waivers authorize services for: elderly, blind and physically handicapped individuals; developmentally disabled individuals; and medically fragile individuals, AIDS. Services under the waiver program are provided to both medicaid -eligible individuals and those who have income and resources in excess of medicaid standards. Within the HCA, the medical assistance division (MAD) is responsible for developing policy and regulations for these waiver programs.
F. Energy assistance:
(1) Purpose: Three energy assistance programs to assist low-income households during periods of high heating costs are administered by HCA:
(a) low income home energy assistance program (LIHEAP);
(b) emergency crisis intervention assistance program (ECIAP); and
(c) low income utility assistance program (LIUAP).
(2) Energy assistance is provided for home heating costs incurred during the months of November, December, January, and February of each year. The HCA may extend the program season by one or more months subject to the availability of supplemental state or federal funds.
(3) Legal basis: These programs are governed by the federal, state and other pertinent laws and regulations established for a defined program period, including but not limited to the following:
42 USC Section 8601: Chapter 94, Subchapter II, Low Income Home Energy Assistance Act (LIHEAA);
Sections 27-6-11 to 27-6-16 NMSA 1978 (Repl. 1984) Low Income Utility Assistance Act (LIUAA).
(4) Funding for the LIHEAP and ECIAP programs is from the LIHEAA block grant.
G. Child support services:
(1) Every specified parent/relative caretaker who applies for or receives NMW from HCA is required, as a condition of eligibility, to make an assignment of support rights to the state and to cooperate with the state, if necessary, in establishing paternity and securing support.
(2) Exception: The cooperation requirement is not applied in cases where it would not be in the best interests of the child to cooperate.
(3) The provisions of the child support enforcement program are contained in Title IV-D of the Social Security Act, and the agency responsible for its implementation is frequently referred to as the IV-D agency. In New Mexico, the IV-D agency is the HCA child support services division (CSSD).
[8.100.100.11 NMAC - Rp 8.100.100.11 NMAC, 7/1/2024]
A. Division responsibilities: The income support division (ISD) is responsible for administering all relevant assistance programs in an accurate and timely fashion while treating clients with respect and dignity. The division administers those programs described in 8.100.100.10 NMAC, categories of assistance, and 8.100.100.11 NMAC, general program description.
B. Central office responsibilities: The division’s central office includes the director, deputy directors and staff. Generally, central office is responsible for developing and managing division programs, program and organizational budgets and division personnel. It provides oversight and supervision of division field offices.
C. Field office responsibilities: ISD county field offices are located in the majority of counties in the state. Counties without ISD field offices may be served by scheduled itinerant visits. The county field office is the ISD unit responsible for the direct administration of ISD's food, medical, energy and financial assistance programs. The offices administer programs according to HCA regulations and policies. Each county office is supervised by a county director, who is responsible for the overall operation of the office, supervising office employees, and administering ISD programs. County directors report to and are supervised by ISD’s deputy director for field operations.
D. Privacy:
(1) Procedures used to determine eligibility must respect the rights of the client under the United States constitution, the Social Security Act, Title VI of the Civil Rights Act of 1964, or any other relevant provisions of state and federal laws. Intrusions on a client's privacy and personal dignity are limited to what is reasonably necessary to make sure that expenditures made under the programs are accurate and legal.
(2) Prohibited activities: Specifically prohibited activities include:
(a) entering a home by force or without permission;
(b) making home visits outside of normal ISD working hours; and
(c) searching a home for clues of possible deception.
[8.100.100.12 NMAC - Rp 8.100.100.12 NMAC, 7/1/2024]
A. Both the Social Security Act and the Food Stamp Act require the state agencies responsible for the administration of these programs to provide for the confidentiality of information about applicants for and recipients of program benefits.
B. "Confidential information" includes all information about an applicant for or recipient of program assistance contained in division records, as well as information obtained by division employees in their official capacity, whether such information is recorded or not. The term also includes records of division evaluations of recorded information. The term does not include general information of a statistical nature that cannot be identified with a particular individual or family group.
C. Access to Information: All information and documentation contained in a case record, with the exception of medical information and narrative dated before February 1, 1977, may be released to an adult family member or their representative on request. In financial assistance cases, confidential information is not released to the dependent children or the spouse (if not the other parent) of the specified relative, unless permission to do so is given by the specified relative.
D. Specific legal basis:
(1) Federal law: The Social Security Act, as amended, requires that state agencies administering the temporary assistance for needy families (TANF) program limit the release or use of information about applicants or recipients, including medical reports, to:
(a) purposes directly connected with the administration of TANF (Title IV-A), child support enforcement (Title IV-D), medicaid (Title XIX), social services (Title XX), SSA program (Title V), and SSI program (Title XVI);
(b) investigations, prosecutions or civil or criminal proceedings conducted in connection with the administration of these programs;
(c) agencies administering any other federal or federally-aided program which provides assistance in cash, in kind, or in services directly to individuals based on need, provided that the client's permission to release the information has been obtained in writing; the Food Stamp Act of 1977 and succeeding amendments require safeguards restricting the use or disclosure of information obtained from applicant or recipient households to persons directly connected with the administration or enforcement of the provisions of the act or regulations issued pursuant to the act.
(2) State law: Section 17 of the New Mexico Works Act of 1998 requires the HCA to establish and enforce rules governing the custody and use of records, papers, files and communications and restricting the use or disclosure of information in these documents concerning applicants and recipients of assistance in accordance with federal legislation.
[8.100.100.13 NMAC - Rp 8.100.100.13 NMAC, 7/1/2024]
A. ISD case record:
(1) ISD case records, consisting of forms, records, narrative material, correspondence and documents, are scanned into electronic format and maintained in the HCA’s secure electronic data management system. Documents submitted in person will be electronically scanned and returned to the individual. Original documents mailed to or left with the office will be photocopied and the originals mailed back to the client at their last known address known to the HCA. The copied documents will be electronically scanned and destroyed once successful completion of a scan into electronic format is confirmed. The case record documents the current and historical eligibility of a recipient group and thereby to establish the validity of decisions to approve or deny assistance.
(2) Case records are the property of the HCA and are established and maintained solely for use in the public assistance programs administered by the HCA. Information contained in the case record(s) is confidential and is released only under the limited circumstances and conditions as provided in federal and state laws and regulations, including Sections 13 through 15, 8.100.100 NMAC. Case records and their contents must remain in the possession of the HCA, its contractors, or approved federal employees. Copies of case records may be released in accordance with federal and state laws and regulations or pursuant to a court order.
(3) Electronic eligibility system information: Client information stored on the HCA's electronic eligibility system is subject to the same guidelines for release of information as the HCA’s case record.
B. Persons with access to confidential information:
(1) Client: The name of an individual(s) providing confidential information to the HCA regarding a client is not released to a client or the client’s authorized representative. The release of all other case information is subject to the following conditions:
(a) A client or their authorized representative must complete a request for access to a case record each time they wish to have access to the case record. If the client wishes to have their authorized representative review the record in their absence, the client must provide formal documentation authorizing the named individual(s) to access the identified case information for a specified purpose and time frame. This includes an individual(s) acting as the client’s authorized representative in a fair hearing. Only the client or the client’s authorized representative may authorize another individual(s) to review the record.
(b) The record must be reviewed in the presence of the county director or designee.
(c) If a client disagrees with information contained in the case record, he or she may make a written rebuttal which is made part of the case record. Contested material may not be removed from the case record.
(2) Inquiries on client’s behalf: Inquiries made on behalf of a client regarding eligibility for or amount of assistance received are treated as coming from private individuals, regardless of whether they come from a private citizen, elected official, or public or private agency. The HCA must receive formal documentation from the client or the client’s authorized representative permitting the release of information.
(3) HCA employees: Confidential information is available to employees or agents of the HCA who need it in connection with the various services and public assistance programs administered by the HCA. This includes field and central office staff, representatives of the child support services division (CSSD) and medical assistance division (MAD), and private firms or other agencies under contract with the HCA that perform work or provide services related to public assistance programs. Confidential information is also available to employees of the federal government concerned with the public assistance programs administered by the HCA.
(4) Non-HCA employees: Confidential information about applicants for and recipients of public assistance may be released to other agencies or individuals including law enforcement officers that meet all of the following standards:
(a) agency or individual is involved in the administration of a federal or a federally-assisted program that provides assistance in cash, in kind or in services, directly to individuals on the basis of need;
(b) information is to be used for the purpose of establishing eligibility, determining amount of assistance or for providing services for applicants or recipients;
(c) agency or individual is subject to standards of confidentiality comparable to those of the HCA; and
(d) agency or individual has actual or implied consent of the applicant or recipient to release the information; in an emergency, information may be released without permission, but the client must be informed of its release immediately thereafter; consent may be considered as implied if a recipient or member of the assistance group has made application to the inquiring agency for a benefit or service.
(5) Funding agencies/auditors: The HCA’s public assistance programs’ funding agencies and auditors may have access to and use of client information and is subject to the confidentiality requirements specified above and in accordance with federal and state laws and regulations.
(6) Employers: To claim a tax credit on wages paid to cash assistance recipients, as provided under the Revenue Act of 1978, an employer may request and receive information from the HCA as to whether an employee is a recipient who meets the criteria for either:
(a) the welfare tax credit (NMW recipient during the three month period consisting of the month hired and the two months immediately preceding the date of hire); or
(b) the targeted jobs tax credit (recipient of GA who received GA for at least 30 days, ending within the 60 day period which ends on the hiring date). Such releases are to be made on a case by case basis and must be accompanied by a consent to release information signed by the client.
C. Medical records: Medical reports and medical information in the HCA’s possession, regardless of how they were obtained, may not be shown to a client, unless they are released as part of a fair hearing. Because of the potentially upsetting nature of the facts contained in some reports and because a physician's knowledge is frequently necessary to interpret those facts, a client shall be referred to their physician regarding any questions.
D. Court proceedings:
(1) Program-related court cases:
(a) Criminal or civil court proceedings involving the establishment of paternity and enforcement of child and medical support for recipients, prosecution for fraud, suits for recovery of fraudulently obtained public assistance benefits, third-party recovery, and custody hearings regarding custody of children for whom public assistance is being provided are considered part of the public assistance programs administered by the HCA. The HCA or its interests may be represented in such cases by an attorney from the office of general counsel (OGC), CSSD, CYFD, by a local district attorney, by a representative of the attorney general's office or by a federal prosecutor.
(b) If information contained in a case record or known to an HCA employee is needed in preparation for or as part of a court proceeding, the HCA employee(s) will cooperate in making sure that needed information is supplied. Although employees may receive a subpoena to testify in such a court proceeding, a subpoena is not needed if the court proceeding relates to the public assistance programs administered by the HCA. To the extent possible, attorneys responsible for a case, or other persons helping in preparing the case for court action, will notify the HCA, or other custodian of a case record, in advance and in writing, of the need for court testimony, whether the record should be brought, and of the time, date and place of hearing. If there is not enough time before the hearing to provide written notice, a phone call that the HCA logs in the narrative section of the case record, is sufficient. If it is not clear whether a court proceeding relates to the public assistance programs administered by the HCA, the local county office may contact the OGC or the appropriate division director’s office for help.
(2) Non-program related court cases: Any person or attorney seeking confidential information from a case record for a non-program related court case should direct a properly issued subpoena to the appropriate local county office with a copy also sent to the HCA’s OGC. The HCA will seek to preserve the confidentiality of the case record unless the release of the information is expressly authorized by federal and state laws and regulations or is otherwise ordered by a court of competent jurisdiction.
[8.100.100.14 NMAC - Rp 8.100.100.14 NMAC, 7/1/2024]
A. Policy and procedures manual: The regulations for the public assistance programs administered by the HCA are located on the official website of the New Mexico administrative code located at http://www.nmcpr.state.nm.us/nmac/. Procedures and policy guidance is located at the official HCA website under the specified division at http://www.HCA.nm.gov. Copies of appropriate regulations and procedures and policy guidance will be provided to the claimant as part of the summary of evidence in a fair hearing pursuant to Subsection F of 8.100.970.10 NMAC.
B. State program and plan materials: The HCA state plans are available at the official HCA website under the specified division at http://www.HCA.nm.gov.
C. Other printed materials: Additional printed materials, such as brochures and pamphlets describing basic financial and nonfinancial eligibility criteria, the application process, and participant rights and responsibilities, are available at the local county offices, social security administration offices, state employment services offices, other agencies providing public assistance services, and the official HCA website at http://www.HCA.nm.gov.
D. Federal laws, regulations and other materials: Federal materials should be obtained by contacting the responsible federal agency directly. The university of New Mexico is a federal repository. Many federal agencies post regulations, planning documents and requirements as well as program instructions on the internet.
[8.100.100.15 NMAC - Rp 8.100.100.15 NMAC, 7/1/2024]
A. Statement of nondiscrimination: HCA programs must be administered in a manner which makes sure that no person is denied any aid, care, services or other benefits on the grounds of race, color, age, sex, handicap, religious creed, national origin or political beliefs, or is otherwise subjected to unlawful discrimination.
B. Right to file complaint: Any individual who thinks they are being discriminated against because of race, color, sex, handicap, religious creed, national origin or political beliefs has the right to file a complaint with the central or any local HCA office, or with the U.S. department of health and human services, the U.S. department of justice, the U.S. department of agriculture, or the civil rights commission in Washington D.C.
(1) Complaint form: Individuals wishing to file complaints with HCA may use forms provided by ISD on request. A letter or statement, written or oral, expressing a belief of being unlawfully discriminated against is also accepted as a complaint.
(2) Unwritten complaints: If an individual alleges that a discriminatory act has been committed, but refuses or is reluctant to put the complaint in writing, the person receiving the complaint does so.
(3) Written complaints: Written complaints are accepted even if the information listed below (in Paragraph 6 of Subsection B of 8.100.100.16) is incomplete.
(4) Investigation: HCA investigates any complaints received. Individuals making complaints are told whether unlawful discrimination is found to exist and what other action may be taken by complainants who are not satisfied with the decision.
(5) Food stamp complaint deadline: A complaint claiming unlawful discrimination in the food stamp program must be filed no later than 180 days after the date of the alleged discrimination. However, this deadline may be extended by the U.S. secretary of agriculture.
(6) Information needed:
(a) name, address and telephone number or other means of contacting complainant;
(b) location and name of individual/agency responsible for delivering service and accused of discriminatory practices;
(c) nature of incident or action causing the complainant to allege unlawful discrimination; or an example of the aspect of the program administration which is alleged to harm potential participants or the individual making the complaint;
(d) basis on which complainant feels unlawful discrimination exists (age, race, handicap, sex, religious creed, color, national origin or political beliefs);
(e) names, titles and addresses of persons who may have knowledge of the discriminatory acts;
(f) date or dates on which the alleged discriminatory actions occurred.
C. Complaint system: Complaints regarding individual case deficiencies, such as processing standards or service to participants and applicants, are referred to the relevant county office.
(1) Exclusions: This procedure does not include:
(a) complaints that can be pursued through a fair hearing; and
(b) some mail issuance complaints: for example, if a recipient complains of nonreceipt of coupons through the mail, the procedures for replacement of coupons lost in the mail are followed; however, if the complaint concerns the mailing system, (staggered issue, use of certified mail, etc.) the complaint is handled through the complaint procedure.
(2) Filing: No special format is necessary for an individual to file a complaint. Instead, the complainant is encouraged to lodge a complaint by telephone (using HCA's toll-free number), through the mail, or in person. If a complainant needs help lodging the complaint, an ISS provides this help.
(3) Response: A complainant receives a response to their complaint within 10 days after receipt of the complaint.
(4) Public information: ISD personnel give information regarding the complaint system and civil rights complaints to all program recipients, applicants, and other interested persons. Such information is provided to clients during interviews, included in brochures, and publicized by posters displayed in all ISD offices.
D. Bilingual services: The state provides bilingual outreach materials and staff. This service is provided to households without an English-speaking adult. If a recipient has limited literacy or comprehension of English, the HCA employee provides, in a language understood by the recipient, an explanation containing the following elements:
(1) that the information requested is needed to determine eligibility for assistance;
(2) the consequences of providing incorrect or incomplete information;
(3) that changes in circumstances must be reported to HCA according to specific program changes;
(4) the consequences of failure to report changes;
(5) that HCA takes appropriate legal and administrative steps to recover overpayments which result from incorrect, incomplete or late reporting of information;
(6) a list of all information or changes which must be reported;
(7) monthly or other periodic reporting requirements.
[8.100.100.16 NMAC - Rp 8.100.100.16 NMAC, 7/1/2024]
A. Electronic benefit transfer (EBT): SNAP and cash benefits are issued through a direct deposit into an EBT account. The benefits are maintained in a central database and accessed by the household through an individual debit card issued to the household.
B. Initial issuance of EBT card: The EBT card is issued to the designated payee of the eligible household or to the designated authorized representative.
(1) The EBT card is mailed to the head of household or the designated authorized representative on the first working day after the application is registered. The applicant or recipient shall receive training on the use of the EBT card prior to activation of the EBT card.
(2) The EBT card shall be issued to the payee for an eligible household through the most effective means identified by HCA which may include issuance at the county office or by mail.
(3) The applicant or recipient must verify their identity.
(4) The payee for the eligible household may select the four-digit personal identification number that will allow access to the household’s benefits.
C. Replacement of the EBT card : The recipient or designated authorized representative shall be instructed on the procedure for replacement of an EBT card that has been lost, stolen or destroyed.
(1) The recipient or designated authorized representative may report a lost, stolen or destroyed EBT card through the HCA EBT contractor customer service help desk, HCA EBT customer service help desk or any ISD field office.
(2) The lost, stolen, or destroyed EBT card shall be deactivated prior to a replacement card being issued to the household.
(3) ISD shall make replacement EBT cards available for client to pick up or place the card in the mail within two business days following notice by the household to ISD that the card has been lost, stolen or damaged.
(4) ISD may impose a replacement fee by reducing the monthly allotment of the household receiving the replacement card, however, the fee may not exceed the cost to replace the card.
D. Excessive replacement cards: The HCA office of inspector general (HCA OIG) will generate a warning letter to SNAP recipients that have replaced their EBT card five or more times in a 12 month period. The letter is a notice of warning and will explain that as a result of the recipient’s high number of replacement EBT cards, their EBT SNAP transactions will be closely monitored. The letter will become part of the recipient’s case record. The letter will:
(1) be written in clear and simple language;
(2) meet the language requirements described at 7 CFR 272.4(b);
(3) specify the number of cards requested and over what period of time;
(4) explain that the next request, or the current request if the threshold has been exceeded, requires contact with ISD before another card is issued;
(5) provide all applicable information on how contact is to be made in order for the client to comply, such as whom to contact, a telephone number and address; and
(6) include a statement that explains what is considered a misuse or fraudulent use of benefits and the possibility of referral to the fraud investigation unit for suspicious activity.
E. Inactive EBT accounts: EBT accounts which have not been accessed by the recipient in the last 90 days are considered a stale account. HCA may store stale benefits offline after notification to the household of this action.
(1) The notification to the household shall include the reason for the proposed action and the necessary steps required by the recipient to reactive the account.
(2) The recipient may request reinstatement of their EBT account anytime within 364 days after the date of the last benefit account activity.
F. EBT benefit expungement: When benefits have had no activity:
(1) SNA P: HCA may expunge benefits that have not been accessed by the household after a period of 274 days. HCA must attempt to notify the household prior to expungement. Expunged benefits are no longer available to the household. Requests for reactivation must be received prior to expungement and a determination shall be made by the director or designee of the income support division.
(2) Cash: Cash assistance benefits which have had no activity for an excess of 180 days will be expunged. All benefits older than 180 days in the account will no longer be accessible to the household. The household loses all rights to all expunged benefits. The department shall attempt to notify the household no less than 45 days prior to the expungement of the cash assistance benefits.
[8.100.100.17 NMAC - Rp 8.100.100.17 NMAC, 7/1/2024]
A. General statement: Effective staff development and training is an integral part of successful ISD program operations. ISD supports employee attendance at job-relevant training opportunities. Attendance at training sessions needs supervisory approval. Priorities for such approval are:
(1) training to improve skills needed in an employee's current position;
(2) training to add new skills useful in an employee's current position;
(3) training for an employee's career development.
B. Budget: ISD managers are encouraged to develop training plans and budgets for their administrative units. Such plans must be coordinated with the ISD training staff. ISD training staff members are available for consultation in developing these plans and budgets.
[8.100.100.18 NMAC - Rp 8.100.100.18 NMAC, 7/1/2024]
A. Personnel: New employees: ISD encourages prompt attendance at new-employee orientation sessions and requires completion of these sessions as specified in the division's training plan(s).
B. Professional development: ISD supports attendance at training sessions for an employee's professional development needs and goals. Such attendance requires supervisory review and approval and must not interfere with timely performance of an employee's ongoing duties.
[8.100.100.19 NMAC - Rp 8.100.100.19 NMAC, 7/1/2024]
A. New employee training: The division maintains a new-employee training curriculum for all major programs administered by ISD. This program is accessible to all division and HCA employees who need training in food stamps, financial assistance or medical assistance programs.
B. Training standards: ISD training programs conform to the following standards:
(1) Needs assessments: Training programs are developed based upon generally accepted methods of training needs assessment, for example; formal analysis, training needs survey, performance statistics.
(2) Objectives and skills: Training developed and presented by ISD staff must be objective or competency based.
(3) Agenda and prior notification: Training provided to ISD staff members by other HCA employees must, at a minimum:
(a) be planned in advance with enough notice to adjust work schedules;
(b) have a written agenda;
(c) be coordinated with the ISD training staff.
(4) Training event report: All individuals who provide individual training sessions to ISD staff must complete an ISD training event report and submit the form to the ISD training staff.
[8.100.100.20 NMAC - Rp 8.100.100.20 NMAC, 7/1/2024]
Provision of training sessions - The ISD training staff provides program training to providers on request as scheduling permits.
[8.100.100.21 NMAC - Rp 8.100.100.21 NMAC, 7/1/2024]
A. Physical property: It is the responsibility of each ISD county director or bureau chief to develop and maintain plans for ensuring the security office equipment, furniture and facilities according to department and other state and federal government guidelines.
B. Personnel security: ISD staff are provided training in tools and techniques to reduce the incidence or likelihood of violence or threats directed towards the ISD employee.
[8.100.100.22 NMAC - Rp 8.100.100.22 NMAC, 7/1/2024]
A. ISD provides itinerant service to clients residing at a distance from local ISD offices. Income support specialists visit specified locations on a regularly scheduled basis and conduct required interviews.
B. Itinerant schedules are available through local ISD offices. An itinerant location may not be eliminated by ISD without public notice and adequate justification.
[8.100.100.23 NMAC - Rp 8.100.100.23 NMAC, 7/1/2024]
History of 8.100.100 NMAC:
Pre-NMAC History: The material in this part was derived from that previously filed with the State Records Center and Archives:
ISD Rule 100, Program Descriptions, 2/9/1988.
ISD Rule 131, Administrative Policy, 2/10/1988.
ISD Rule 141, Treatment of Clients, 2/9/1988.
ISD Rule 141, Treatment of Clients, 6/18/1990.
ISD Rule 150, Confidential Information, 2/9/1988.
History of Repealed Material:
8 NMAC 3.ISD.000, 8 NMAC 3.ISD.010, 8 NMAC 3.ISD.020, 8 NMAC 3.ISD.030, 8 NMAC 3.ISD.050, 8 NMAC 3.ISD.060, General Administration and 8 NMAC 3.ISD.100, General Operating Procedures - Repealed, 7/1/1997.
8.100.100 NMAC, General Operating Procedures, (filed 3/26/2001)- Repealed effective 7/1/2024.
Other: 8.100.100 NMAC, General Operating Procedures, (filed 3/26/2001)- Replaced by 8.100.100 NMAC, General Operating Procedures, effective 7/1/2024.
New Mexico Health Care Authority.
[8.100.110.1 NMAC - Rp 8.100.110.1 NMAC, 7/1/2024]
The rule applies to the general public .
[8.100.110.2 NMAC - Rp 8.100.110.2 NMAC, 7/1/2024]
A. Section 27 NMSA 1978 (1992 Repl.) provides for the health care authority to "...adopt, amend and repeal bylaws, rules and regulations...." It also provides for administration of public assistance programs.
B. The income support division (ISD) of the health care authority was created by the HCA secretary under authority granted by Paragraph (3) of Subsection B of Section 9-8-6 NMSA 1978.
C. Section 9-8-1 et seq. NMSA 1978 establishes the health care authority (HCA) as a single, unified department to administer laws and exercise functions relating to health care facility licensure and health care purchasing and regulation.
[8.100.110.3 NMAC - Rp 8.100.110.3 NMAC, 7/1/2024]
Permanent.
[8.100.110.4 NMAC - Rp 8.100.110.4 NMAC, 7/1/2024]
July 1, 2024, unless a later date is cited at the end of a section.
[8.100.110.5 NMAC - Rp 8.100.110.5 NMAC, 7/1/2024]
The objective of these regulations is to provide general policy and procedures for income support division (ISD) administered programs.
[8.100.110.6 NMAC - Rp 8.100.110.6 NMAC, 7/1/2024]
[ RESERVED ]
[8.100.110.7 NMAC - Rp 8.100.110.7 NMAC, 7/1/2024]
Each individual shall have the opportunity to apply for public assistance programs administered by the HCA or to have an authorized representative do so on their behalf. Paper application forms must be readily accessible in the ISD local office lobby and provided to any person who requests the form. Applications are made in a format prescribed by the HCA to include paper forms or electronic submissions. All forms and notices will be accessible to individuals with limited-English proficiency or disabilities. ISD will post signs in local field offices which explain the application processing standards and the right to file an application on the day of initial contact.
A. Screening: Every applicant shall have the opportunity to meet, face to face or telephonically, with ISD when an application is submitted during regular business hours. ISD will review the application, assist the applicant in completing the application, if it is incomplete or assistance is otherwise necessary, and will assist in identifying the public assistance program(s) for which the applicant wishes to apply.
(1) Screening for supplemental nutrition assistance program (SNAP) expedited service: ISD will screen SNAP applicants for entitlement to expedited processing, using the standard formula and documenting the application, at the time the household requests assistance.
(a) If the applicant is eligible for expedited service, the SNAP application will be processed in accordance with 8.139.110.16 NMAC.
(b) If expedited SNAP processing is denied, the applicant will be informed of the right to request an agency review conference to be held within two days of the request unless the household requests a later date pursuant to Paragraph (4) of Subsection E of 8.100.970.10 NMAC.
(2) Proof checklist: ISD shall provide each household at the time of application for certification and recertification with a notice that informs the household of the verification requirements the household must meet as part of the application process. The notice shall also inform the household of ISD’s responsibility to assist the household in obtaining required verification provided the household is cooperating with ISD as specified in 7 C.F.R. 273.2(d)(1) and Section F of 8.139.110.11 NMAC. The notice shall be written in clear and simple language and shall meet the bilingual requirements designated in 7 C.F.R. 272.4(b) . At a minimum, the notice shall contain examples of the types of documents the household should provide and explain the period of time the documents should cover.
(3) Scheduling the appointment: ISD must schedule an interview for all applicant households who are not interviewed on the day their application is received by ISD. An interview should be held within 10 working days from the date the application is received by ISD and, to the extent possible, convenient for both the applicant and ISD. To the extent practicable, ISD must schedule the interview to accommodate the needs of groups with special circumstances, including working households. ISD must schedule all interviews as promptly as possible to ensure eligible households receive an opportunity to participate within 30 days after the application is filed. ISD will send an appointment letter for an interview that includes contact information for ISD, date, time and place of the appointment. ISD must notify each household that misses its interview appointment that it missed the scheduled interview and that the household is responsible for rescheduling a missed interview. If the household contacts ISD within the 30-day application processing period, ISD must schedule a second interview. ISD may not deny a household's application prior to the 30th day after application if the household fails to appear for the first scheduled interview. If the household requests a second interview during the 30-day application processing period and is determined eligible, ISD must issue prorated benefits from the date of application.
B. Alternative interviews: Specific requirements for telephone and out of office interviews are outlined in each program's chapter on this topic.
C. Screening applications received by alternative means: ISD will screen applications for all public assistance programs and for expedited SNAP eligibility which includes applications received by alternative means. Alternative means include mail, fax, online, electronic transmission, or through an authorized representative.
[8.100.110.8 NMAC - Rp 8.100.110.8 NMAC, 7/1/2024]
Applicants may submit forms to a local county office in person or through an authorized representative, through the approved HCA web portal, by fax or by mail. The date the application and forms are received by ISD will be documented on the form. Applications submitted after regular business hours shall be considered received after business hours.
A. Incomplete application: An applicant has the right to file an incomplete form as long as the form contains the applicant's name, address and the signature of a responsible household or benefit group member or the household or benefit group's authorized representative, if one is designated.
B. Requesting application forms: When ISD receives a request for an application for assistance, ISD will mail, fax or hand deliver a paper application and provide the approved web portal address (for online applications), as indicated by the requestor, on the same day the request is received.
C. ISD shall provide households that complete an on-line electronic application in person at the ISD office the opportunity to review the information that has been recorded electronically and provide them with a copy of that information for their records, upon request.
[8.100.110.9 NMAC - Rp 8.100.110.9 NMAC, 7/1/2024]
Specific requirements for the interview are outlined in each program's chapter on this topic. Related verification issues for the interview are located in the verification section.
[8.100.110.10 NMAC - Rp 8.100.110.10 NMAC, 7/1/2024]
A . Cash Assistance (CA)/SNAP combined cases: To facilitate participation in SNAP, the Food Stamp Act requires that individuals applying for CA be able to apply for SNAP benefits at the same time.
(1) Application: A household applying jointly for CA and SNAP is required to file only one application on a form prescribed by ISD. The application contains the information necessary to complete the application process whether it was submitted by paper format or electronically online. If it is unclear to ISD whether the applicant intends to apply for SNAP, ISD will ask the applicant during the CA interview or other contact may be made with the applicant. An application for SNAP will be processed in accordance with time standards and procedures set forth in federal and state laws and regulations governing SNAP, including expedited processing provisions.
(2) Single interview: Whenever possible, a single interview will be held with an applicant who applies jointly for CA and SNAP benefits.
(3) Categorical eligibility: A SNAP household that meets criteria set forth in 8.139.420.8 NMAC is categorically eligible. If a household does not meet SNAP eligibility criteria, but is potentially categorically eligible, ISD must postpone denying the SNAP application until the 30th day.
(4) Application processing: Shall be processed in accordance with 7 C.F.R 273.2 j(1)(iv). As a result of differences in CA and SNAP application processing procedures and timeliness standards, eligibility for SNAP benefits may be determined prior to CA eligibility determination. Action on a SNAP application may be postponed until categorical eligibility is established to afford the household any benefits of this provision. However, SNAP approval may not exceed the applicable SNAP expedited or regular application processing timeliness standards.
(5) Application is denied: If a CA application is denied, an applicant is not required to file a new SNAP application. SNAP eligibility will be determined on the basis of the original application filed jointly for CA and SNAP, as well as any other documentation and information obtained in the course of the CA determination that is relevant to SNAP eligibility and benefit amount. A SNAP application may not be denied based on a CA denial reason, but must be based on the SNAP eligibility criteria.
(6) Denial retrieval: A SNAP application that is denied on the 30th day must be readily retrievable for another 30 days, in case the household is later determined eligible for CA or supplemental security income (SSI) benefits. When this occurs, ISD will use the original SNAP application, update any information and approve the SNAP case with prorated benefits as of the date of CA or SSI approval or payment effective date, whichever is later. A second interview is not necessary, however, the applicant or authorized representative should initial all changes and sign and date the verification of the changes.
B. Reporting changes: All participants in public assistance programs administered by the HCA are required to report any changed circumstances that relate to their eligibility for assistance or level of benefits. Each participant is provided with a list of the specific information they are required to report and the reporting time limits. When a change is reported, ISD must ensure that adjustments are made in the client's eligibility status or allotment for those months that the reported change is in effect, in accordance with each program's chapter on this topic.
(1) Notice: Whenever a client's benefits are altered as a result of changes, or whenever a certification period is shortened to reflect changes in the household's circumstances, the client is notified of the action by ISD in accordance with the notice requirements found in 8.100.180.10 NMAC and 8.100.180.11 NMAC. If the certification period is shortened, the household's certification period may not end any earlier than the second month following the month ISD determines the certification period should end. This allows adequate time to send a notice of expiration and for the household to timely reapply. If CA benefits are terminated, but the household is still eligible for SNAP benefits, members of the household must be informed about SNAP employment & training and ABAWD requirements, if applicable.
(2) CA reduction or termination within SNAP certification period: Whenever a reported change results in the reduction or termination of a client's CA benefits within the SNAP certification period, action will be taken to determine how the change affects the client's SNAP eligibility and benefit levels.
(a) Sufficient information: When there is sufficient information to determine how the change affects SNAP eligibility and benefit levels, the following actions will be taken:
( i ) Reduction/termination of SNAP benefits: A change that reduces or terminates SNAP, CA or both benefits will generate a notice of adverse action for each category of assistance that is sent to the household and authorized representative. The notice(s) of adverse action will inform the household of its fair hearing rights and method for requesting continuation of benefits.
(ii) Increase in SNAP benefits: If the reduction/termination of CA benefits results in the increase of SNAP benefits, the increase in SNAP benefits occurs after the CA notice period expires and the CA grant is actually reduced or terminated.
(b) Insufficient information: Whenever there is insufficient information to determine how the CA change affects the client's SNAP eligibility and benefit level, the following actions shall be taken:
( i ) CA notice of adverse action required: Where a CA notice of adverse action has been sent and the client requests a fair hearing and CA benefits are continued pending the appeal, the household's SNAP benefits will be continued on the same basis. However, the household must recertify for SNAP benefits if the SNAP certification period expires before the fair hearing process is completed.
(ii) CA notice of adverse action not required: If a CA notice of adverse action is not required, or the client decides not to request a fair hearing and continuation of CA benefits, the household must be notified that its certification period will expire at the end of the month following the month the notice of expiration is sent, and that it must reapply if it wishes to continue to participate in the SNAP. The notice of expiration will also explain to the household that the certification period is expiring because of changes in its circumstances that may affect its SNAP eligibility and benefit level.
(3) Certification periods: ISD will assign CA and SNAP certification periods that expire at the same time. In no event are CA and SNAP benefits to be continued beyond the end of a certification period.
(4) Recertification: Households in which all members are contained in a single CA grant or in a single general assistance (GA) grant will have their SNAP interviews for recertification, to the extent possible, at the same time they are redetermined for CA.
(5) Reopened cases: If the CA and SNAP cases are closed or the SNAP certification expires, and the former recipient reapplies for one or both programs for the month following closure or expiration, benefits are prorated from the date of application for SNAP. If reapplication is made for CA or SNAP or both, following a break of one full month or more, SNAP and CA benefits for the month of application will be determined prospectively under beginning month provisions.
C. Other processing standards:
(1) SSI Households: Households in which all members are applying for SSI benefits are handled in the same manner as CA households with respect to the postponement of SNAP approval or denial and the retrieval of denied SNAP applications.
(a) Since ISD cannot monitor the progress of the SSI application, and if the SNAP application is denied on the 30th day, the household must be advised to reapply for SNAP when it has been notified of SSI approval.
(b) SSI households are also entitled to apply for SNAP and be recertified at the social security administration (SSA) offices. SSA will accept the application and forward the completed application, transmittal form, and any available verification to the designated local ISD field office. When SSA accepts and refers the application, the household is not required to appear at a second office interview, although ISD may request additional verification or information needed to make an eligibility determination. Processing time limits begin when the SNAP application is registered at the SSA office.
(2) GA households: Households in which all members are applying for state administered GA are to be processed jointly for GA and SNAP benefits. However, since these households are not, nor will they become categorically eligible, the provisions to postpone approval or denial and to retrieve denied SNAP applications do not apply.
(3) Mixed households: Households in which some but not all of the household members are applying for NMW benefits will file separate applications for CA and SNAP benefits. Applications will be handled under the same processing provisions required for nonfinancial assistance households. However, if those not applying for CA benefits are recipients of SSI, the SNAP application would be jointly processed, because SSI recipients are already considered CA recipients.
(4) Application processing standards joint applications other than CA/SNAP: Each type of benefit applied for will be processed according to its specific procedures and timeliness standards. No benefit’s processing will be delayed waiting for other benefit’s requirements.
[8.100.110.11 NMAC - Rp 8.100.110.11 NMAC, 7/1/2024]
A decision shall be made promptly on applications in accordance with the timeliness standards set forth in 8.100.130.11 NMAC. These deadlines ensure that eligibility decisions are made promptly without restricting the applicant's right to supply verification of eligibility factors throughout the application processing period.
[8.100.110.12 NMAC - Rp 8.100.110.12 NMAC, 7/1/2024]
History of 8.100.110 NMAC:
Pre-NMAC History: The material in this part was derived from that previously filed with the State Records Center and Archives:
ISD Rule 170, FA/FS Combined Cases, 2/9/1988.
History of Repealed Material :
8 NMAC 3.ISD.110, General Operating Policies, Applications - Repealed, 7/1/1997.
8.100.110 NMAC - General Operating Policies - Applications (filed 3/26/2001) Repealed, effective 7/1/2024.
Other: 8.100.110 NMAC - General Operating Policies - Applications (filed 3/26/2001) Replaced by 8.100.110 NMAC - General Operating Policies – Applications, effective 7/1/2024
New Mexico Health Care Authority.
[8.100.120.1 NMAC - Rp 8.100.120.1 NMAC, 7/1/2024]
The rule applies to the general public.
[8.100.120.2 NMAC - Rp 8.100.120.2 NMAC, 7/1/2024]
A. Section 27 NMSA 1978 (1992 Repl.) provides for the health care authority to "...adopt, amend and repeal bylaws, rules and regulations..." It also provides for administration of public assistance programs.
B. The income support division (ISD) of the health care authority (HCA) was created by the HCA secretary under authority granted by Paragraph (3) of Subsection B of Section 9-8-6 NMSA 1978.
C. Section 9-8-1 et seq. NMSA 1978 establishes the health care authority (HCA) as a single, unified department to administer laws and exercise functions relating to health care facility licensure and health care purchasing and regulation.
[8.100.120.3 NMAC - Rp 8.100.120.3 NMAC, 7/1/2024]
Permanent.
[8.100.120.4 NMAC - Rp 8.100.120.4 NMAC, 7/1/2024]
July 1, 2024, unless a later date is cited at the end of a section.
[8.100.120.5 NMAC - Rp 8.100.120.5 NMAC, 7/1/2024]
The objective of these regulations is to provide general policy and procedures for income support division (ISD) administered programs.
[8.100.120.6 NMAC - Rp 8.100.120.6 NMAC, 7/1/2024]
[ RESERVED ]
[8.100.120.7 NMAC - Rp 8.100.120.7 NMAC, 7/1/2024]
County directors are responsible for equitable and efficient assignment of assistance cases.
[8.100.120.8 NMAC - Rp 8.100.120.8 NMAC, 7/1/2024]
County directors and ISS supervisors conduct case reviews as directed by their district operations managers.
[8.100.120.9 NMAC - Rp 8.100.120.9 NMAC, 7/1/2024]
History of 8.100.120 NMAC:
Pre-NMAC History: [ RESERVED ]
History of Repealed Material:
8 NMAC 3.ISD.120, General Operating Policies, Case Management - Repealed, 7/1/1997.
8.100.120 NMAC - General Operating Policies - Case Management - Applications (filed 3/26/2001) Repealed, effective 7/1/2024.
Other: 8.100.120 NMAC - General Operating Policies - Case Management - Applications (filed 3/26/2001) Replaced by 8.100.120 NMAC - General Operating Policies - Case Management - Applications effective 7/1/2024.
New Mexico Health Care Authority.
[8.100.130.1 NMAC - Rp 8.100.130.1 NMAC, 7/1/2024]
The rule applies to the general public.
[8.100.130.2 NMAC - Rp 8.100.130.2 NMAC, 7/1/2024]
A. Section 27 NMSA 1978 (1992 Repl.) provides for the health care authority to "...adopt, amend and repeal bylaws, rules and regulations...." It also provides for administration of public assistance programs.
B. The income support division (ISD) of the health care authority (HCA) was created by the HCA secretary under authority granted by Chapter 9, Article 8 NMSA 1978 (Repl. 1983).
C. Section 9-8-1 et seq. NMSA 1978 establishes the health care authority (HCA) as a single, unified department to administer laws and exercise functions relating to health care facility licensure and health care purchasing and regulation.
[8.100.130.3 NMAC - Rp 8.100.130.3 NMAC, 7/1/2024]
Permanent.
[8.100.130.4 NMAC - Rp 8.100.130.4 NMAC, 7/1/2024]
July 1, 2024, unless a later date is cited at the end of a section.
[8.100.130.5 NMAC - Rp 8.100.130.5 NMAC, 7/1/2024]
The objective of these regulations is to provide general policy and procedures for income support division (ISD) administered programs.
[8.100.130.6 NMAC - Rp 8.100.130.6 NMAC, 7/1/2024]
[ RESERVED ]
[8.100.130.7 NMAC - Rp 8.100.130.7 NMAC, 7/1/2024]
The income support division (ISD) is responsible for administering food, cash, energy, and medical assistance programs. These programs are funded through federal or state sources and provide assistance to individuals who meet certain eligibility factors. State and federal regulations determine eligibility factors for each program. ISD determines if an individual qualifies for a program, and ensures that eligible individuals receive the assistance as quickly as possible and, in any event, within the application time frames for the applicable program.
A. Proof of eligibility: Determining eligibility for assistance requires that certain verification regarding an applicant/recipient’s circumstances be made available to ISD. This verification is retained in the case record or noted in the case narrative.
(1) Applicant/recipient responsibility: The applicant/recipient is responsible to provide and obtain the verification necessary to determine eligibility.
(2) ISD responsibility: ISD is responsible for the following:
(a) to explain program participation requirements and the program specific eligibility factors to applicants/recipients;
(b) to explain the information and documents that must be provided to establish eligibility under each eligibility factor for a specific program;
(c) to offer and provide assistance in obtaining verification of an eligibility factor when the applicant/recipient indicates that verification may be difficult or costly to obtain; difficulty in obtaining verification may arise as a result of such circumstances as an applicant/recipient’s limited ability to read, speak or understand the English language, mental impairments, physical illness, disability, lack of funds, lack of transportation or lack of knowledge about how to obtain the information; assistance by ISD includes explaining written information orally in the applicant/recipient’s language, providing an interpreter, providing an address or telephone number of a person or agency, making telephone or written inquiries, allowing an applicant/recipient to use the telephone, locating a document, instructing an applicant in obtaining a document, requesting a document on behalf of an applicant/recipient or contacting a collateral contact; the assistance offered and provided is based on the particular needs of the applicant and ISD’s ability to address those needs;
(d) to inform applicants/recipients in writing of their responsibility to provide necessary verification.
(3) Incomplete information: When available information is inconclusive, incomplete or indefinite, ISD shall be responsible for explaining, in writing, what questions remain and how they can be resolved. The explanation must make it clear that eligibility cannot be established without the information or documents and that failure to provide them shall result in denial, reduction or termination of assistance.
(a) The applicant/recipient shall also be informed they may reapply at any time but that the information, documentation or actions may affect the reapplication. If the applicant/recipient does not provide all of the verification needed, a decision shall be made to the extent possible, based on the existing verified information.
(b) For MAGI medicaid purposes, reasonable compatibility will be effectuated in accordance with 42 CFR 435.952.
(c) When assistance is denied, reduced, delayed or terminated due to failure to provide information or documents as requested, the case record must contain the explanation that such failure is the basis for the action. The client shall be informed in writing of the action.
B. Failure to provide verification: An applicant/recipient cannot be considered eligible for assistance until necessary verification is obtained. To the extent possible, ISD shall make eligibility determinations based on verified eligibility issues rather than failure to provide information.
C. Applicants/recipients may submit documentary evidence in person, by mail, facsimile, or other electronic device or through an authorized representative.
[8.100.130.8 NMAC - Rp 8.100.130.8 NMAC, 7/1/2024]
A. Verification to determine eligibility and benefit level is obtained through six methods. Not all methods will necessarily be used in each case. The six methods are outlined in Subsections B through G of this section as well as the circumstance in which they may be used.
B. Prior case data not subject to change: Verification of an eligibility factor not subject to change which previously has been verified is accepted. At the application interview, ISD shall advise the applicant/recipient of any eligibility factors which have previously been established through documents in ISD’s possession and that are not subject to change. ISD shall not require further verification of any eligibility factors already established. Such factors include: U.S. citizenship, permanent residency, birth date, relationship, social security enumeration and deprivation due to the death of a parent.
C. Electronic data: Every applicant/recipient shall be informed that the information provided is subject to verification through federal, state, local and contracted data systems. ISD shall review the information received from the data source with the applicant/recipient and not require additional verification of such information unless it is disputed by the applicant/recipient, the information is otherwise questionable, or the information does not comply with specific benefit requirements. Questionable information is defined in 8.100.130.12 NMAC. Electronic data checks are automatically made and are not considered to be collateral contacts. The electronic data checked includes, but is not limited to:
(1) SSA and SSI information through the beneficiary data exchange (BENDEX) and the state data exchange (SDX) systems:
(a) the household shall be given an opportunity to verify the information from another source if the SDX or BENDEX information is contrary to the information provided by the household or is unavailable;
(b) eligibility and benefit level determination shall not be delayed past the application processing standards of 8.100.130.11 NMAC of this part if SDX or BENDEX data is unavailable;
(2) wage data and unemployment compensation benefits (UCB) through the interface with the New Mexico department of workforce solutions (NMDWS) - unemployment insurance database;
(3) interest, dividends, unearned income and self-employment wages through interfaces with the BENDEX wage data and internal revenue service (IRS) available through income and eligibility verification systems (IEVS):
(a) if the IEVS-obtained information is questionable, this information shall be considered unverified upon receipt and ISD shall take action to request verification of the information;
(b) except as noted in this paragraph, prior to taking action to terminate, deny or reduce benefits based on IEVS-obtained information, ISD shall request verification of the information;
(4) vehicle registration and driver's license information available from the New Mexico motor vehicle division; and
(5) child support payment information and absent parent information available from the child support services division.
(6) Restrictions: I nformation on earnings, benefits, resources and absent parents disclosed through government data systems shall be used only for the purpose of:
(a) verifying an applicant/recipient's eligibility;
(b) verifying the proper amount of benefits;
(c) investigating to determine whether recipients received benefits to which they were not entitled; and
(d) substantiating information which will be used in conducting criminal or civil prosecution based on receipt of benefits to which recipients were not entitled.
D. Documentary evidence: ISD shall use documentary evidence as the primary source of verification for all items except residency and household size. These items may be verified either through readily available documentary evidence, collateral contact or data from federal, state, local or contracted data sources, without a requirement being imposed that documentary evidence must be the primary source of verification. Documentary evidence consists of a written confirmation of a household's circumstances. Although documentary evidence shall be the primary source of verification, acceptable verification shall not be limited to any single type of document and may be obtained through the household or other source. Whenever documentary evidence cannot be obtained or is insufficient to make a determination of eligibility or benefit level, the eligibility worker may require collateral contacts or home visits. ISD is responsible for obtaining verification from acceptable collateral contacts. If a collateral contact is not available, a sworn statement shall be accepted from the household. ISD shall provide applicants/recipients with receipts for verification documents provided.
E. Collateral contacts: A collateral contact is an oral or written confirmation of a household's circumstances by a person outside the household. ISD shall document the reason for utilizing a collateral contact in the case file.
(1) A collateral contact can be used only when the applicant/recipient selects a collateral contact as the source of verification and:
(a) ISD cannot verify using a trusted electronic source;
(b) the applicant/recipient indicates difficulty in obtaining acceptable documentary evidence; or
(c) the documentary evidence provided by the applicant/recipient is inadequate or questionable.
(2) Selection of a collateral contact: The applicant/recipient and ISD shall select a mutually agreed upon collateral contact. A collateral contact must have knowledge of the applicant/recipient's circumstances and must be able to give accurate third party information.
(a) ISD may select a collateral contact only if the household fails to designate one or designates one who lacks knowledge of the applicant/ recipient's circumstances or cannot give accurate information. If the applicant/recipient does not agree to the collateral contact and does not designate an acceptable collateral contact, the application may, in appropriate circumstances, be denied for failure to verify.
(b) A collateral contact shall not be rejected solely based on the following criteria:
( i ) they are related to the applicant/recipient;
(ii) they are a recipient of public assistance; or
(iii) they do not have a telephone.
(3) Failure on the part of a collateral contact: ISD shall not deny or delay an eligibility decision solely because of failure of a collateral contact to provide information. ISD shall decide the applicant/recipient’s eligibility and benefit amounts based on all readily available information.
F. Home visits: Home visits may be used as verification only when electronic data or documentary evidence is insufficient to make a firm determination of eligibility or benefit level, or cannot be obtained. Home visits shall be selected as a method of verification with the applicant/recipient’s consent. ISD shall schedule the home visit with the applicant/recipient in advance during normal business hours. ISD shall document the reason for the home visit in the case record.
G. Sworn statements:
(1) If the applicant/recipient has an immediate need for assistance, ISD shall accept and, if necessary, assist the applicant/recipient to identify necessary factors to be included in the statement, an applicant/recipient’s sworn statement to verify one or more eligibility factors when there is:
(a) a reasonable explanation as to why electronic data documentary verification or a collateral contact is not readily available to establish the factors; and
(b) the applicant/recipient’s statement does not contradict other credible information received by ISD; in such instances where the statement contradicts the other information, ISD may require additional verification within a reasonable time after approval and authorization of assistance: an applicant/recipient who objects to such an additional request for information shall have the right to request and receive a fair hearing.
(2) A sworn statement is defined as the applicant/recipient’s statement signed under penalty of perjury.
[8.100.130.9 NMAC - Rp 8.100.130.9 NMAC, 7/1/2024]
Verification shall be requested only when necessary to establish a specific eligibility factor or benefit amount for a program and is not available or acceptable from an electronic source, in accordance with other benefit requirements. The method of verification which is selected to establish eligibility on a factor is determined through discussion between ISD and the applicant/recipient.
A. Only necessary verification: ISD shall only request verification which is necessary to establish eligibility or benefit amounts for the assistance program(s) for which the applicant/recipient has applied.
B. Ready availability: The determination that verification is readily available will be made through discussion with the applicant/recipient. A readily available document is one which can be obtained by the applicant/recipient within five working days and at no cost to the applicant/recipient.
C. Verification of a negative statement: Verification, other than by sworn statement, of a negative statement shall not be required unless the statement is or becomes questionable as defined in 8.100.130.12 NMAC and at least one specific method of verifying the statement is readily available. A negative statement is a statement by an applicant/recipient that something does not exist or did not occur. Negative statements may be discussed with the applicant/recipient depending on the applicant/recipient's circumstances.
D. Verifying more than one factor: To the extent possible, ISD shall use a document to establish more than one eligibility factor.
[8.100.130.10 NMAC - Rp 8.100.130.10 NMAC, 7/1/2024]
An applicant/recipient is always allowed the complete time processing deadline for the program to provide necessary verification. The minimum amount of time allowed is specific to the program. This requirement pertains to requests for verification for initial applications as well as for verification for ongoing eligibility. Below are the time frames for provision of verification by type of assistance. ISD shall make an eligibility decision within three work days of the receipt of all necessary verification.
A. Food assistance and NMW/EWP cash assistance programs: The application disposition deadline for SNAP and cash assistance programs is 30 calendar days.
(1) Expedited (emergency) SNAP: If applicant is eligible for expedited SNAP processing, issue benefits no later than the sixth day following the date of application to be available to the applicant/recipient on the seventh day or the preceding work day if the sixth day falls on a weekend or holiday.
(2) Day 1: Calendar day following date of application.
(3) Approvals: If verification provided establishes eligibility and the 30th calendar day after the application is:
(a) Monday by the preceding Friday, the 27th day;
(b) Tuesday by the preceding Monday, the 29th day;
(c) Wednesday by the preceding Tuesday, the 29th day;
(d) Thursday by the preceding Wednesday, the 29th day;
(e) Friday by the preceding Thursday, the 29th day;
(f) Saturday by the preceding Friday, the 29th day;
(g) Sunday by the preceding Friday, the 28th day;
(h) Monday holiday by the preceding Friday, the 27th day;
( i ) if necessary verification is not received by these deadlines but is received on or before the end of the processing period, approve on the day that full verification is provided.
(4) Need-based determination: ISD must make a need-based eligibility determination for SNAP within 30 days of the date of the application or by the preceding work day if the 30th day falls on a weekend or holiday, if all mandatory verification has been received, with the following specific provisions. If one or more household members have failed to turn in mandatory individual verification that is not required for all the mandatory members of a household, ISD will deny those members missing verification, and will determine eligibility for the remaining members.
(5) Procedural denials:
(a) Lack of verification: In cases where ISD was able to conduct an interview and request all necessary verification on the same day or any day before the 30 th day after the application was filed, and no subsequent requests for verification have been made, ISD may deny the application on the 30 th day. Following the day of application, if ISD provided assistance to the household in obtaining the verification in accordance with 7 CFR 273.2(f)(5), but the household failed to provide the requested verification, ISD may deny the application on the 30 th day after the application was filed.
(b) Missed interview: If the household failed to appear for a scheduled interview and made no subsequent contact with ISD to express interest in pursuing the application, the application shall be denied on the 30th day following the day of application. The household must file a new application if it wishes to participate in the program.
(6) Extension of time beyond the 30th day: If ISD does not determine a household’s eligibility and provide an opportunity to participate within 30 days following the date the application was filed, ISD shall take action in accordance with 7 CFR 273.2(h).
(a) Household caused: If by the 30th day ISD cannot take any further action due to the fault of the household, the household shall lose its entitlement to benefits for the month of application and a notice of denial shall be issued. The household will be given an additional 30 days to take the required action.
( i ) If the household takes the required action within 60 days following the date of application, the case shall be reopened without requiring a new application. If the household is found eligible during the second 30 day period, benefits shall be provided only from the month following the month of application. The household is not entitled to benefits for the month of application when the delay was the fault of the household.
(ii) If the household is at fault for not completing the application process within 60 days following the date of initial application, ISD shall deny the application and require the household to file a new application if it wishes to participate.
(b) ISD caused:
( i ) Whenever a delay in the initial 30 day period is the fault of ISD, immediate corrective action shall be taken. If the household is found to be eligible during the second 30 day period, the household shall be entitled to benefits retroactive to the date of application. If, however, the household is found to be ineligible, ISD shall deny the application.
(ii) If ISD is at fault for not completing the application process by the end of the second 30-day period, and the case is otherwise complete, ISD shall continue to process the original application until an eligibility determination is reached.
(iii) If ISD is at fault for not completing the application process by the end of the second 30-day period, but the case is not complete enough to reach an eligibility determination, ISD may continue to process the original application, If ISD was also at fault for the delay in the initial 30 days, the amount of benefits lost would be calculated from the month following the month of application.
B. Medical assistance: As per 42 CFR 435.912 (c)(3), the determination of eligibility for any medicaid applicant may not exceed:
(1) 90 days for applicants who apply for medicaid on the basis of disability; and
(2) 45 days for all other medicaid applicants.
C. The 45-day processing timeframe is the following:
(1) Day 1: The date of application is the first day.
(2) No later than day 44 by the preceding work day if day 44 falls on a weekend or holiday:
(a) if verification provided establishes eligibility or ineligibility; or
(b) if the day following day 44 is not a work day, then decision must be made earlier than day 44 to allow for mailing on or before the deadline.
(3) No later than day 45 by the next work day if day 45 falls on a weekend or holiday, if needed verification is not provided until day 42 through 44.
(4) Day 45 by the next work day if day 45 falls on a weekend or holiday, if needed verification is provided on day 45, or is not provided.
(5) After day 45:
(a) When an applicant/recipient requests one or more 10-day extensions of time to provide needed verification. An applicant/recipient is entitled to receive up to three 10-day extensions of time upon request.
(b) The eligibility decision must be made as soon as possible and within three work days of receipt of all necessary verification.
(c) HCA provides a reasonable opportunity period to individuals who have made a declaration of citizenship or satisfactory immigration status in accordance with 8.200.410.13 NMAC.
D. The 90-day processing timeframe is the following: An application for medicaid shall be processed no later than 90 days from the date the application is filed.
(1) No later than day 89: by the previous work day if day 89 falls on a weekend or holiday:
(a) if verification provided establishes eligibility or ineligibility; or
(b) if day following day 89 is not a work day, then decision must be made earlier than day 89 to allow for mailing on or before deadline.
(2) No later than day 90 by the next work day if day 90 falls on a weekend or holiday, if needed verification is not provided until day 87 through 89.
(3) Day 90 by the next work day if day 90 falls on a weekend or holiday, if needed verification is provided on day 90, or is not provided. The eligibility decision must be made as soon as possible and within three-work days of receipt of all necessary verification.
E. General assistance: An application for general assistance shall be processed no later than 90 days from the date the application is filed.
(1) No later than day 89: by the previous work day if day 89 falls on a weekend or holiday:
(a) if verification provided establishes eligibility or ineligibility; or
(b) if day following day 89 is not a work day, then decision must be made earlier than day 89 to allow for mailing on or before deadline.
(2) No later than day 90 by the next work day if day 90 falls on a weekend or holiday, if needed verification is not provided until day 87 through 89. The only exceptions are days with system maintenance activities and network outage or down time.
(3) Day 90 by the next work day if day 90 falls on a weekend or holiday, if needed verification is provided on day 90. The eligibility decision must be made as soon as possible and within three-work days of receipt of all necessary verification.
(4) If needed verification is not provided, case must be processed on day 90.
(5) Reconsideration: A reconsideration of a disability determination may be requested, verbally or in writing, by a client within 15 days of the date of the denial for not meeting conditions of disability. The reconsideration period shall not exceed 30 days from the date of denial. Disability will be evaluated based on additional medical evidence provided by the client during the reconsideration period. Should no request be made or the client does not provide additional medical evidence during the reconsideration period the denial shall remain and the client may reapply.
(6) Tracking the application processing time limit: The application processing time limit begins on the day after the signed application is received in the ISD county office.
(7) Delayed determination: If an eligibility determination is not made within the required application processing time limit, the applicant/recipient shall be notified in writing of the reason for the delay and that the applicant/recipient has the right to request a fair hearing regarding ISD’s failure to act within the time limits. Where applicable, NMAC subsections for specific programs detail how delays will be notified.
[8.100.130.11 NMAC - Rp 8.100.130.11 NMAC, 7/1/2024]
A. To be considered questionable, incomplete or inadequate, the information or verification must be documented as one of the following:
(1) inconsistent with statements made by the applicant/recipient;
(2) inconsistent with other information on the application or previous applications;
(3) inconsistent with credible information received by ISD;
(4) questionable on its face.
B. Resolving questionable information: Upon receiving questionable, incomplete or inadequate verification needed to determine an applicant/recipient's eligibility or benefit amount, ISD shall promptly provide the applicant/recipient a notice which shall include the following:
(1) advise the applicant/recipient of the receipt of the information;
(2) why it is questionable, incomplete or inadequate;
(3) the additional information that must be provided;
(4) the alternative methods of providing the information,
(5) the deadline for supplying the information (10 working days or the end of the applicable application processing time period, whichever is later);
(6) that the applicant/recipient may discuss with ISD whether any other readily available verification is acceptable;
(7) that ISD is available to assist the applicant/recipient if the information is not readily available; and
(8) that a failure to supply the needed information or contact ISD by the deadline may result in a delay, a denial of eligibility, a reduction in the amount of benefits or termination of benefits.
[8.100.130.12 NMAC - Rp 8.100.130.12 NMAC, 7/1/2024]
A. SNAP and cash assistance programs: Verification of identity for the applicant is mandatory at application for the SNAP and cash assistance programs. Documents that can be used to verify identity for the SNAP and cash assistance programs include, but are not limited to:
(1) photo ID; including driver's license;
(2) birth certificate;
(3) school record;
(4) church record;
(5) hospital or insurance card;
(6) letter from community resources;
(7) voter registration card;
(8) work ID;
(9) ID for another assistance or social service program;
(10) wage stubs;
(11) additional items as listed in ISD 135, “proof checklist”; or
(12) if documentary evidence is not readily available, use other acceptable methods of verification as in 8.100.130.9 NMAC.
B. Medical assistance programs: Verification of citizenship and identity for the applicant/recipient is mandatory at initial application. Acceptable documentary evidence of citizenship and identity is found at 8.200.410.12 NMAC in accordance with 42 CFR 435.407.
[8.100.130.13 NMAC - Rp 8.100.130.13 NMAC, 7/1/2024]
NONCONCURRENT RECEIPT OF ASSISTANCE:
A. Verification of nonconcurrent receipt of assistance is mandatory. ISD has responsibility for verifying nonconcurrent receipt of benefits usually through government data systems or other state agencies.
(1) For SNAP purposes, non-receipt of SNAP benefits from this state or another state or receipt of tribal commodities must be verified.
(2) For medicaid , ineligibility to receive medicaid benefits from this state or another state in the current month must be verified.
(3) For cash assistance, ineligibility for and non-receipt of assistance from the supplemental security income (SSI) program and bureau of Indian affairs general assistance (BIA GA) program, TANF assistance from New Mexico tribal programs, cash assistance from a HCA administered program and adoption subsidies funded through Title IV-E of the Social Security Act must be verified.
B. Non-receipt of benefits from another state must be verified for applicants who indicate a recent move to New Mexico from another state and prior receipt of assistance from that state.
C. Methods which can be used to verify nonconcurrent receipt of assistance include:
(1) ISD eligibility system for non-receipt of assistance from ISD programs;
(2) state data exchange (SDX) for non-receipt of SSI;
(3) contact with the New Mexico children, youth and families department for non-receipt of assistance;
(4) document from another state showing termination of benefits;
(5) collateral contact - oral statement from other state for termination of SNAP, TANF, or medicaid ;
(6) collateral contact - oral statement from bureau of Indian affairs for non-receipt of BIA-GA; or
(7) collateral contact - oral statement from tribal TANF programs for non-receipt of tribal TANF.
[8.100.130.14 - Rp 8.100.130.14 NMAC, 7/1/2024]
A. Verification that the enumeration requirement for an applicant/recipient has been met is mandatory for applicants who are seeking benefits for themselves unless the benefit program does not require enumeration, or the applicant seeking benefits is in an immigration status not requiring enumeration. The applicant/recipient must provide the social security number (SSN) which has been issued to the individual no later than 60 days following approval. ISD shall verify the SSN through the following methods:
(1) When an SSN is provided: The SSN will be verified through a data match with the SSA. If the SSN is not validated through the data match, the following sources of verification listed below may be utilized to validate the SSN:
(a) ISD eligibility system;
(b) social security card (OA-702);
(c) ISD social security number validation report form (ISD 260);
(d) an original SSA document containing the SSN; or
(e) the individual who has provided their SSN will not be required to produce proof of SSN unless the SSN is found to be questionable.
(2) When an SSN is not provided: The applicant/recipient must provide verification of application for an SSN. The verification must indicate an application was made prior to approval of the individual for assistance. The verification shall be retained in the case record. Documents that can be used to verify an application for SSN include:
(a) SSA 2853 enumeration at birth form;
(b) signed and dated statement from the hospital showing enumeration at birth has been done;
(c) original SSA document showing an application for SSN has been made and accepted; or
(d) completed SS-5; the completed SS-5 must be dated and submitted prior to the date of approved; a copy of the completed and submitted SS-5 must be retained in the case record.
B. There is no requirement of enumeration for medicaid -newborn (Category 31).
[8.100.130.15 - Rp 8.100.130.15 NMAC, 7/1/2024]
This section details the specific types of information and documents to be used in establishing the citizenship and non-citizen status for individuals who are applying for food assistance, cash assistance and medical assistance programs for themselves.
A. Citizenship for SNAP and cash assistance: Citizenship for SNAP and cash assistance programs will be verified only when questionable (as defined by 8.100.130.12 NMAC). Information and documents that can be used to verify citizenship include:
(1) social security number;
(2) birth certificate;
(3) naturalization papers from the department of homeland security United States citizenship and immigration services (DHS) such as DHS Forms I-179 or I-197;
(4) U.S. passport;
(5) military service papers;
(6) hospital record of birth;
(7) baptismal record, when place of birth is shown;
(8) Indian census records;
(9) DHS 400 for non-citizen children who can derive citizenship through citizen father or mother;
(10) additional items as listed on ISD 135, “proof checklist”;
(11) any document listed in Subsection B of this section; or
(12) if electronic verification is not available, and documentary evidence is not readily available, use other acceptable methods of verification as described in 8.100.130.9 NMAC.
B. Medical assistance programs: After July 1, 2006, an individual seeking medical assistance benefits for themselves must provide the income support division with a declaration signed under penalty of perjury that the applicant is a citizen, or a national of the United States, or is in an eligible immigration status. Applicants must present information allowing for verification of attested status. A non-citizen applicant who declares to be in an eligible immigration status is required to present immigration status information that can be used to verify attested status (such as an “A-number” or an “I-94 number”). Verification of citizenship for the applicant/recipient is mandatory at initial application. Acceptable documentary evidence of citizenship and identity is found at 8.200.410.12 NMAC in accordance with 42 CFR 435.407.
C. Non-citizen status: A non-citizen must have information allowing attested status to be verified.
D. Systematic alien verification for entitlement (SAVE):
(1) All applicants who attest to eligible immigration status will be subject to verification through the United States department of homeland security’s (USDHS) database (SAVE) system.
(2) Conflicting information regarding the citizenship status provided by the applicant/recipient will require additional verification by the USDHS.
[8.100.130.16 - Rp 8.100.130.16 NMAC, 7/1/2024]
A. Verification of New Mexico residence is mandatory. Residence may be verified by the use of documentary evidence provided for other eligibility criteria.
B. Documents that can be used to verify residency include:
(1) rent or mortgage receipt;
(2) statement from landlord;
(3) utility bills;
(4) statement from an employer;
(5) employment records;
(6) tax office records;
(7) post office records;
(8) church or synagogue records;
(9) utility company records;
(10) school records;
(11) proof of ownership of property;
(12) current driver's license;
(13) canceled letters;
(14) additional items as listed on ISD 135, “proof checklist”; or
(15) if documentary evidence is not readily available, use other acceptable methods of verification as in 8.100.130.9 NMAC.
[8.100.130.17 - Rp 8.100.130.17 NMAC, 7/1/2024]
A. The applicant/recipient's statement regarding household composition will be accepted.
B. Household composition will only be verified when determined questionable as defined by 8.100.130.12 NMAC. Documents that may be used to verify household composition include:
(1) lease agreement listing household members;
(2) landlord's written statement of household composition;
(3) additional items as listed on ISD 135, “proof checklist”; or
(4) if documentary evidence is not readily available, use other methods of verification as in 8.100.130.9 NMAC.
[8.100.130.18 - Rp 8.100.130.18 NMAC, 7/1/2024]
A. Age of child: Verification of age of children is mandatory for cash and medical assistance for children programs.
(1) For cash assistance: Age of the child is verified prior to approval.
(2) For medical assistance for children: Age of the child is verified to determine if the child is under the specified age limit .
B. Age of adults: Age of adult members is verified in the following circumstances if age is questionable:
(1) SNAP:
(a) if the individual is claiming a medical deduction on the basis of age (60 and over); or
(b) if the individual is working and income is being disregarded due to age (under age 18).
(2) Cash assistance:
(a) if the parent/caretaker relative is being considered for work program participation on the basis of being a minor parent and the parent claims to be age 20 or over;
(b) if the parent is living in their parent's home and is claiming emancipation on the basis of age (18 or over);
(c) if the parent/caretaker relative is not living in their parents' home and cooperation with child support enforcement is an issue due to age of the specified relative (under 18); or
(d) if the caretaker relative, parent or other adult member claims exemption from work program participation requirements based on age (60 and over).
(3) General assistance for the disabled:
(a) if the individual is claiming to be 18 or over and evidence is to the contrary; or
(b) if the individual is claiming to be under age 65 and evidence is to the contrary.
(4) Medical assistance for pregnant women:
(a) if the pregnant woman is living in her parent's home and is claiming emancipation on the basis of age (18 or over); or
(b) if the pregnant woman is under the age of 18 and is not living in her parent’s home and cooperation with child support enforcement is an issue.
(5) Documents that can be used to verify age include:
(a) birth certificate;
(b) adoption papers or records;
(c) hospital or clinic records;
(d) church records;
(e) baptismal certificate;
(f) bureau of vital statistics records;
(g) U.S. passport;
(h) Indian census records;
( i ) local government records;
(j) immigration and naturalization records;
(k) social security records;
(l) school records;
(m) census records;
(n) court support order;
(o) physician's statement;
(p) juvenile court records;
(q) voluntary social service agency records;
(r) insurance policy;
(s) minister's signed statement;
(t) military records;
(u) driver's license;
(v) additional items as listed on ISD-135, “proof checklist”; or
(w) if documentary evidence is not readily available, use other acceptable methods of verification as in 8.100.130.9 NMAC.
[8.100.130.19 - Rp 8.100.130.19 NMAC, 7/1/2024]
A. The statement of the parent, specified relative, or caretaker of school attendance for children under 18 years of age is acceptable to verify school attendance for the cash assistance program, unless questionable.
B. Verification of school attendance for all minor unmarried parents and dependent children over 18 years of age is mandatory for the cash assistance program. Documents that can be used to verify school attendance include:
(1) written statement from school official;
(2) current report card;
(3) additional items as listed on ISD 135, “proof checklist”; or
(4) if the preceding documentary evidence is not readily available, other acceptable methods of verification are set forth in 8.100.130.9 NMAC.
[8.100.130.20 - Rp 8.100.130.20 NMAC, 7/1/2024]
A. Verification of relationship is mandatory in the cash assistance program. The relationship between the parent or other caretaker relative and each child included in the benefit group must be verified.
B. Documents that can be used to verify relationship include:
(1) birth certificate;
(2) adoption papers or records;
(3) Indian census records;
(4) bureau of vital statistics or local government records;
(5) DHS records;
(6) hospital or public health records of birth and parentage;
(7) baptismal records;
(8) marriage certificate showing legal marriage between parents;
(9) court records of parentage such as support orders, divorce decrees, etc.;
(10) juvenile court records;
(11) paternity records from CSSD;
(12) ISD acknowledgment of paternity form;
(13) CSSD acknowledgment of paternity packet for alleged or non-court ordered determined parents living with children;
(14) church records including a statement from a priest, minister, etc.;
(15) additional items as listed on ISD 135, “proof checklist”; or
(16) if documentary evidence is not readily available, use other acceptable methods of verification as set forth in 8.100.130.9 NMAC.
C. The documentary evidence must contain the names of both the child and the specified relative. When the last name of the child differs from the specified relative, the difference must be resolved and documented in the case record. Divorce papers or marriage licenses can be used to help establish the relationship when the child's last name differs from the last name of the specified relative.
(1) If the relative is other than a parent, the relationship must be traced.
(2) In situations involving both parents in the home and the father is not the legal father, where paternity has not been established by operation of law or determined through court order, it will be necessary to establish the relationship of the child to the father by completion of the CSSD acknowledgment of paternity packet.
(3) If the child is living with a relative of the alleged father, it will also be necessary to establish the father-child relationship. The preferred method of proving the relationship will be through acknowledgment of paternity, although other documents will be acceptable means of establishing relationship.
[8.100.130.21 - Rp 8.100.130.21 NMAC, 7/1/2024]
A. Fraud conviction for dual state receipt of benefits: The existence of a fraud conviction for simultaneous receipt of benefits from two states is determined based upon client statement on the application form. If ISD receives other information indicating the existence of a dual state benefit fraud conviction, ISD shall verify it by contacting the appropriate authorities.
B. Fleeing felon, probation or parole violator:
(1) Fleeing Felon: An individual determined to be a fleeing felon shall be an ineligible household member. To establish an individual as a fleeing felon ISD must verify that an individual is a fleeing felon. A federal, state, or local law enforcement officer acting in their official capacity must present an outstanding felony arrest warrant that conforms to one of the following national crime information center uniform offense classification codes, to the department to obtain information on the location of and other information about the individual named in the warrant:
(a) escape (4901); or
(b) flight to avoid prosecution, confinement, etc. (4902); or
(c) flight-escape (4999).
(2) Probation or parole violator: An individual determined a parole or probation violator shall not be considered to be an eligible household member. To be considered a probation or parole violator, an impartial party, as designated by ISD, must determine that the individual violated a condition of their probation or parole imposed under federal or state law and that federal, state, or local law enforcement authorities are actively seeking the individual to enforce the conditions of the probation or parole. Actively seeking is defined as:
(a) a federal, state, or local law enforcement agency informs ISD that it intends to enforce an outstanding felony warrant or to arrest an individual for a probation or parole violation within 20 days of submitting a request for information about the individual to ISD; or
(b) a federal, state, or local law enforcement agency presents a felony arrest warrant as provided in Paragraph (1) of Subsection B of this section; or
(c) a federal, state, or local law enforcement agency states that it intends to enforce an outstanding felony warrant or to arrest an individual for a probation or parole violation within 30 days of the date of a request from ISD about a specific outstanding felony warrant or probation or parole violation.
(3) Certain convicted felons: An individual who is or has been determined to be convicted on or before February 7, 2014, as an adult of the following crimes shall not be eligible for inclusion in the cash assistance benefit group:
(a) aggravated sexual abuse under section 2241 of title 18, United States Code;
(b) murder under section 1111 of title 18, United States Code;
(c) an offense under chapter 110 of title 18, United States Code;
(d) a federal or state offense involving sexual assault, as defined in section 40002(a) of the Violence Against Women Act of 1994 (42 U.S.C. 13925(a)); or
(e) an offense under state law determined by the attorney general to be substantially similar to an offense described in clause ( i ), (ii), or (iii); and
(f) the individual is not in compliance with the terms of the sentence of the individual or the restrictions under 8.139.400.12 C NMAC.
(4) Response time: ISD shall give the law enforcement agency 20 days to respond to a request for information about the conditions of a felony warrant or a probation or parole violation, and whether the law enforcement agency intends to actively pursue the individual. If the law enforcement agency does not indicate that it intends to enforce the felony warrant or arrest the individual for the probation or parole violation within 30 days of the date of ISD’s request for information about the warrant, ISD shall determine that the individual is not a fleeing felon or a probation or parole violator and document the household’s case file accordingly. If the law enforcement agency indicates that it does intend to enforce the felony warrant or arrest the individual for the probation or parole violation within 30 days of the date of ISD’s request for information, ISD will postpone taking any action on the case until the 30-day period has expired. Once the 30-day period has expired, ISD shall verify with the law enforcement agency whether it has attempted to execute the felony warrant or arrest the probation or parole violator. If it has, ISD shall take appropriate action to deny an applicant or terminate a participant who has been determined to be a fleeing felon or a probation or parole violator. If the law enforcement agency has not taken any action within 30 days, ISD shall not consider the individual a fleeing felon or probation or parole violator, shall document the case file accordingly, and take no further action.
(5) Application processing: ISD shall continue to process the application while awaiting verification of fleeing felon or probation or parole violator status. If ISD is required to act on the case without being able to determine fleeing felon or probation or parole violator status in order to meet the time standards in 7 CFR 273.2(g) or 273.2( i )(3), ISD shall process the application without consideration of the individual’s fleeing felon or probation or parole violator status.
[8.100.130.22 - Rp 8.100.130.22 NMAC, 7/1/2024]
The applicant/recipient’s statement is acceptable for verification of resources unless the household is near the resource maximum limit and the information given is not questionable. If information is questionable, inconsistent or the household is near the maximum; ISD must clearly document why the household’s statement was questionable in the case record and request additional verification. When further information or verification is requested the following items shall be acceptable:
A. Bank accounts (checking, savings, certificates of deposit, savings bond, or Keogh's). Documents which may be used to verify bank or financial institution accounts include:
(1) current bank statement;
(2) statement from the bank or institution showing the value of the resource or the penalties for early withdrawal of deposit showing the total value and the penalty for early withdrawal;
(3) savings bond(s) showing total value and statement from bank/institution of penalty for early withdrawal;
(4) additional items as listed in ISD 135, “proof checklist”; or
(5) if documentary evidence is not readily available, use other acceptable methods of verification as set forth in 8.100.130.9 NMAC.
(6) Joint bank accounts: see appropriate program chapter for proper verification requirements.
B. Stocks and bonds: Documents which may be used to verify the value of stocks or bonds include:
(1) newspaper publications of the stock exchange;
(2) statement from the stock broker;
(3) additional items as listed in ISD 135, “proof checklist”; or
(4) if documentary evidence is not readily available, use other acceptable methods of verification as in 8.100.130.9 NMAC.
C. Life insurance: Documents which may be used to verify the cash surrender value of life insurance include:
(1) insurance policy;
(2) statement from the insurance company, insurance agent, lodges or fraternal organizations;
(3) statement from the union or employer who provide the insurance;
(4) statement from the veteran's administration;
(5) additional items as listed in ISD 135, “proof checklist”; or
(6) if documentary evidence is not readily available, use other acceptable methods of verification as in 8.100.130.9 NMAC;
(7) if the cash surrender value of the life insurance policy makes the applicant/recipient ineligible, liens against the insurance shall be explored; this will be done through use of acceptable methods of verification set forth in 8.100.130.9 NMAC; the cash surrender value of life insurance is necessary in programs only where it is countable.
D. Real estate contracts, purchase contracts: Documents which may be used to verify the value of real estate or purchase contracts include:
(1) statement from a bank or financial institution, commodity broker, real estate agent, or expert in the field of real estate contracts or purchase contracts;
(2) additional items as listed in ISD 135, “proof checklist”; or
(3) if documentary evidence is not readily available, use other acceptable methods of verification as in 8.100.130.9 NMAC.
E. Non-recurring lump sum payment: Documents which may be used to verify a nonrecurring lump-sum payment include:
(1) statement from a company, agency or organization that provided payment;
(2) copy of a check or check stub;
(3) award letters;
(4) statement from an attorney;
(5) additional items as listed in ISD 135, “proof checklist”; or
(6) if documentary evidence is not readily available, use other acceptable methods of verification as in 8.100.130.9 NMAC.
F. Tools and equipment: Documents which may be used to verify the value of tools and equipment include:
(1) recent sales slips;
(2) insurance or tax appraisals;
(3) catalogs or newspaper ads;
(4) statement from a bank, broker, local merchant or expert on tools and equipment;
(5) additional items as listed in ISD 135, “proof checklist”; or
(6) if documentary evidence is not readily available, use other acceptable methods of verification as in 8.100.130.9 NMAC.
G. Real property: Documents which may be used to verify the value of real property the applicant/recipient does not use include:
(1) a written statement from a real estate agent or broker stating the fair market value of property;
(2) statement from a bank or financial institution stating value and equity;
(3) additional items as listed in ISD 135, “proof checklist”; or
(4) if documentary evidence is not readily available, use other acceptable methods of verification as in 8.100.130.9 NMAC.
[8.100.130.23 - Rp 8.100.130.23 NMAC, 7/1/2024]
Verification of income is mandatory for all programs.
A. Social security benefits (OASDI, SSI): Documents which may be used to verify OASDI/SSI benefits include:
(1) award letter (Form SSA 1610);
(2) copy of a check(s) - amount of medicare premium must be added in;
(3) letter from SSA;
(4) direct deposit receipt - amount of medicare premium must be added in;
(5) additional items as listed in ISD 135, “proof checklist”; or
(6) if documentary evidence is not readily available or is questionable, a collateral contact with the social security administration (TPQY) may be selected as verification of OASDI/SSI or use other acceptable methods of verification as set forth in 8.100.130.9 NMAC.
B. Veteran's benefits: Documents which may be used to verify veteran's benefits include:
(1) award letter;
(2) copy of a check(s);
(3) written verification from a regional VA office;
(4) direct deposit receipt(s);
(5) additional items as listed in ISD 135, “proof checklist”; or
(6) if documentary evidence is not readily available or is questionable, a collateral contact with the veteran's administration may be selected as verification of veteran's benefits use other acceptable methods of verification as in 8.100.130.9 NMAC.
C. Railroad retirement benefits: Documents which may be used to verify railroad retirement benefits include:
(1) award letter;
(2) copy of a check;
(3) letter from SSA;
(4) direct deposit receipt;
(5) additional items as listed in ISD 135, “proof checklist”; or
(6) if documentary evidence is not readily available or is questionable, a collateral contact with the regional director of retirement claims may be selected as verification of railroad retirement benefits or use acceptable methods of verification as in 8.100.130.9 NMAC.
D. Military allotments: Documents which may be used to verify military allotment include:
(1) written statement from the appropriate military service center;
(2) copy of the allotment authorization;
(3) copy of a check;
(4) direct deposit receipt;
(5) additional items as listed in ISD 135, “proof checklist”; or
(6) if documentary evidence is not readily available or is questionable, a collateral contact with the appropriate military service center may be selected as verification of a military allotment or use other acceptable methods of verification as set forth in 8.100.130.9 NMAC.
E. Workers' compensation benefits: Documents which may be used to verify worker's compensation include:
(1) employer's statement;
(2) written statement from workers’ compensation administration;
(3) written statement from insurance company;
(4) additional items as listed in ISD 135, “proof checklist”; or
(5) if documentary evidence is not readily available or is questionable, a collateral contact with the New Mexico department of workforce solutions (NMDWS) or with the insurance company may be selected as verification of workers' compensation benefits or use other acceptable methods of verification as set forth in 8.100.130.9 NMAC.
F. Unemployment compensation benefits (UCB): Verification of unemployment compensation benefits should first be explored through the NMDWS web link. If it is not available through the NMDWS web link, the following documents may be used to verify UCB include:
(1) award letter;
(2) copy of a check;
(3) statement from the New Mexico DWS;
(4) additional items as listed in ISD 135, “proof checklist”; or
(5) if documentary evidence is not readily available, a collateral contact with the NMDWS may be selected as verification of unemployment compensation benefits or use other acceptable methods of verification as set forth in 8.100.130.9 NMAC.
G. Child/spousal support: Verification of child or spousal support should first be explored through the CSSD automated system. If verification is not available through the CSSD system, documents which may be used include:
(1) written statement from the contributor;
(2) written statement from the court;
(3) copy of a check or a canceled check;
(4) divorce or separation decree;
(5) court order;
(6) support agreement;
(7) correspondence from the contributor regarding support payments;
(8) court records;
(9) attorney's records;
(10) income tax return from the prior year;
(11) employer's record of attached wages;
(12) additional items as listed in ISD 135, “proof checklist”; or
(13) if documentary evidence is not readily available or is questionable, a collateral contact may be selected to verify child/spousal support or use other acceptable methods of verification as set forth in 8.100.130.9 NMAC;
(14) no contact with the absent parent shall be made without the consent of the applicant/recipient. If good cause for failure to cooperate with CSSD has been filed, contact with the absent parent must not be made.
H. Educational scholarships, grants or loans: Documents which may be used to verify amounts of an educational scholarship, grant, or loan include:
(1) financial aid award letter or a budget sheet from the institution;
(2) written statement from the institution;
(3) written statement from veteran's administration;
(4) additional items as listed in ISD 135, “proof checklist”;
(5) as educational expenses are deducted from the educational scholarship, grant or loan, it will be necessary to obtain verification of the expenses; verification may be obtained from the institution; or
(6) if documentary evidence is not readily available or is questionable, a collateral contact with the institution may be selected as verification of an education scholarship, grant or loan or use other acceptable methods of verification as set forth in 8.100.130.9 NMAC.
I. Non-recurring lump sum: See Subsection E of 8.100.130.23 NMAC.
J. Contributions: Documents which may be used to verify contributions include:
(1) written statement from the contributor;
(2) additional items as listed in ISD 135, “proof checklist”; or
(3) if documentary evidence is not readily available or is questionable, a collateral contact with the contributor may be selected as verification of a contribution or use other acceptable methods of verification as set forth in 8.100.130.9 NMAC.
K. Loans: Verification of a loan must contain the name of the person making the loan, the amount of the loan, date the loan was made and the repayment arrangement for the loan. Documents which may be used to verify loans include:
(1) written statement from the person or organization making the loan;
(2) promissory note;
(3) loan agreement;
(4) additional items as listed in ISD 135, “proof checklist”; or
(5) if documentary evidence is not readily available or is questionable, a collateral contact with the person or organization making the loan may be selected as verification of a loan or use other acceptable methods of verification as set forth in 8.100.130.9 NMAC.
L. Individual development accounts (IDA):
(1) The IDA is verified by reviewing the trust documents creating the IDA and documents verifying deposits and withdrawals from the account during the period since the previous certification. The trust documents must show the terms and conditions governing the IDA, including withdrawal provisions.
(2) ISD shall review deposits and withdrawals to ensure that no funds are being withdrawn except for those allowed under IDA policy and to ensure that the individual was employed during the time that any deposits were made.
[8.100.130.24 NMAC - Rp 8.100.130.24 NMAC, 7/1/2024]
A. Wages and salaries: Documents which may be used to verify current wages and salaries include:
(1) wage stubs;
(2) written statement from the employer;
(3) additional items as listed in ISD 135, “proof checklist”; or
(4) if documentary evidence is not readily available or is questionable, a collateral contact with the employer may be selected as verification of wages and salaries or use other acceptable methods of verification as set forth in 8.100.130.9 NMAC.
B. Self-employment: Verification of required tax and employer identification numbers, and tax-related and employer-related forms that the applicant/recipient was required to file is mandatory. It may not be possible to verify self-employment income through any single document. Documents which are used to verify self-employment income include:
(1) required state and federal tax and employer identification numbers;
(2) required federal and state tax forms for the current and prior tax year, including state and federal income and employer wage reporting and withholding reporting forms, gross receipts and occupation tax reporting forms;
(3) bills which indicate self-employment costs;
(4) other papers showing income and business expenses;
(5) all required business and occupation licenses;
(6) completed personal wage record;
(7) additional items as listed in ISD 135, “proof checklist”; or
(8) if documentary evidence of non-mandatory documents is not readily available, use other acceptable methods of verification as in 8.100.130.9 NMAC.
[8.100.130.25 NMAC - Rp 8.100.130.25 NMAC, 7/1/2024]
A. The applicant/recipient’s statement is acceptable for verification of shelter expenses, if the information given is not questionable. If information is questionable or inconsistent; ISD must clearly document why the household’s statement was unacceptable and what information requires additional verification. When further information or verification is requested the following items shall be acceptable:
(1) An obligation to pay for shelter is considered a deduction for SNAP. If the expense is questionable and verification of a shelter expense is requested and not provided, SNAP benefits will be determined without allowing a deduction for shelter expenses. When further verification is requested, documents which may be used to verify an obligation to pay for shelter include:
(a) mortgage payment book;
(b) written statement from the bank or other financial institution;
(c) rent receipt;
(d) written statement from the landlord;
(e) lease agreement;
(f) copies of bills for property taxes or house insurance;
(g) correspondence with the taxing authority or insurance agency; or
(h) additional items as listed on ISD 135 “proof checklist”.
(2) If documentary evidence is not readily available or is questionable, a collateral contact may be selected to verify the obligation to pay shelter or use other acceptable methods of verification as set forth in 8.100.130.9 NMAC.
B. Utilities: The applicant/recipient’s statement is acceptable for verification of utility expenses, if the information given is not questionable. If information is questionable or inconsistent; ISD must clearly document why the household’s statement was unacceptable and what information requires additional verification. Documents which may be used to verify an obligation to pay for utilities include:
(1) utility bills;
(2) rent receipt, lease agreement, or written statement from the landlord showing the household is responsible for payment of utilities;
(3) written statement from a utility provider;
(4) additional items as listed on ISD 135 “proof checklist”; or
(5) if documentary evidence is questionable, a collateral contact with the landlord or the utility provider may be selected to verify the obligation to pay for utilities or use other acceptable methods of verification as set forth in 8.100.130.9 NMAC.
[8.100.130.26 NMAC - Rp 8.100.130.26 NMAC, 7/1/2024]
A. Verification of medical expenses is mandatory for SNAP if the applicant/recipient meets one of the criteria listed below. The applicant/recipient’s statement that no reimbursement will be received will be accepted unless questionable. If the household claims a reimbursement, a deduction cannot be allowed until the un-reimbursed portion of the expense is verified.
(1) the individual claiming the medical expense is age 60 or older or disabled; and
(2) the amount of the medical expenses exceeds $35; or
(3) allowance of the medical expenses would potentially result in a deduction;
(4) failure to provide verification of medical expenses will result in a determination of eligibility and amount of benefits without considering medical expenses.
B. Documents which may be used to verify a medical expense include:
(1) current bill;
(2) monthly statement from the provider;
(3) medical insurance policy;
(4) appointment cards, travel receipts (lodging and transportation) to verify travel costs associated with obtaining medical care;
(5) additional items as listed in ISD 135 “proof checklist”; or
(6) if documentary evidence is questionable, a collateral contact with the landlord or the utility provider may be selected to verify the obligation to pay for utilities or use other acceptable methods of verification as set forth in 8.100.130.9 NMAC.
[8.100.130.27 NMAC - Rp 8.100.130.27 NMAC, 7/1/2024]
A. The applicant/recipient’s statement is acceptable for verification of dependent care expenses, if the information given is not questionable. If information is questionable or inconsistent; ISD must clearly document why the household’s statement was unacceptable and why information requires additional verification.
B. Documents which may be used to verify dependent care costs:
(1) current bill;
(2) written statement from the provider;
(3) additional items as listed in ISD 135 “proof checklist”; or
(4) if documentary evidence is not readily available, or is questionable a collateral contact with the care provider may be used as verification of dependent care costs or use other acceptable methods of verification as set forth in 8.100.130.9 NMAC.
[8.100.130.28 NMAC - Rp 8.100.130.28 NMAC, 7/1/2024]
HISTORY OF 8.100.130 NMAC:
Pre-NMAC History: The material in this part was derived from that previously filed with the State Records Center and Archives:
ISD Rule 160, Eligibility and Verification Standards, 2/9/1988.
ISD Rule 160, Eligibility and Verification Standards, 9/15/1993.
History of Repealed Material:
8 NMAC 3.ISD.130, General Operating Policies, Eligibility/Verification Standards, filed 6/16/1997 - Repealed, 7/1/1997.
8.100.130 NMAC, General Operating Policies - Eligibility and Verification Standards, filed 3/26/2001 - Repealed, 8/1/2008.
8.100.130 NMAC, General Operating Policies - Eligibility and Verification Standards, filed 7/17/2008 - Repealed NMAC effective, 7/1/2024.
Other: 8.100.130 NMAC, General Operating Policies - Eligibility and Verification Standards, filed 7/17/2008 - Replaced by 8.100.130 NMAC, General Operating Policies - Eligibility and Verification Standards effective, 7/1/2024.
New Mexico Health Care Authority .
[8.100.140.1 NMAC - Rp, 8.100.140.1 NMAC, 11/27/2013 ; A, 7/1/2024 ]
The rule applies to the general public .
[8.100.140.2 NMAC - Rp, 8.100.140.2 NMAC, 11/27/2013]
A. Section 27 NMSA 1978 (1992 Repl.) provides for the department to "...adopt, amend and repeal bylaws, rules and regulations..." It also provides for administration of public assistance programs.
B. The income support division (ISD) of the health care authority (HCA) was created by the [ HSD ] HCA secretary under authority granted by Paragraph (3) of Subsection B of Section 9-8-6 NMSA 1978.
C. Section 9-8-1 et seq. NMSA 1978 establishes the health care authority as a single, unified department to administer laws and exercise functions relating to health care facility licensure and health care purchasing and regulation .
[8.100.140.3 NMAC - Rp, 8.100.140.3 NMAC, 11/27/2013 A, 7/1/2024]
Permanent.
[8.100.140.4 NMAC - Rp, 8.100.140.4 NMAC, 11/27/2013]
November 27, 2013, unless a later date is cited at the end of a section.
[8.100.140.5 NMAC - Rp, 8.100.140.5 NMAC, 11/27/2013]
The objective of these regulations is to provide general policy and procedures for the ISD administered programs.
[8.100.140.6 NMAC - Rp, 8.100.140.6 NMAC, 11/27/2013]
[Reserved]
A. ISD case records consisting of forms, records, narrative material, correspondence, and documents are scanned into electronic format and maintained in the department’s secure electronic data management system. Documents submitted in person will be electronically scanned and returned to the individual. Original documents mailed to or left with the office will be photocopied and the originals mailed back to the client at his/her last known address known to the department. The copied documents will be electronically scanned and destroyed once successful completion of a scan into electronic format is confirmed. The case record documents the current and historical eligibility of a recipient group and thereby to establish the validity of decisions to approve or deny assistance.
B. Case records are the property of the department and are established and maintained solely for use in the public assistance programs administered by the department. Information contained in the case records is confidential and is released only under the limited circumstances and conditions as provided in federal and state laws and regulations, including 8.100.100 NMAC, Sections 13 through 15. Case records and their contents must remain in the possession of the department, its contractors, or approved federal employees. Copies of case records may be released in accordance with federal and state laws and regulations or pursuant to a court order.
C. Electronic eligibility system information: Client information stored on the department’s electronic eligibility system is subject to the same guidelines for release of information as the department’s case record.
[8.100.140.8 NMAC - Rp, 8.100.140.8 NMAC, 11/27/2013]
The following narrative outline is used on all applications for assistance, and to record data and verification concerning all variable conditions of eligibility. After the initial determination of eligibility for assistance, no additional data are required in redeterminations except for those eligibility conditions which are subject to change.
A. The case narrative is used for the comprehensive recording of relevant factual information in the case record. Narrative entries must be made promptly, with dates of relevant contacts.
B. Recorded information should be limited to items which are applicable to the case, such as changes in eligibility factors since the last review. Information which does not change, such as social security numbers, is not repeated.
C. The items below are intended as a minimum requirement for case narratives. Each county office manager has the privilege of expanding it at his/her discretion.
[8.100.140.9 NMAC - Rp, 8.100.140.9 NMAC, 11/27/2013]
A. Heading: Case name and number.
B. Application and intake:
(1) date of application, program applied for and reason for application stated in terms of the client's circumstances;
(2) documentation of worker's explanation of client's rights and responsibilities;
(3) names of individuals for whom application is being made.
C. Basic eligibility factors: Explanation of how each basic eligibility factor has been established, including: residence; non-transfer of property; school attendance; nonconcurrent receipt of assistance; living in the home of the specified relative; citizenship; parentage; and age.
D. Child support enforcement division (CSED) cooperation: Status of cooperation with the CSED.
E. Enumeration: Status of enumeration (social security number) of each person.
F. Retroactive medicaid status: Status of eligibility for retroactive medicaid requested by applicant.
G. Work program status:
(1) current work program participation status, work participation agreement, assessment certification or copy of assessment and individual responsibility plan for each benefit group member subject to work program requirements;
(2) disability determination request for applying for limited work participation status;
(3) determination of limited work participation status request;
(4) any other work program related documentation.
H. Medical resources - third party liability: Verification of third party liability that includes the name(s) of the private health insurance, type of available coverage, name of each insured individual(s), the policy and group number for each insured individual, and other information, as needed, in accordance with federal and state laws and regulations.
I. Need:
(1) documentation and discussion of all pertinent factors relating to the condition of eligibility;
(2) list of amounts, verifications and dates of income and resources by individual;
(3) explanation of earned income computations.
J. Shelter (for applicable programs) : Documentation of shelter information, including whether housing is subsidized by the government.
K. SNAP: Status of the certification. Explanation of circumstances affecting SNAP certification.
L. Disposition of application: Effective date of approval/denial. Reference to appropriate manual section for denials.
M. Follow-up: Necessary follow-ups.
[8.100.140.10 NMAC - Rp, 8.100.140.10 NMAC, 11/27/2013]
A. date of interview and how household composition or living arrangements are established;
B. documentation of school attendance of children in benefit group;
C. documentation of current resources and income; accounting for all formerly reported income and resources;
D. updated information on non-custodial parents and status of cooperation with the CSED;
E. review of work and work program participation and planning;
F. disposition of SNAP certification; and
G. list of necessary follow-ups.
[8.100.140.11 NMAC - Rp, 8.100.140.11 NMAC, 11/27/2013]
History of 8.100.140 NMAC:
Pre-NMAC History: The material in this part was derived from that previously filed with the State Records Center:
ISD Rule 131, Administrative Policy, filed 2/10/1988.
History of Repealed Material:
8 NMAC 3.ISD.140, General Operating Policies, Case Files, filed 6/16/1997 - Repealed effective 7/1/1997.
8.100.140 NMAC, General Operating Policies Case Files, filed 3/26/2001 - Repealed effective 11/27/2013.
New Mexico Health Care Authority.
[8.100.150.1 NMAC - Rp 8.100.150.1 NMAC, 7/1/2024]
The rule applies to the general public .
[8.100.150.2 NMAC - Rp 8.100.150.2 NMAC, 7/1/2024]
A. Section 27 NMSA 1978 (1992 Repl.) provides for the health care authority to "...adopt, amend and repeal bylaws, rules and regulations…." It also provides for administration of public assistance programs.
B. The income support division (ISD) of the health care authority (HCA) was created by the HCA secretary under authority granted by Paragraph (3) of Subsection B of Section 9-8-6 NMSA 1978.
C. Section 9-8-1 et seq. NMSA 1978 establishes the health care authority (HCA) as a single, unified department to administer laws and exercise functions relating to health care facility licensure and health care purchasing and regulation.
[8.100.150.3 NMAC - Rp 8.100.150.3 NMAC, 7/1/2024]
Permanent.
[8.100.150.4 NMAC - Rp 8.100.150.4 NMAC, 7/1/2024]
July 1, 2024, unless a later date is cited at the end of a section.
[8.100.150.5 NMAC - Rp 8.100.150.5 NMAC, 7/1/2024]
The objective of these regulations is to provide general policy and procedures for income support division (ISD) administered programs.
[8.100.150.6 NMAC - Rp 8.100.150.6 NMAC, 7/1/2024]
[ RESERVED ]
[8.100.150.7 NMAC - Rp 8.100.150.7 NMAC, 7/1/2024]
Various records, forms and documents have differing periods of relevance and usefulness. Certain material in the record should be deleted on a scheduled basis when the material is no longer needed. To facilitate record management, as well as to establish the minimum period of time for which material must be retained, specific retention periods for case record materials have been established. Record retention schedules for each form are listed in the HCA forms manual table of contents.
[8.100.150.8 NMAC - Rp 8.100.150.8 NMAC, 7/1/2024]
A. P-retain permanently: Forms and documents must be retained in the case record permanently.
B. 4-retain four years: Federal regulations provide that fiscal documents must be retained for three years after the end of the period to which they apply. By retaining these records for four years, adjustment is made for post-closure reporting and audit periods within the federal requirements. If a record is part of a federal exception in an audit, the record is kept until the audit exception is resolved.
C. 1 -r etain one year: Many financial and medical assistance administrative forms, appointment letters, change notices, review schedules, etc., not needed for eligibility or benefit determination do not need to be kept for long periods of time, and can be destroyed when superseded or obsolete. Disposal of general correspondence not related to the eligibility conditions of clients is authorized when the purpose of the correspondence has been served.
D. SI -s pecial instructions: There are some forms that can be destroyed when obsolete or no longer needed, or that are not filed in the case record. These forms have been identified under "SI" for reference purposes, and the user decides suitable disposition.
[8.100.150.9 NMAC - Rp 8.100.150.9 NMAC, 7/1/2024]
A. Narrative: All narratives are kept permanently.
B. Documents: Copies of documents such as court orders, medical information, birth certificates, social security cards, death certificates, contracts, etc., are filed in the record permanently.
[8.100.150.10 NMAC - Rp 8.100.150.10 NMAC, 7/1/2024]
Correspondence used to establish eligibility should be retained for four years. Correspondence not used to establish eligibility may be deleted after one year.
[8.100.150.11 NMAC - Rp 8.100.150.11 NMAC, 7/1/2024]
History of 8.100.150 NMAC:
Pre-NMAC History: The material in this part was derived from that previously filed with the State Records Center and Archives:
ISD Rule 131, Administrative Policy, 2/10/1988.
History of Repealed Material:
8 NMAC 3.ISD.150, General Operating Policies, Records Retention/Management - Repealed, 7/1/1997.
8 NMAC 3.ISD.150, General Operating Policies, Records Retention/Management, filed 7/1/1997 - Repealed effective 7/1/2024.
New Mexico Health Care Authority.
[8.100.180.1 NMAC - Rp 8.100.180.1 NMAC, 7/1/2024]
The rule applies to the general public.
[8.100.180.2 NMAC - Rp 8.100.180.2 NMAC, 7/1/2024]
A . Section 27 NMSA 1978 (1992 Repl.) provides for the health care authority to "...adopt, amend and repeal bylaws, rules and regulations...." It also provides for administration of public assistance programs.
B. The income support division (ISD) of the health care authority (HCA) was created by the HCA secretary under authority granted by Paragraph (3) of Subsection B of Section 9-8-6 NMSA 1978.
C . Section 9-8-1 et seq. NMSA 1978 establishes the health care authority (HCA) as a single, unified department to administer laws and exercise functions relating to health care facility licensure and health care purchasing and regulation.
[8.100.180.3 NMAC - Rp 8.100.180.3 NMAC, 7/1/2024]
Permanent.
[8.100.180.4 NMAC - Rp 8.100.180.4 NMAC, 7/1/2024]
July 1, 2024, unless a later date is cited at the end of a section.
[8.100.180.5 NMAC - Rp 8.100.180.5 NMAC, 7/1/2024]
The objective of these regulations is to provide general policy and procedures for income support division (ISD) administered programs.
[8.100.180.6 NMAC - Rp 8.100.180.6 NMAC, 7/1/2024]
[ RESERVED ]
[8.100.180.7 NMAC - Rp 8.100.180.7 NMAC, 7/1/2024]
Both oral and written communications with applicants/recipients must be courteous. ISD shall inform the client promptly and in accord with state and federal regulations of actions relating to an application or ongoing case.
[8.100.180.8 NMAC - Rp 8.100.180.8 NMAC, 7/1/2024]
Prompt notification of action on a specific application is required. See specific program sections in this manual.
[8.100.180.9 NMAC - Rp 8.100.180.9 NMAC, 7/1/2024]
Before any action to withhold a cash assistance payment or to reduce or terminate medical, food stamp or cash assistance benefits, the HCA must issue timely and adequate advance notice of an adverse action.
A. Adverse action defined: Adverse action means an action taken by HCA that adversely affects eligibility or the amount of benefits a household or benefit group receives, including withholding, suspending, reducing or terminating benefits.
B. Timing: A notice shall be issued to the household or benefit group before taking an adverse action. Benefits will not be reduced until 13 days from the date on the adverse action notice. If the 13th day falls on a weekend or holiday, the next working day is counted as the last day of the 13-day adverse action notice period.
C. Contents:
(1) General: An adverse action notice shall contain, in easily understood language:
(a) reason for the proposed action, including the specific regulations supporting the action and the information on which the proposed action is based;
(b) date the action will take place;
(c) statement of the right to request a fair hearing and how to request a fair hearing;
(d) phone number of the caseworker in the event the client wants more information or wants to request a fair hearing;
(e) date by which the client must request a fair hearing to continue receiving assistance at the current rate;
(f) liability of the recipient for any overissuance or overpayment;
(g ) right to be represented by legal counsel, friend or other spokesperson;
(h) notice that free legal help may be available to the household;
( i ) the current benefit amount and proposed benefit amount after reduction for any reason.
(2) Specific:
(a) For a disqualification from participation in the food stamp program, the notice must also include the disqualification period, as appropriate, and the action the disqualified individual must take to end ineligibility.
(b) For sanctions from cash assistance, the notice must also include the conciliation period, if applicable, and the sanction period, as appropriate, as well as the action the sanctioned individual must take to end ineligibility.
(c) For termination of cash assistance benefits due to reaching the TANF 60-month term limit, the notice must also include the actions the participant must take to apply for a hardship extension, found at 8.102.410.17 NMAC, and the availability of support services in the event the benefit group is not eligible for a hardship extension.
[8.100.180.10 NMAC - Rp 8.100.180.10 NMAC, 7/1/2024]
A concurrent notice is one which is mailed no later than the date the benefit is or would have been received. It is also referred to as an adequate notice.
A. Food stamps: HCA notifies a household that its FS benefits are reduced or terminated no later than the date the household receives, or would have received, its allotment, in the following circumstances:
(1) the household reports the information which results in the reduction or termination;
(2) the reported information is in writing and signed by an adult household member;
(3) HCA can determine the household's allotment or ineligibility based solely upon the household's written information;
(4) the household retains its right to a fair hearing;
(5) the household retains its right to continued benefits by requesting a fair hearing within the time period provided by the adverse action notice;
(6) HCA continues (or supplements) the household's previous benefit level, if necessary, within five working days of the household's request for a fair hearing.
B. FA and medical: HCA notifies a benefit group that its benefits are reduced or terminated by no later than the date the group receives, or would have received, its benefit in the following circumstances.
(1) Death: Termination or reduction of assistance is necessary because of the death of an FA benefit group member or a MA recipient whose death is documented.
(2) Admission to institution: Reduction of assistance is necessary because the client enters a skilled nursing home or intermediate care facility, or termination is necessary because of the client's admission to an institution which makes him/her ineligible for payment.
(3) Client request: The client requests in writing that the FA or MA assistance be reduced or terminated; the client gives information in a signed statement that causes a termination or reduction of services and the client indicates in writing that the client understands this is the consequence of supplying such information.
(4) Whereabouts unknown: Withholding FA or MA assistance is necessary because of the unknown whereabouts of the client, as evidenced by agency mail to the client's last known address having been returned to the ISD as undeliverable.
(5) Other assistance: The client is accepted for FA or MA assistance in another county or state, or under another jurisdiction (including SSI) and the effective date of coverage has been established.
(6) Removal of child: Termination or reduction of FA is necessary because of the removal of a recipient child from the home through judicial determination or the voluntary placement of the child in foster care by the legal guardian or specified relative.
(7) Change in medical care: A change in a client's level of medical care is prescribed by their physician.
(8) Special allowance: A special allowance granted to a client for a specific period of time is terminated and the client has been informed at the time the allowance was granted that it would terminate at a specific time.
(9) Fair Hearings: An adverse action has been suspended pending a fair hearing and the fair hearing determination is not in the client’s favor.
(10) Recertification: A recertification is not completed by the time the certification expires and a notice of suspension is issued, or the non-certified case has been in payment suspension for a month, and the case is being closed.
(11) Sanction: An FA payment is being reduced or terminated because an individual is not cooperating with the child support enforcement program or is failing to meet work program requirements.
(12) A client is also informed of their right to request a hearing on the action, the way to make such a request, and the conditions under which assistance will be continued if a hearing is requested. In any contact with the county office or in a hearing, the client may speak for themselves, or be represented by legal counsel or a friend or other spokesperson.
[8.100.180.11 NMAC - Rp 8.100.180.11 NMAC, 7/1/2024]
Adverse action notices are not required under the following conditions.
A. Mass changes: The state initiates a mass change.
B . Death: The ISS determines, based on reliable information, that all members of a household have died.
C. Move from project area: The ISS determines, based on reliable information, that the household has moved from the project area, or will move before the next FS issue.
D. Completion of restoration of lost benefits: The client has been receiving an increased allotment to restore benefits, the restoration is complete, and the client has been previously notified in writing when the increased allotment would end.
E. Anticipated changes in monthly benefit amount: A household's allotment varies from month to month within the certification period to take into account changes which are anticipated at the time of certification, and the household was notified at the time of certification of the allotment variations.
F. Benefit reduction upon approval of household's FA application: The household jointly applied for FA and FS benefits, and has been receiving food stamps pending the approval of the FA grant, and was notified at the time of certification that FS benefits would be reduced upon approval of the FA grant.
G. Household member disqualified for intentional program violation: The benefits of the remaining household members are reduced or terminated to reflect the disqualification of a household member.
H. Benefits contingent upon providing postponed verification: The ISS has assigned a normal certification period to a household certified on an expedited basis, for whom verification was postponed, and the household was given a written notice that the receipt of benefits beyond the month of application was contingent upon its providing the required verification.
I. Conversion: Converting a household from cash or FS benefit recovery to recoupment (benefit reduction) because of failure to make agreed-upon repayment.
J. Loss of certification by drug or alcoholic treatment center or group living arrangement.: The ISS terminates the eligibility of a resident of a drug or alcoholic treatment center or a group living arrangement because the facility loses either its certification from the New Mexico health department or other appropriate state agency, or has its status as an authorized representative suspended because FCS has disqualified it as a retailer.
K. Transfer between FSP and food distribution programs: If a local office is notified by the appropriate Indian tribal organization (ITO) that a participating household wishes to switch programs, the ISS:
(1) advises the ITO of the earliest date that program transfer may occur without risk of dual participation;
(2) closes the FS case without advance notice; and
(3) follows up with the appropriate ITO-provided form.
L . Household requests termination:
[8.100.180.12 NMAC - Rp 8.100.180.12 NMAC, 7/1/2024]
If the agency obtains facts indicating that FA or MA should be suspended, terminated or reduced because of probable fraud by the recipient which has been verified, if possible, by collateral sources, notice of the action being taken is mailed at least five days before the action is to become effective.
[8.100.180.13 NMAC - Rp 8.100.180.13 NMAC, 7/1/2024]
If a fair hearing request is filed, benefits are continued, under the circumstances described below, until the fair hearing determination is completed.
A. Timely requests:
(1) Advance notice: If a household requests a fair hearing within the advance notice period provided by the advance adverse action notice, and its certification period has not expired, the household's participation in the program is continued on the same basis authorized immediately before the adverse action notice, unless the household specifically waives a continuation of benefits.
(2) All fair hearing request forms contain a space for a household to indicate whether or not continuation of benefits is requested. If the form does not positively indicate that the household has waived continuation of benefits, the ISS assumes that continuation of benefits is desired and the benefits are issued accordingly. Such benefits are continued until the end of the certification period or the resolution of the fair hearing, whichever is first.
B. Concurrent notice: If a benefit group requests a fair hearing within 13 days of issuance of a concurrent adverse action notice, and its certification period has not expired, cash assistance, food stamps and medicaid benefits are reinstated. Unless other intervening changes occur, assistance is not reduced or terminated, nor may the manner or form of payment be changed to a protective payment, during the period until the hearing decision is rendered, except as provided in regulations at 8.100.180.10 and 8.100.180.15.
(1) Additionally, receipt of continued benefits ends if a determination is made at the hearing that the sole issue is one of federal policy or law, or change in such policy or law, and not one of incorrect grant computation.
(2) If a later change affecting the client's grant occurs while the hearing decision is pending and the client does not request a hearing regarding the change, the payment which the client continues to receive during the hearing period is adjusted only by the amount required by the change.
(3) If assistance is to be continued, it is continued through the end of the month in which a decision on the hearing is reached.
(4) If hearing decisions are delayed, assistance is continued only if the delay is caused by HCA or if a delay of five days or less is requested by the client because of unusual circumstances beyond the client’s control.
C. Late requests:
(1) If a hearing request is not made within the period provided by the adverse action notice, benefits are reduced or terminated as provided in the notice.
(2) If a client demonstrates that failure to make the request within the advance notice period was for good cause, benefits are reinstated to the previous level. The hearing unit supervisor decides if the failure was for good cause.
[8.100.180.14 NMAC - Rp 8.100.180.14 NMAC, 7/1/2024]
A. General: Certain changes initiated by the state or federal government may affect the entire caseload or significant portions of it. These changes include, but are not limited to, increases or decreases in eligibility or payment standards changes in excluded or deducted items or amounts. Mass changes affecting income include annual adjustments of Social Security, SSI, and other federal benefit programs, and any other changes in eligibility criteria based on legislative or regulatory actions.
B. Notice of mass changes: Adverse action notices are required for mass changes resulting from statutory or regulatory changes in eligibility or payment standards, benefit, changes in excluded or deducted items or amounts for purposes of eligibility or calculation of benefit levels. The HCA will either provide concurrent notice to affected households of the mass change no later than the date the household receives, or would have received, its benefit issuance, or the affected cases will be notified through the media, and posters in county offices.
C. Appeal rights: Notice of the change will include the recipient’s right to appeal. A hearing is not available, and benefits are not continued, when automatic benefit adjustments are required by federal or state law unless the specific, express basis for the hearing request is incorrect benefit computation. If the recipient requests a fair hearing within the advance notice period, benefits will be continued at the former amount. If the appeal results in a decision that the reduction or closure was incorrect, the difference between what the recipient received pending the appeal decision and the amount that should have been received will be restored to the recipient.
[8.100.180.15 NMAC - Rp 8.100.180.15 NMAC, 7/1/2024]
If a client and the ISS disagree about the continuation of benefits, the client may request a fair hearing. Adverse action defined. "Adverse action" is action taken by HCA which adversely affects the amount of benefits a client receives. Such actions include holding mailing of assistance warrants, and suspension, reduction or termination of benefits.
[8.100.180.16 NMAC - Rp 8.100.180.16 NMAC, 7/1/2024]
The worker shall give advance notice to an applicant or recipient of any visit to the applicant’s or recipient’s home.
A. Verbal notice: The advance notice may be in the form of a verbal communication between the worker and the applicant or recipient. The time and date of the visit must be mutually agreeable and should, in most cases, be made at least one day in advance of the visit. The worker shall provide an explanation of the need for the visit to the applicant or recipient. The worker shall document the discussion in the case narrative and provide a justification if the period of advance notice is any less than one day.
B. Written notice: The home visit notice may be written. The written notice shall be mailed at least 10 days in advance of the intended visit. The notice shall indicate the time, date, and purpose of the visit. The notice shall request the applicant or recipient to confirm the appointment date with the worker. In the absence of a response from the applicant or recipient, the visit shall take place and the applicant or recipient is expected to be at home for the visit.
[8.100.180.17 NMAC - Rp 8.100.180.17 NMAC, 7/1/2024]
History of 8.100.180 NMAC:
Pre-NMAC History: The material in this part was derived from that previously filed with the State Records Center and Archives:
ISD Rule 180, Notice Requirements, 2/9/1988.
History of Repealed Material:
8 NMAC 3.ISD.180, General Operating Policies, External Communications - Repealed, 7/1/1997.
8.100.180 NMAC - General Operating Policies - External Communications (filed 3/26/2001) - Repealed effective 7/1/2024.
Other: 8.100.180 NMAC - General Operating Policies - External Communications (filed 3/26/2001) - Replaced by 8.100.180 NMAC - General Operating Policies - External Communications effective 7/1/2024.
New Mexico Health Care Authority.
[8.100.390.1 NMAC - Rp 8.100.390.1 NMAC, 7/1/2024]
The rule applies to the general public .
[8.100.390.2 NMAC - Rp 8.100.390.2 NMAC, 7/1/2024]
A. Section 27 NMSA 1978 (1992 Repl.) provides for the health care authority to "...adopt, amend and repeal bylaws, rules and regulations...." It also provides for administration of public assistance programs.
B. The income support division (ISD) of the health care authority (HCA) was created by the HCA secretary under authority granted by Paragraph (3) of Subsection B of Section 9-8-6 NMSA 1978.
C. Section 9-8-1 et seq. NMSA 1978 establishes the health care authority (HCA) as a single, unified department to administer laws and exercise functions relating to health care facility licensure and health care purchasing and regulation.
[8.100.390.3 NMAC - Rp 8.100.390.3 NMAC, 7/1/2024]
Permanent.
[8.100.390.4 NMAC - Rp 8.100.390.4 NMAC, 7/1/2024]
July 1, 2024, unless a later date is cited at the end of a section.
[8.100.390.5 NMAC - Rp 8.100.390.5 NMAC, 7/1/2024]
The objective of these regulations is to provide general policy and procedures for income support division (ISD) administered programs.
[8.100.390.6 NMAC - Rp 8.100.390.6 NMAC, 7/1/2024]
[ RESERVED ]
[8.100.390.7 NMAC - Rp 8.100.390.7 NMAC, 7/1/2024]
A. Official form defined: An official form is any form with the HCA logo and a number assigned in central office. An official form must include a statement as to the purpose of the form and instructions for completion, distribution, and retention of the form.
(1) All statements regarding participant rights and responsibilities which appear on forms must be exactly as they are in the policy manual.
(2) Forms used in ISD field offices will be indexed in the forms manual.
B. Forms covered by these procedures and forms not covered by these procedures: All forms used in ISD county offices and intended for public use are to be developed in accordance with these procedures. Forms intended for internal office use only may be developed by an office without using these procedures. Internal use forms are forms not sent out of the office and not used, received, or reviewed by program participants.
C. Sources for new and revised forms and pamphlets: New forms and pamphlets, and revisions to existing forms and pamphlets, may be proposed and developed by each division, as well as other HCA staff. In addition, the public information officer may also initiate new pamphlets and revisions to existing pamphlets in coordination with the appropriate program staff.
D. Assigning form numbers: Each division is responsible for developing its own forms numbering system. Numbering systems should appear in some reasonable order. It is recommended that this be done in the order in which forms are used in case processing. Sufficient space should be left between form numbers to allow for expansion of the system.
E. Responsibilities:
(1) Forms - program specific: The division, or program area responsible for the policy which is addressed by a form will have primary responsibility for the development and revision of the form. Each division will assign its own form numbers and maintain a log of its form numbers. A central log of all form numbers will also be kept by the graphics unit.
(2) ISD forms - program shared: Forms which are shared by more than one program and forms which do not involve any specific program will be assigned the suffix "ISD." The ISD form numbers log will be maintained by the ISD forms manager. The division or program area which proposes a new form or revision to an existing form will have primary responsibility for developing the new form or revising the existing form. The cost of producing the new or revised form will be prorated among the program areas which rely on the form. This proration will be based on caseload size.
(3 ) Forms - other sources: If the proposal for a new form or a revision comes from a field staff person or unit, the appropriate program, or division will review and approve the form prior to submission to the forms advisory team
(4) Pamphlets: Pamphlets should provide information and improve access to HCA programs. The most common purposes for the development of pamphlets are:
(a) HCA implements new programs;
(b) HCA makes significant policy changes; or
(c) auxiliary services are available.
(5) Responsibility for each pamphlet will reside with the which has primary responsibility for the policy issues addressed in the pamphlet. The unit which originates and develops the pamphlet will have responsibility for the distribution of the pamphlet within the HCA and elsewhere as required by the governing federal oversight agency. The public information officer will handle any other distribution of the pamphlet.
(6) All other situations: In the absence of clear responsibility, the forms advisory team will assign responsibility for the design and development of the new or revised form. The division forms manager is available for consultation on forms manual issues.
F. Forms review procedures: All proposed new forms will be typed or printed in draft for review. Drafts of revisions to existing forms will be submitted on copies of the existing forms with changes marked clearly in red. Once the draft of the form and its instructions are complete, it may be necessary for the draft and instructions to be submitted to various agencies for review. Not all forms will be reviewed. Some will be reviewed in all four areas below and some will receive no review in these areas.
(1) Literacy review: All applications and forms pertaining to the eligibility process must be reviewed for appropriate literacy level. This will be accomplished by the office which develops the new form or revises an existing form.
(2) Review by general counsel: Any form to be sent to or completed by HCA clients or applicants must be reviewed by the HCA Office of general counsel in order to assure compliance with current legal standards. All drafts of pamphlets and informational items for general distribution to the public must also be reviewed by the office of general counsel before being sent to the public information officer for final approval.
(3) Approval by the public information officer: Following review by the office of general counsel, all drafts of pamphlets and informational items for general distribution to the public will be sent to the public information officer for final approval (see PIO-033.1).
(4) Review by inspector general: Forms authorizing certain payment, e.g. client medical travel expense, may also require review by the office of the inspector general. This requirement may change periodically. Those developing or revising forms of this nature should first consult with the OIG. Forms requiring review in any of these areas must be returned for re-review if any changes are made.
G. Forms advisory team review: After the new or revised form has been given all necessary review, the form and its instructions will be forwarded to the ISD forms manager. The forms manager will acknowledge receipt of the form and notify the primary program of the date of the review by the forms advisory team. A member of the program staff should be present when the forms advisory team meets to review the new or revised form.
(1) For new and revised forms, the forms advisory team will consider:
(a) Does the form address a new policy or program change?
(b) Does the form address a significant policy change?
(c) Is a form necessary or would clear procedural instructions meet the needs of implementation?
(d) If the form is necessary, is it user friendly and time efficient, and will it enhance the accuracy rate of the HCA?
(2) For revised forms, the forms advisory team will also require that one of the following three conditions be met:
(a) the current form no longer addresses all policy issues;
(b) the revision will streamline the user's completion of the form; or
(c) the revision is necessary to comply with audit/accountability/program policy requirements.
(3) Once the form has been reviewed and approved by the forms advisory team, it will be returned to the originating staff for submission to the graphics unit for printing.
[8.100.390.8 NMAC - Rp 8.100.390.8 NMAC, 7/1/2024]
A. The originating staff will complete a request/format approval form HCA 053 (green copy), attach the approved draft, and submit to the graphics unit. All drafts of proposed new forms submitted to the graphics unit must be typed or printed. The request/format approval form must include:
(1) quantity;
(2) dimensions;
(3) weight and type of paper;
(4) color of paper and inks;
(5) multiple copies;
(6) padding;
(7) stapling;
(8) drilling;
(9) stitching;
(10) wrapping;
(11) and any other special instructions.
B. The graphics unit will prepare a camera ready copy and contact the GSD state printing facility to obtain a price quote for the preparation of the procurement document. The graphics unit will return the price quote with the specifications to the originating staff who will prepare the procurement document. A copy of the camera ready will be reviewed, approved, and signed for by the originating staff. After approval and signature by the originating staff, the graphics unit will submit the camera ready to the GSD's state printing facility for printing. In some instances, camera readies may be copied at the HCA copy center. This decision will be made by the originating staff.
[8.100.390.9 NMAC - Rp 8.100.390.9 NMAC, 7/1/2024]
Forms that are generated by automated systems are controlled by the information systems bureau general supporting policy 8.100.390 NMAC.
[8.100.390.10 NMAC - Rp 8.100.390.10 NMAC, 7/1/2024]
For forms stored at the HCA central warehouse, originating staff should consult the warehouse manager to determine: inventory status of the form; status of outstanding orders; and estimated date the form supply will be exhausted. This information will be used to determine the quantity of revised forms to be ordered and the revision date to be indicated on the revised form. The warehouse will notify the originating staff within 24 hours of receipt of the revised form/pamphlet. The originating staff will not release the form or pamphlet to the field offices until the warehouse has stock from which the field can order.
[8.100.390.11 NMAC - Rp 8.100.390.11 NMAC, 7/1/2024]
Once notified by the warehouse that a supply of the new or revised form is available, the originating staff will prepare the manual revision cover memo. A copy of the completed manual revision, form, and instructions will be submitted to the ISD forms manager. The forms manager will update the forms manual indexes and submit the manual revision to the director's office for signature and numbering. The signed and numbered manual revision will be returned by the director's office to the originating staff for distribution to the field.
[8.100.390.12 NMAC - Rp 8.100.390.12 NMAC, 7/1/2024]
To re-order forms, the originating staff member fills out a form order/re-order memo and submits it to the warehouse manager for processing. The warehouse manager will complete the purchase document and return it to the program staff for signature.
[8.100.390.13 NMAC - Rp 8.100.390.13 NMAC, 7/1/2024]
If an originating staff member determines a form is to be discontinued and destroyed, the originating staff will first consult with the forms advisory team. When the discontinuation or destruction of a form is agreed on, the originating staff will fill out a form discontinuation memo and submit it to the forms manager for processing along with a copy of the manual revision deleting the form from the forms manual. This will ensure the updating of the index. The forms manager will then submit the documents to the warehouse manager.
[8.100.390.14 NMAC - Rp 8.100.390.14 NMAC, 7/1/2024]
History of 8.100.390 NMAC:
Pre-NMAC History: [ RESERVED ]
History of Repealed Material:
8 NMAC 3.ISD.390, General Support, Information Systems - Repealed, 7/1/1997.
8.100.390 NMAC - General Support - Information Systems (filed 3/26/2001) Repealed effective 7/1/2024.
Other: 8.100.390 NMAC - General Support - Information Systems (filed 3/26/2001) replaced by 8.100.390 NMAC - General Support - Information Systems effective 7/1/2024.
New Mexico Health Care Authority.
[8.100.640.1 NMAC - N, 09/30/2013; A, 7/1/2024]
The rule applies to the general public.
[8.100.640.2 NMAC - N, 09/30/2013]
A. Chapter 27 NMSA 1978 (1992 Repl.) provides for the health care authority (HCA) to "...adopt, amend and repeal bylaws, rules and regulations..." It also provides for administration of public assistance programs.
B. The ISD of the[ HSD ] HCA was created by the HCA secretary under authority granted by Paragraph (3) of Subsection B of Section 9-8-6 NMSA 1978.
C. Section 9-8-1 et seq. NMSA 1978 establishes the Health Care Authority as a single, unified department to administer laws and exercise functions relating to health care facility licensure and health care purchasing and regulation.
[8.100.640.3 NMAC - N, 09/30/2013 ; A, 7/1/2024]
Permanent.
[8.100.640.4 NMAC - N, 09/30/2013]
September 30, 2013, unless a later date is cited at the end of a section.
[8.100.640.5 NMAC - N, 09/30/2013]
The objective of these regulations is to provide regulations in accordance with federal and state laws and regulations for the ISD administered programs.
[8.100.640.6 NMAC - N, 09/30/2013]
Unless otherwise apparent from the context, the following definitions shall apply throughout these regulations.
A. Claim: means correcting the over-issuance of benefits an eligibility determination group received, but was not entitled to receive, subject to the recovery of such overpayments.
B. Administrative or agency error (AE) claim: means any claim for an overpayment caused by an action or failure to take action by the department.
C. Eligibility determination group: means the basic assistance unit for a category of assistance, or a group of people, either mandatory or optional, to be included in determining the monthly benefit amount.
D. Inadvertent household error (IHE) claim: means any claim for an overpayment resulting from a misunderstanding or unintended error on the part of the eligibility determination group.
E. Intentional program violation (IPV) claim: means any claim for an overpayment or trafficking resulting from an individual committing an IPV, as defined in regulation in Subsection D of 8.139.647.8 NMAC.
F. Restoration: means the issuance of benefits to an eligibility determination group that it was entitled to receive, but did not receive due to:
(1) an agency error or department discovered error;
(2) judicial action; a favorable fair hearing decision or an erroneous administrative disqualification for an IPV that is later reversed; or
(3) a regulation specifically requiring issuance of lost benefits.
G. Sponsored aliens: means an alien lawfully admitted for permanent residence in the United States as an immigrant, as defined in Subsection 101(a)(15) and Subsection 101(a)(2) of the Immigration and Nationality Act.
H. Supplement: means the amount of benefits issued in addition to the monthly benefit amount the eligibility determination group has already received that equals the amount of benefits the group was entitled to receive for that month.
[8.100.640.7 NMAC - N, 09/30/2013]
An erroneous payment exists when an error is made by the client or the department that resulted in an underpayment or overpayment of program benefits. The difference between the amount issued and the corrected amount is the amount of the payment error. The department shall take action to correct errors in the supplemental nutrition assistance program (SNAP), state SNAP supplement, New Mexico combined application project (NMCAP), New Mexico works (NMW) cash assistance, general assistance for disabled adults and unrelated children (GA), adult residential shelter care home (ARSCH), education works (EWP), refugee cash assistance, medical assistance, and LIHEAP benefits issued to an eligibility determination group regardless of the cause of the error. NMW cash assistance, GA, ARSCH, EWP, refugee cash assistance will be referenced as cash assistance programs throughout the regulations unless otherwise specified.
A. The department will correct the error by restoring benefits for an underpayment or establishing claims for an overpayment.
B. SNAP: The amount of the restoration or claim is determined by using the maximum SNAP benefit amount and applying the allowable deductions in place for a particular month, including any federal law placing a restriction on the use of deductions.
C. Cash assistance programs: The amount of the restoration or claim is determined using the standard of need the case was eligible for on the first day of a month. If the standard of need increases during the month, the higher amount shall be allowed for the entire month.
[8.100.640.8 NMAC - N, 09/30/2013]
A. An erroneous payment occurs when an error is made by the client or the department that resulted in an underpayment or overpayment of program benefits or assistance.
B. Restoration of benefits: If benefits must be restored to an eligibility determination group, the department shall determine each month for which the eligibility determination group was underpaid benefits. The month(s) may or may not be consecutive. In some cases, federal regulations mandate the restoration of SNAP benefits to eligibility determination groups for a specific time period.
C. Overpayment of benefits:
(1) Establishing period of overpayment: If benefits have been overpaid to an eligibility determination group, the department shall determine each month in which the eligibility determination group received benefits to which it was not entitled. The months may or may not be consecutive.
(a) The first month in which a benefit is considered erroneous is the month in which the eligibility determination group received a benefit amount differing from the amount that the eligibility determination group was entitled to receive.
(b) The last month of an erroneous payment ends on the last day of the last month in which payment is discovered. In the case of an overpayment, if the period of overpayment has been extended while a proposed reduction or termination is the subject of an administrative hearing decision, it is included in the overpayment claim period.
(2) Establishing a claim: A claim will be established against any eligibility determination group for any month in which the eligibility determination group received an overpayment of benefits if it exceeds the claims establishment threshold as defined in Subsection G of 8.100.640.11 NMAC.
(a) At a minimum, the department shall take action on claims for which twelve (12) months or less have elapsed between the month an overpayment occurred and the month the overpayment was discovered.
(b) The department may choose to take action on claims for which more than twelve (12) months have elapsed.
(c) No action will be taken on claims for which more than six years have elapsed between the month an overpayment occurred and the month an overpayment was discovered.
[8.100.640.9 NMAC - N, 09/30/2013]
A. Entitlement:
(1) Program benefits will be restored to an eligibility determination group when the loss was caused by:
(a) agency error;
(b) SNAP administrative disqualification for IPV that is later reversed; or
(c) a regulation specifically requiring restoration of lost benefits.
(2) Unless there is a specific regulation authorizing benefit restoration for a longer period, SNAP benefits will be restored for not more than the twelve (12) months prior to whichever of the following occurred first:
(a) date the department receives a request for restoration from an eligibility determination group; or
(b) date the department is notified or otherwise discovers that a loss to an eligibility determination group has occurred; or
(c) if the resolution of a request extends beyond the twelve (12) month limit, an eligibility determination group will be entitled to more than twelve (12) months of restored benefits.
B. Errors in benefits:
(1) ISD discovered errors:
(a) If the department determines that a loss of benefits has occurred, and that an eligibility determination group is entitled to a restoration of benefits, action will be taken automatically to restore lost benefits. No action by the eligibility determination group is necessary.
(b) Benefits will not be restored if benefits were lost more than twelve (12) months before the month the loss was discovered in the normal course of business, or loss occurred more than twelve (12) months before the month the department was notified, in writing or orally, of a possible loss to a specific eligibility determination group.
(c) The department shall notify the eligibility determination group of entitlement to lost benefits; amount of benefits to be restored; any offsetting that will be done; method of restoration, and right to appeal through the fair hearing process if the eligibility determination group disagrees with any aspect of the proposed restoration.
(2) Judicial action:
(a) The department shall restore benefits found by any judicial action to have been wrongfully withheld.
(b) If the judicial action is the first action the recipient has taken to obtain restoration of lost benefits, then benefits will be restored for a period of not more than twelve (12) months from the date the court action was initiated.
(c) If the judicial action is a review of the department’s action, benefits will be restored for a period of not more than twelve (12) months from the first of the following dates:
(i) date the department receives a request for restoration;
(ii) if a request for restoration is not received, date the fair hearing action was initiated; but never more than one (1) year from the date the department is notified of, or discovers, the loss.
(3) Disqualification for SNAP IPV:
(a) For each month an eligibility determination group member is erroneously disqualified, not to exceed twelve (12) months, the amount to be restored is determined by comparing the SNAP benefit amount the eligibility determination group received with the amount the eligibility determination group would have received if the disqualified member had been allowed to participate.
(b) Participation in an administrative disqualification hearing in which the eligibility determination group is contesting the department’s assertion of IPV is considered notification that the eligibility determination group is requesting restored SNAP benefits.
(4) Agency errors:
(a) If an eligible eligibility determination group's application has been erroneously denied, the month the loss initially occurred will be the month of application; or for an eligible eligibility determination group filing a timely reapplication, the month following the expiration of its certification period.
(b) If an eligible eligibility determination group's application was delayed, the months for which benefits were lost will be calculated in accordance with application processing guidelines for delayed eligibility determinations in Subsection D of 8.139.110.13 NMAC, Subsection D of 8.102.110.12 NMAC and Subsection C of 8.106.110.12 NMAC.
(c) If an eligibility determination group's benefits were erroneously terminated, the month the loss initially occurred will be the first month that benefits were not received as a result of the erroneous action.
C. Processing the restoration:
(1) SNAP: Regardless of whether an eligibility determination group is currently eligible or ineligible, the department shall restore lost benefits to an eligibility determination group by issuing an amount equal to the amount of benefits that were lost. The amount restored is issued in addition to the benefit amount a currently eligible eligibility determination group is entitled to receive.
(a) For each month affected by the loss, the department shall determine if the eligibility determination group was actually eligible.
(b) In cases where there is no information in the eligibility determination group's case record to document that the eligibility determination group was actually eligible, the department shall notify the eligibility determination group in writing of what information is necessary to determine eligibility for these months. For each month the eligibility determination group cannot provide the necessary information to demonstrate its eligibility, the eligibility determination group will be determined ineligible.
(2) Cash assistance programs: The department shall restore lost cash assistance benefits for eligibility determination groups who are currently eligible under the cash assistance program that the error occurred or would be eligible except for the error causing the underpayment.
(a) A restoration to a denied applicant or to a former participant who is not eligible at the time the error is discovered shall be corrected if the applicant is, or participant becomes, eligible at a later date.
(b) Before issuing a benefit correcting an underpayment, the department subtracts from the amount owed to the participant any outstanding claim against the participant in the cash assistance program that the error is being corrected.
(3) Medical assistance programs : The department shall restore months of eligibility for individuals who are currently eligible under the medical assistance program that the error occurred or would be eligible except for the error causing the ineligibility.
[8.100.640.10 NMAC - N, 09/30/2013]
The department shall take action to establish a claim against any eligibility determination group that received more benefits than it was entitled to receive, including LIHEAP benefits paid to a vendor on behalf of the eligibility determination group, whether or not the overpayment occurred because of an IHE, an AE, or an IPV.
A. Claim recovery:
(1) All adult eligibility determination group members will be jointly liable for any overpayment of benefits to the eligibility determination group.
(2) A claim will be established against any or all of the adult members of an eligibility determination group at the time an overpayment occurred.
(3) A claim will be established against any eligibility determination group that contains an adult member who was an adult member of another eligibility determination group that received more benefits than it was entitled to receive.
(4) The earned income deduction of twenty percent is not allowed when determining an overpayment due to the failure of an eligibility determination group to report earned income in a timely manner.
B. Types of claims for all programs:
(1) IHE claims:
(a) A claim will be handled as an IHE claim if the overpayment was caused by:
(i) the misunderstanding or unintended error on the part of the eligibility determination group; or
(ii) the misunderstanding or unintended error on the part of a categorically eligible eligibility determination group, provided that a claim can be calculated based on a change in the eligibility determination group's net income, eligibility determination group size, or both; or
(iii) a social security administration action, or failure to take action, resulting in an eligibility determination group becoming or continuing categorical eligibility, provided that a claim can be calculated based on a change in net income, eligibility determination group size, or both.
(b) Instances of IHE’s that may result in a claim include, but are not limited to, the following:
(i) eligibility determination group unintentionally failed to provide the department with correct or complete information; or
(ii) eligibility determination group unintentionally failed to report changes in its circumstances; or
(iii) eligibility determination group unintentionally received benefits or received more benefits than it was entitled to receive pending a fair hearing decision because the eligibility determination group requested a continuation of benefits based on the mistaken belief it was entitled to them; or
(iv) eligibility determination group received benefits solely because of categorical eligibility, but was later determined ineligible for cash assistance; or
(v) social security administration took action or failed to take appropriate action, resulting in the eligibility determination group improperly receiving supplemental security income (SSI).
(2) Administrative or agency errors:
(a) A claim will be handled as an AE claim if the overpayment was caused by the department’s action or failure to take action.
(b) In the case of a SNAP categorical eligibility, a claim will be handled as an AE if action by an agency of the state or local government resulted in the eligibility determination group's improper eligibility for cash assistance.
C. IPV claims established for SNAP:
(1) A claim will be handled as an IPV claim only if:
(a) an administrative disqualification hearing official or a court of appropriate jurisdiction has determined that an eligibility determination group member committed an IPV; or
(b) an individual is disqualified as a result of signing a waiver of disqualification hearing in a case referred for prosecution; or
(c) an individual has signed a disqualification consent agreement in a case of deferred adjudication; or
(d) an individual has signed a waiver of an administrative disqualification hearing in a case referred for disqualification.
(2) Before the determination of an IPV or the signing of either the waiver of right to a disqualification hearing or a disqualification consent agreement, the claim against an eligibility determination group is handled as an IHE claim.
D. Claims for medical assistance benefits: Upon a determination that the individual is not eligible for the category of assistance in which they were enrolled, the department shall determine if the individual is eligible for any category of assistance. If the individual is ineligible for any category, the department shall determine which months the individual was not eligible and forward the documentation to the medical assistance division for the determination of repayment of fee for service payments or the capitation payments made to the health maintenance organization on behalf of the individual for months the individual was not eligible for the category of assistance. The department will pursue the repayment of capitation amounts paid to the health maintenance organization for the months the individual was ineligible for any medical assistance programs and received medical services.
E. Development of information: When quality control review findings, or information reported or received indicate, that benefits may have been issued incorrectly; the department shall attempt to obtain and verify whether benefits were provided in error.
F. When claims are not established: Overpayment c laims shall not be established for administrative or IHE’s, if an over-issuance occurred because the department did not ensure that the following procedural requirements were fulfilled:
(1) an application form was signed; or
(2) appropriate work registration code was entered.
G. Claim establishment threshold: Claims for SNAP, cash assistance and LIHEAP will not be established when the cumulative amount of the claim is less than the establishment thresholds.
(1) Claims for all programs resulting from an administrative error will not be established if the cumulative claim is less than five hundred dollars ($500).
(2) Claims resulting from an IHE will not be established if the cumulative error is less than two hundred fifty dollars ($250).
(3) Claims resulting from fraud or an IPV will always be established for the full amount of the overpayment.
[8.100.640.11 NMAC - N, 09/30/2013]
A. SNAP:
(1) Calculating the claim for an IHE and AE: For each month that benefits have been over-issued to an eligibility determination group because of an IHE or AE, the department shall determine the correct benefit amount the eligibility determination group was entitled to receive.
(a) The total amount of the claim is calculated, based at a minimum, on the monthly overpayment amount which occurred during the twelve (12) months preceding the date the overpayment was discovered.
(b) The department shall calculate the amount of the claim back to the month the error occurred regardless of the length of time that elapsed until the error was discovered.
(c) The department shall not include in the calculation any overpayment amount that occurred in a month more than six (6) years before the date the overpayment was discovered.
(2) Calculating the claim for an IPV:
(a) For each month that benefits have been over-issued to an eligibility determination group because of an IPV, the department shall determine the correct amount of benefits the eligibility determination group was entitled to receive.
(b) The amount of the IPV claim will be calculated back to the month the IPV occurred, regardless of the length of time that elapsed until the determination of an IPV was made.
(c) The department may not include in the calculation any amount of the overpayment that occurred in a month more than six (6) years prior to the date the overpayment was discovered.
(d) If an eligibility determination group member is determined to have committed an IPV by intentionally failing to report a change in eligibility determination group circumstances, the first month affected by the failure to report will be the first month in which the change would have been effective if it had been timely reported.
(e) In no event shall the department determine as the first month that the change would have been effective any month later than two (2) months after the month that the change in eligibility determination group circumstances occurred.
(f) If an eligibility determination group received a larger benefit amount than it was entitled to receive, a claim will be established against the eligibility determination group equal to the difference between the benefit amount the eligibility determination group received and the amount the eligibility determination group should have received.
(g) Earned income deduction penalty: When determining the amount of benefits the eligibility determination group should have received, the twenty percent (20%) earned income deduction is not applied to that portion of earned income that the eligibility determination group intentionally failed to report. A claim must be recomputed if it was initially handled as an IHE claim.
(3) Offsetting the claim: Once the amount of the claim for IPV, IHE, and AE is established, the department may offset the amount of the claim against any benefit amount not yet restored to the eligibility determination group. Action must be taken to initiate collection of the remaining balance, if any.
B. Cash assistance programs:
(1) Claims for administrative and client caused errors: Claims are established when the department issues more than the eligibility determination group was eligible to receive due to an AE or if the eligibility determination group fails, either intentionally or unintentionally, to report correct information at application or while receiving benefits.
(a) For each month of eligibility, the grant determinations are made using the standard of need, case information and policy in effect for that month.
(b) The department shall recover all cash assistance overpayments, including overpayments resulting from an AE, and any assistance paid while pending a fair hearing decision.
(c) An historical change that results in a lower payment than was originally issued, results in an overpayment and the establishment of a claim if it exceeds the claims establishment thresholds listed in Subsection G of 8.100.640.11 NMAC.
(d) If a change occurs that makes the eligibility determination group eligible for a lower benefit payment for a month, the adult member(s) of the eligibility benefit group is responsible for paying the difference back to the department.
(e) If a change occurs that lowers the standard of need for which the eligibility determination group is eligible, the eligibility determination group shall be allowed the amount that they were eligible on the first day of the month.
(2) Overpayments to sponsored aliens:
(a) Aliens and sponsors are jointly liable for overpayments caused by failure of the sponsor to provide correct information, unless the sponsor is without fault or has good cause. "Without fault" or "good cause" exists when:
(i) the agency failed to request information from the sponsor; or
(ii) the sponsor can show that the sponsor provided all information available to the sponsor at the time the information was provided;
(iii) the alien provided incorrect information without the knowledge of the sponsor; or
(iv) the sponsor can show that the giving of incorrect information was not intentional on the part of the sponsor.
(b) If good cause is found to exist, the alien has sole responsibility for repayment.
(3) Developing substantiating information:
(a) Upon receiving indication that a possible error exists, the department shall investigate whether an erroneous payment has occurred. Pertinent information shall be requested from the participant. Because this information may be used to prosecute the participant for fraud, the participant shall not be required to provide such information; however, if the participant declines to provide information crucial to the determination of overpayment, the participant shall be ineligible for the period in question because of failure or refusal to provide information.
(b) The same standards shall be used in determining erroneous payments as are used to determine initial and ongoing eligibility and payment.
(c) The participant must be periodically reminded of the reporting responsibilities and must indicate, no less frequently than at every certification, that the participant understands these requirements. This requirement is met by the use of a department form that reminds participants at each certification of their reporting responsibilities. This form also serves as the participant's statement that the participant understands the reporting responsibilities. If it is determined that a participant may have difficulty understanding the reporting responsibilities because of language, literacy, or mental or emotional problems, the department shall supplement the written notice with an oral explanation. All such oral explanations must be documented in the case record.
(d) The participant shall become ineligible on a continuing basis if there is a continuing failure to provide information affecting the participant's current eligibility.
(4) Offsetting the claim: Once the amount of the claim for IPV, IHE and AE is established, any restoration the eligibility determination group is eligible to receive is reduced or offset by the amount of the claim. Action must be taken to initiate collection of the remaining balance, if any.
C. LIHEAP:
(1) A claim shall be established for LIHEAP benefits that have been overpaid regardless of the reason of the overpayment.
(2) The department may establish a claim that exceeds the claim establishment threshold, as identified in Subsection G of 8.100.640.11 NMAC, for LIHEAP benefits overpaid up to six (6) years prior to the date the overpayment occurred.
(3) Offsetting the claim: A benefit amount may be offset during the issuance process in order to recover a LIHEAP overpayment. The amount that is offset shall be conveyed to the restitutions bureau to be applied to the eligibility determination group's overpayment.
D. Claims involving reported changes: In cases involving reported changes, the department shall determine the first month the overpayment occurred.
(1) Inadvertent household error: If caused by an inadvertent error on the part of the eligibility determination group (failure to report a change in circumstances within the required time frames), the first month affected by the eligibility determination group's failure to report is the first month in which the change would have been effective if it had been reported timely. In no event will the department determine as the first month in which the change would have been effective any month later than two (2) months from the month in which the change in eligibility determination group's circumstances occurred.
(2) Agency error: If an eligibility determination group reported a change timely but the department did not act on the change within the required time frame, the change should have taken effect the first month following the reported change, if it had been acted upon within the time frame. In no event shall the department determine as the first month in which the change would have been effective any month later than two (2) months from the month in which the change in eligibility determination group circumstances occurred. If an adverse action notice was required but was not provided, the department shall assume for the purpose of calculating the claim that the maximum advance notice period would have expired without the eligibility determination group requesting a fair hearing.
[8.100.640.12 NMAC - N, 09/30/2013]
The department shall initiate collection action by sending the eligibility determination group an overpayment notice.
A. Adverse action notice: If the amount of the claim was not established by a fair hearing decision, the eligibility determination group will be provided with an adverse action notice. The adverse action notice is sent on all claims established after March 26, 1990 and on any preexisting claims if at any time after March 26, 1990 a follow-up demand letter is sent on the claim. A one-time adverse action notice that informs the eligibility determination group that it has ninety (90) days to appeal the amount of the claim will satisfy notice requirements.
B. Demand letter: Collection action is initiated by sending the eligibility determination group a demand letter. The demand letter informs the eligibility determination group of the claim amount, the reason for the claim, time period for which there is a claim, any offset that reduces the claim and how the eligibility determination group may pay the claim. The first demand letter to a participating eligibility determination group shall inform the eligibility determination group:
(1) that unless the eligibility determination group selects an acceptable method of payment and informs the department within the specified time limit, or timely requests a fair hearing and continued benefits, their SNAP benefit amount will be reduced;
(2) that benefit reduction will affect the eligibility determination group’s monthly benefits, only if the department has not otherwise informed the eligibility determination group;
(3) that if the eligibility determination group timely selects an acceptable benefit reduction amount, the reduction will begin with the first benefit month that is issued after the selection;
(4) that if the eligibility determination group fails to make a timely selection or fails to request a fair hearing and continued benefits, the benefit reduction will be effective with the first benefit issued after timely notice of such selection or request for hearing is due to the department; and
(5) advise the eligibility determination group of any individual or organization that provides free legal representation.
C. Collection action:
(1) Initiating action: The department shall initiate collection action on all claims unless the claim is collected through an offset or one of the following conditions applies:
(a) the total amount of the claim is less than the established claims threshold outlined in Subsection G of 8.100.640.11 NMAC, and the claim cannot be recovered by reducing the eligibility determination group's SNAP benefit amount; or
(b) the department has documentation that establishes the eligibility determination group cannot be located.
(2) Postponing action: Collection action will be postponed on claims where an eligibility determination group is being referred for possible prosecution or for administrative disqualification, and the determination is made that collection action will prejudice the case.
(3) Collection action: Restitution bureau shall pursue collection as specified in 8.100.640.13 NMAC.
D. SNAP Intentional program violation (IPV):
(1) Initiating collection: If an eligibility determination group member is found to have committed an IPV or has signed either a waiver or a disqualification consent agreement, the department shall initiate collection action against the individual's eligibility determination group. Personal contact with the eligibility determination group is made, if possible. The department is required to initiate such collection unless:
(a) the eligibility determination group has repaid the overpayment already; or
(b) the department has documentation establishing that the eligibility determination group cannot be located; or
(c) the department determines that collection action will prejudice the case against an eligibility determination group member referred for prosecution.
(2) Partially paid claim: The department shall initiate collection action for an unpaid or partially paid claim, even if collection action was previously initiated while the claim was being handled as an IHE claim.
(3) In cases where an eligibility determination group member has been found guilty of misrepresentation or fraud by a court or has signed a disqualification consent agreement in a case referred for prosecution, the department shall request that the matter of restitution be brought before the court or be addressed in the agreement reached between the prosecutor and the accused individual.
(4) Changes in eligibility determination group composition:
(a) Collection action will be initiated by the restitution bureau against the eligibility determination group containing the member found to have committed an IPV.
(b) If a change in eligibility determination group composition occurs, collection action is pursued against any or all of the adult members of an eligibility determination group at the time an overpayment occurred.
(c) Collection action is pursued against any eligibility determination group which has a member who was an adult member of the eligibility determination group that received the overpayment.
E. Fraud exception: Notice of overpayment and administrative hearings rights shall not be given if the department has decided to pursue criminal prosecution for fraud. In such cases, the participant's notice of rights are limited to those afforded by state criminal statutes. No attempt shall be made by department staff to recover overpayments in such cases, nor shall any offers to refund the overpayment be accepted by the county office.
F. Recovery action:
(1) Overpayments of less than $1,000: Overpayments of less than one thousand dollars ($1,000) to currently eligible cases shall be immediately processed by the department for recoupment.
(2) Overpayments over $1,000: Overpayments of more than one thousand dollars ($1,000) to currently eligible cases shall be referred to the office of inspector general (OIG) for a fraud action decision.
(3) Response to referral:
(a) The department shall be notified by the OIG within thirty (30) days whether fraud action has or will be taken on an open case. If no fraud action is contemplated, the case shall be immediately processed for either recoupment or cash recovery.
(b) If a response is not received from the OIG within thirty (30) days of referral, the county will initiate recoupment from currently eligible cases.
G. Fraud referral:
(1) Fraud elements:
(a) By state statute, Section 30-16-6, NMSA 1978, fraud is the intentional misappropriation or taking of anything of value that belongs to another by means of fraudulent conduct, practices or representations.
(b) Fraud exists when:
(i) a person, by words or conduct, misrepresents facts to the department with the intention to deceive the department; and
(ii) because of the misrepresentation and the department's reliance upon it, the eligibility benefit group has obtained benefits from the department to which they were not entitled.
(2) Referral for investigation: If the department decides that fraud may exist, the case is referred to the OIG for further investigation or possible prosecution.
[8.100.640.13 NMAC - N, 09/30/2013]
A. Recoupment: The department shall retain the value of benefits collected to repay a claim against a participating eligibility determination group, whether or not the claim occurred because of an IHE, an AE, or an IPV. The eligibility determination group's monthly SNAP or cash assistance benefit amount will be reduced to recover any amount of a claim that was not repaid through a lump sum cash or SNAP benefit payment, unless a payment schedule has been negotiated with the eligibility determination group. Collection of a claim by the department may also be obtained through recoupment of unemployment compensation benefits, federal pay, income tax intercepts, or any other method established by the department.
(1) Recoupment from monthly benefit allotments: A claim may be recovered from an eligibility determination group currently participating in SNAP or cash assistance programs by reducing the eligibility determination group’s monthly benefit allotment.
(2) Recoupment amount: The amount of benefits that will be recovered each month through benefit reduction will be determined by one the following methods.
(a) SNAP IHE and AE: The amount of reduction will be ten percent (10%) of the eligibility determination group’s monthly SNAP benefit amount, or ten dollars ($10) per month, or the agreed amount, whichever is greater.
(b) SNAP IPV: The SNAP benefit amount to be recovered will be twenty percent (20%) of the eligibility determination group’s monthly SNAP benefit amount, or twenty dollars ($20) per month, or the agreed amount, whichever is greater.
(c) Cash assistance errors: The cash assistance benefit amount to be recouped is equal to fifteen percent (15%) of the eligibility determination group's payment standard.
(d) Recoupment is the last step in the calculation prior to determining the monthly benefit amount.
B. Cash payment methods:
(1) Lump sum cash:
(a) If the eligibility determination group asks to make a lump sum cash payment or is financially able to repay the claim at one time, the restitution bureau shall collect a lump sum cash payment.
(b) An eligibility determination group will not be required to liquidate all of its resources to make a lump sum payment.
(c) If an eligibility determination group is financially unable to pay the entire amount of the claim at one time and prefers to make a lump sum cash payment as partial payment of the claim, the department shall accept this method of payment.
(d) If an eligibility determination group chooses to make a lump sum payment of benefits from their EBT account as full or partial payment of the claim, the department shall accept this method of repayment, to include:
(i) SNAP benefits to repay a SNAP claim; or
(ii) cash benefits to repay a cash assistance claim or medical assistance claim; or
(iii) cash benefits to repay a SNAP claim.
(2) Installment payment schedules:
(a) The department shall negotiate a payment schedule with the eligibility determination group for repayment of any amounts of the claim not repaid through a lump sum payment.
(b) Payments will be accepted in regular installments.
(c) An eligibility determination group may use its SNAP or cash assistance benefits as full or partial payment of any installment repayment to include:
(i) SNAP benefits to repay a SNAP claim; or
(ii) cash benefits to repay a cash assistance claim or medical assistance claim; or
(iii) cash benefits to repay a SNAP claim.
(3) Repayment of SNAP overpayments:
(a) If an eligibility determination group is currently receiving benefits, and a payment schedule is negotiated for repayment of a claim, the negotiated amount to be repaid each month in installment payments may not be less than the amount that could be recovered through benefit reduction.
(b) The amount to be repaid each month through installment payments will remain unchanged regardless of subsequent changes in the eligibility determination group's monthly SNAP benefit amount.
(4) Repayment of cash assistance overpayments:
(a) Repayments are used to recover cash assistance overpayments from cases no longer receiving cash assistance or where recovery of an overpayment from an active cash assistance case cannot be liquidated within twenty (20) months by recoupment.
(b) The amount the department tries to recover monthly through repayment is based on the following schedule, or, if a court order for repayment exists, in accordance with the court order. If the level of payment sought would cause an extreme hardship on the participant, the restitution bureau may agree to accept a lesser amount. Arrangements for repayments are made by the restitution bureau in all cases, except those where the participant is willing to repay the entire overpayment in a single payment.
(c) Repayment schedule:
Overpayment Amount Monthly Repayment Payment $ 35 -$100 $ 5 $101 - $200 $10 $201 - $300 $15 $ 301 - $400 $20 $401 - $500 $25 $501 - $600 $30 $601 - $700 $35 $701 - $800 $40 $801 - $900 $45 $901 or more $50
(5) Repayment of LIHEAP benefits:
(a) The eligibility determination group will have forty-five (45) days from the date of notification of the claim amount to repay the claim in full or make arrangements to make regular installments to repay the claim.
(b) The department will initiate collection action to recover the claim amount on day forty-five (45) if the eligibility determination group does not repay or make arrangements to repay the amount owed.
(6) Renegotiating payments: The restitution bureau, the eligibility determination group, or both, have the option to initiate renegotiation of the payment schedule if either or both believes that the eligibility determination group's economic circumstances have changed enough to warrant such action.
(7) Failure to pay: If an eligibility determination group fails to make a payment in accordance with the established repayment schedule, (either a lesser amount is paid, or no payment is made), the restitution bureau shall send the eligibility determination group a notice explaining that no payment or insufficient payment was received.
(a) The notice informs an eligibility determination group that renegotiation of the payment schedule may be discussed with the restitution bureau.
(b) The notice also informs an eligibility determination group that unless the overdue payments are made or the restitution bureau is contacted to discuss renegotiation of the payment schedule, the SNAP benefit amount of a currently participating eligibility determination group against which a claim has been established will be reduced without an adverse action notice.
(c) If the eligibility determination group responds to the notice, one of the following actions will be taken by the restitution bureau.
(i) If the eligibility determination group makes the overdue payments and wishes to continue making payments based on the previous schedule, the eligibility determination group is permitted to do so.
(ii) If the eligibility determination group requests renegotiation, and if the restitution bureau concurs, a new payment schedule will be negotiated.
(iii) If the eligibility determination group requests renegotiation of the amount of its repayment schedule, but the restitution bureau believes that the eligibility determination group's economic circumstances have not changed enough to justify the requested settlement, renegotiation will continue until a settlement can be reached.
(d) The restitution bureau has the option to invoke SNAP benefit reduction against a currently participating eligibility determination group for repayment of a claim if a settlement cannot be reached.
(e) If a currently participating eligibility determination group against which a claim has been established fails to respond to the notice, a benefit reduction will be initiated. If benefit reduction is initiated, no notice of adverse action will be required.
C. Other payment methods:
(1) Federal tax intercept: The department may offset an eligibility determination group’s federal income tax return following notification to the eligibility determination group, and apply the offset to the oldest established SNAP claim.
(2) Unemployment compensation benefit reduction: The department may offset the unemployment compensation benefits of an adult eligibility determination group member, following notification to the eligibility determination group, and apply the offset to the oldest established active SNAP claim.
(3) Federal pay: The department may offset an eligibility determination group member’s federal pay, following notification to the eligibility determination group, and apply the offset to the oldest established active SNAP claim.
(4) Any other means: The department may invoke collections by any other means available, including but not limited to, the use of private collection agencies, following notification to the eligibility determination group.
(5) State tax intercept: The department may offset a household’s state income tax return following notification to the household, and apply the offset to the oldest established active cash claim.
[8.100.640.14 NMAC - N, 09/30/2013]
A terminated claim is a claim in which all collection action has ceased. The department may terminate a claim for any of the reasons described in Subsections A through E of this section. SNAP, LIHEAP, TANF, AFDC, GA and refugee cash assistance and support services for participation in the SNAP and TANF work programs can be terminated.
A. Invalid claims: The overpayment is determined to be invalid based on an administrative hearing decision, a court decision or a department determination that the claim was established in error.
B. Death: All adult members responsible for repayment of the claim are deceased.
C. Cost effectiveness: The department has determined that the cost of further collection action is likely to exceed the amount that can be recovered because:
(1) the cumulative amount of all existing claims against the eligibility determination group equals twenty-five dollars ($25) or less; and
(2) a payment on the claim has not been received by the department in at least ninety (90) days.
D. Failure to locate: There is documentation establishing that the eligibility determination group cannot be located and the existing claim has been delinquent for at least six (6) years.
E. Inability to pay: There is written documentation establishing the eligibility determination group has filed for bankruptcy and the department is named as a creditor.
F. Reinstating a terminated claim: A terminated claim may be reinstated when a new collection method or a specific event substantially increases the likelihood of further collections.
G. Uncollectible claims:
(1) A claim may be determined uncollectible after being held in suspense for three (3) years.
(2) A suspended or terminated claim may be offset against any SNAP benefit amount to be restored.
H. Overpaid claims:
(1) If a household has overpaid a claim, the department shall reimburse any overpaid amounts as soon as possible after the overpayment becomes known.
(2) The household may be reimbursed by whatever method the department deems appropriate after considering the household's circumstances.
I. Compromising the claim:
(1) If the full or remaining amount of a claim cannot be liquidated in three (3) years, the restitution bureau may compromise the claim by reducing it to an amount that will allow the household to make restitution within three (3) years.
(2) A compromised claim will be offset by any benefit that has not yet been restored to the household.
(3) Claims caused by a SNAP IPV will not be compromised.
[8.100.640.15 NMAC - N, 09/30/2013]
Writing off a claim means that the claim is no longer considered a receivable subject to any federal or state collection requirements such as the Treasury Offset Program at 31 CFR 285 or the Supplemental Nutrition Assistance Program at 7 CFR 273.18. A claim may be written off if the claim is at least six (6) years old and at least one of the provisions of Subsections A through E of 8.100.640.15 NMAC apply. Only SNAP, LIHEAP and NMW cash assistance claims may be written off.
[8.100.640.16 NMAC - N, 09/30/2013]
A . EBT adjustment pertains to any EBT transaction resulting in a change to a client’s cash or snap benefits. If a system error causes a customer to receive funds to which they were not entitled or causes their account to not be charged for an EBT transaction, an adjustment may be completed to reclaim the funds or settle the transaction.
(1) Client-initiated adjustments: The department must act on all requests for adjustments made by client households within 90 calendar days of the error transaction.
(a) For SNAP the department has 10 business days from the date the household notifies it of the error to investigate and reach a decision on an adjustment and move funds into the client account.
(b) For cash the department has 20 business days from the date the household notifies it of the error to investigate and reach a decision on an adjustment and move funds into the client account.
(c) These timeframes also apply if the department or entity other than the household discovers a system error that requires a credit adjustment to the household. Business days are defined as calendar days other than Saturdays, Sundays, and federal holidays.
B. Retailer-initiated adjustments: The department must act upon all adjustments to debit a household's account no later than 10 business days from the date the error occurred, by placing a hold on the adjustment balance in the household's account. If there are insufficient benefits to cover the entire adjustment, a hold shall be placed on any remaining balance that exists, with the difference being subject to availability only in the next future month. The household shall be given adequate notice. The notice must be sent at the time the initial hold is attempted on the household's current month's remaining balance, clearly state the full adjustment amount, and advise the household that any amount still owed is subject to collection from the household's next future month's benefits.
(1) The household shall have 90 days from the date of the notice to request a fair hearing.
(2) Should the household dispute the adjustment and request a hearing within 10 days of the notice, a provisional credit must be made to the household's account by releasing the hold on the adjustment balance within 48 hours of the request by the household, pending resolution of the fair hearing. If no request for a hearing is made within 10 days of the notice, the hold is released on the adjustment balance, and this amount is credited to the retailer's account. If there are insufficient funds available in the current month to cover the full adjustment amount, the hold may be maintained and settled at one time after the next month's benefits become available.
[8.100.640.17 NMAC - N, 3/1/2020]
Stale benefit accounts are those SNAP and cash assistance accounts that have not been accessed for 90 days from the most recent date of withdrawal.
A. Offline accounts: If EBT accounts are not accessed for 90 days, the department may store such benefits in an offline account.
(1) Notification: The department shall notify the eligibility determination group of this action before storing benefits in an offline account and how to reactivate the account.
(2) Reinstatement: An adult eligibility determination group member or authorized representative may contact the department or the EBT customer service help desk and request reinstatement of their EBT account.
(a) SNAP: SNAP benefits may be restored within 274 days of the initial date of benefit activity. Initial date of benefit activity is the first deposit made to the account upon initial approval of the eligibility determination group’s benefits.
(b) Cash assistance: Cash assistance benefits may be restored within 364 days of the initial date of benefit activity. Initial date of benefit activity is the first deposit made to the account upon initial approval of the eligibility determination group’s benefits.
B. Expungements: SNAP and cash assistance benefits that have not been accessed in excess of the threshold for each program will be expunged. All benefits will no longer be available to the eligibility determination group. The eligibility determination group loses all rights to expunged benefits.
(1) Stale benefit threshold:
(a) SNAP: SNAP benefits will be expunged after no activity within 274 days of the initial date of benefit activity.
(b) Cash assistance: Cash assistance benefits which have had no activity within 180 days of the initial date of benefit activity will be expunged.
(2) Notification: The contractor shall notify the department no less than five days prior to expungement of the SNAP benefits. The department shall identify any SNAP claims against the eligibility determination group and shall apply upon expungement.
(a) SNAP: The department shall notify the eligibility determination group no less than 30 days prior to the expungement of the SNAP benefits. Request from the participant to reinstate any benefit must be received prior to date of expungement.
(b) Cash assistance: The department shall attempt to notify the eligibility determination group no less than 45 days prior to the expungement of the cash assistance benefits. A request from the participant to reinstate any benefit must be received prior to the date of expungement.
(3) Payments of claims against the eligibility determination group. The contractor shall notify the department no less than five days prior to expungement of the SNAP or cash assistance benefits and any claims against the eligibility determination group shall be removed from the account and applied to the claims upon expungement.
[8.100.640.17 NMAC - N, 09/30/2013; A and Rn, 3/1/2020; A, 10/1/2021]
History of 8.100.640 NMAC: [RESERVED]
New Mexico Health Care Authority.
[8.100.970.1 NMAC - Rp, 8.100.970.1 NMAC, 11/27/2013; A, 7/1/2024]
The rule applies to the general public .
[8.100.970.2 NMAC - Rp, 8.100.970.2 NMAC, 11/27/2013]
A. Section 27 NMSA 1978 (1992 Repl.) provides for the department to "...adopt, amend and repeal bylaws, rules and regulations..." It also provides for administration of public assistance programs.
B. The income support division (ISD) of the Health Care Authority (HCA) was created by the secretary under authority granted by Paragraph (3) of Subsection B of Section 9-8-6 NMSA 1978.
C. The New Mexico health insurance exchange (NMHIX) was established by Section 59A-23F-1 of NMSA 1978 et al . Pursuant to 45 CFR 155.505(c) and 155.510(a), NMHIX has designated to the New Mexico health care authority the authority to conduct fair hearings of NMHIX eligibility appeals pursuant to 45 CFR 155 Subpart F.
[8.100.970.3 NMAC - Rp, 8.100.970.3 NMAC, 11/27/2013, A/E, 11/1/2021 ; A, 4/1/2022; A, 7/1/2024]
Permanent.
[8.100.970.4 NMAC - Rp, 8.100.970.4 NMAC, 11/27/2013]
November 27, 2013, unless a later date is cited at the end of a section.
[8.100.970.5 NMAC - Rp, 8.100.970.5 NMAC, 11/27/2013]
The objective of these regulations is to provide general policy and procedures for the public assistance programs administered by the department, as well as policy and procedures for the department to conduct hearings for claimants of adverse actions by NMHIX.
[8.100.970.6 NMAC - Rp, 8.100.970.6 NMAC, 11/27/2013; A/E, 11/1/2021; A, 4/1/2022]
A. Agency review conference (ARC): means an optional conference offered by the department to households adversely affected by a department action that is normally held prior to a fair hearing. An ARC may be attended by all parties responsible for and affected by the adverse action taken by the department, including but not limited to, the ISD field office staff, the child support enforcement division (CSED), a New Mexico works (NMW) representative and the household or its authorized representative for the purpose of informally resolving the dispute. The ARC is optional and shall in no way delay or replace the fair hearing process. This subsection does not apply to appeals of adverse actions by NMHIX.
B. Authorized representative: means an individual designated by a household to represent and act on its behalf during the fair hearing process. The household must provide formal documentation authorizing the named individual(s) to access the identified case information for a specified purpose and time frame. An authorized representative may be an attorney representing a person or household, a person acting under the authority of a valid power of attorney, a guardian ad litem, or any other individual(s) designated by the household.
C. Claimant or Appellant: means the household requesting a fair hearing that is claiming to be adversely affected by an action(s) taken by the department or NMHIX.
D. Informal resolution process: means an opportunity for informal resolution between NMHIX and a household adversely affected by an NMHIX action in accordance with the requirements of 45 CFR section 155.535(a). The informal resolution process happens prior to a fair hearing. The appellant’s right to a hearing is preserved in any case in which the appellant remains dissatisfied with the outcome of the informal resolution process. If the appeal does not advance to a hearing, the informal resolution is final and binding.
[8.100.970.7 NMAC - N, 11/27/2013; A/E, 11/1/2021; A, 4/1/2022]
A. A household aggrieved by an adverse action taken by the department or NMHIX that affects the participation of the household in a department administered public assistance program or in the New Mexico health insurance exchange, if applicable, may appeal the department’s or NMHIX’s decision by requesting a fair hearing in accordance with federal and state laws and regulations.
(1) Medicaid recipients wanting to request a fair hearing due to termination, modification, reduction or suspension of services must do so in accordance with any applicable federal and state laws and regulations, including 8.200.430.12 NMAC and 8.352 NMAC, et seq.
(2) Fair hearings related to adverse actions by NMHIX shall be held in accordance with any applicable federal and state laws and regulations, including those set forth in 45 CFR 155 Subpart F.
B. A household may designate an authorized representative to request a hearing on its behalf and to represent them during the fair hearing process. The claimant or their authorized representative must complete a request for access to a case record each time they wish to have access to the record outside what is provided to the claimant in the summary of evidence (SOE). If the claimant wishes to have their authorized representative review the record in their absence, the claimant must provide formal documentation authorizing the named individual(s) to access the identified case information for a specified purpose and time frame.
C. Hearing rights: Each household has the right to request a fair hearing and:
(1) to be advised of the nature and availability of a fair hearing and an ARC, if applicable;
(2) to be represented by counsel or other authorized representative of the claimant's choice;
(3) to receive reasonable assistance in completing procedures necessary to request a fair hearing; and
(4) to receive a copy of the SOE and any document contained in the claimant's case record in order to prepare for the fair hearing in accordance with Subsection B of 8.100.970.8 NMAC; the department shall forward the SOE and any other document(s) submitted to the fair hearings bureau for admission into the fair hearing record to the claimant’s authorized representative once the department or NMHIX becomes aware that an authorized representative has been designated by the claimant;
(5) to have a fair hearing that safeguards the claimant's opportunity to present a case;
(6) where applicable/for non-NMHIX matters, to elect to continue to receive the current level of benefit, provided the request for hearing is received by the department before the close of business of the 13th day immediately following the date of the notice of adverse action; a claimant that elects to continue to receive the same level of benefit pending the fair hearing decision shall be informed that a hearing decision in favor of the department may result in an overpayment of benefits and a requirement that the household repay the benefits; a claimant may waive a continuation of benefits pending the outcome of the fair hearing;
(7) in matters involving NMHIX, to be considered eligible while an appeal is pending, in accordance with the provisions of 45 CFR section 155.525;
(8) to have prompt notice and implementation of the final fair hearing decision; and
(9) to be advised that judicial review may be invoked to the extent such review is available under state or federal law; and
(10) in matters involving NMHIX, to be advised that a second-tier appeal to the United States department of health and human services is available.
D. The department and NMHIX will neither provide representation for, nor pay for any costs incurred by a claimant or the authorized representative in preparation for, or attendance at an ARC, fair hearings or judicial appeals.
E. Notice of rights:
(1) At the time of application for assistance, the department shall inform each applicant of the applicant’s right to request a fair hearing if the applicant disagrees with an action taken by the department. In matters involving NMHIX, NMHIX shall provide notice of appeal rights and appeal procedures, including the right to request a fair hearing, at the time that the applicant submits an application and the notice of eligibility determination is sent under 45 CFR section 155.310(g) , 155.330(e)(1)(ii), 155.335(h)(1)(ii), and 155.610( i ). The applicant may choose to receive the notice by mail or in electronic format.
(2) The notice shall inform the applicant of the procedure by which a fair hearing may be requested and that the claimant's case may be presented by the claimant or an authorized representative.
(3) The department shall remind the household of its right to request a fair hearing any time the household expresses disagreement with an action taken on its case by the department.
(4) Each county office shall post a notice of the right to request a fair hearing and an ARC, and a copy shall be given, upon request, to any person that has requested a hearing.
(5) Each notice provided to a claimant pursuant to this section shall include a statement that free legal assistance, by an individual or organization outside of the department, may be available to assist with the fair hearing process.
(6) A claimant may request special accommodations for a disability or a language or speech interpreter be available during an informal resolution process, a fair hearing or ARC. An interpreter or special accommodations shall be provided by the department or NMHIX, as applicable, at no cost to the claimant. A request for a language interpreter, a speech interpreter or other disability accommodation must be made within 10 days of the date of the fair hearing. If an interpreter or disability accommodations are not requested timely, the claimant can request postponement of the hearing in accordance with Subsection B of 8.100.970.10 NMAC.
F. Special provisions pertaining to mass changes: Special provisions apply in situations involving mass changes. These provisions are contained at 8.100.180.12 and 15 NMAC, 8.139.120.13 NMAC, 8.139.500.8 and 9 NMAC, 8.106.630.10 and 11 NMAC, 8.102.501.9 NMAC and 8.102.630.10 NMAC.
G. Continuing benefit for cash assistance: If a claimant who is a cash assistance recipient requests a fair hearing before the close of business of the 13th day immediately following the date of the notice of adverse action, the claimant may elect to waive or continue receiving the same amount of cash assistance and services issued immediately prior to the notice of adverse action until a final decision is issued. If there is no indication that the claimant has waived a continuation of benefits, the department will assume a continuation of benefits is desired. The household is required to comply with the reporting and renewal provisions at 8.102.120 NMAC and 8.106.120 NMAC. Cash assistance recipients are to continue compliance with the NMW compliance requirements at 8.102.460 NMAC.
H. Continuing SNAP benefits: If a claimant who is a SNAP recipient requests a fair hearing before the close of business of the 13th day immediately following the date of the notice of adverse action, the claimant may elect to waive or continue receiving the same amount of SNAP benefits issued immediately prior to the adverse action until a final decision is issued. If there is no indication that the claimant has waived a continuation of benefits, the department will assume a continuation of benefits is desired. The claimant is required to comply with the reporting and renewal provisions at 8.139.120 NMAC.
I. Continuing eligibility for a medical assistance program: If a claimant who is a recipient of a medical assistance program requests a fair hearing before the close of business of the 13th day immediately following the date of the notice of adverse action, the claimant may elect to waive or continue receiving the same medical assistance benefit issued immediately prior to the adverse action until a final decision is issued. If there is no indication that the claimant has waived a continuation of benefits, the department will assume a continuation of benefits is desired. If the hearing is regarding the termination, modification, reduction or suspension of medical assistance program services, a continuation of services is governed by all applicable federal and state laws and regulations, including 8.352 NMAC, et seq.
J. Continuing eligibility in cases involving NMHIX: In matters involving NMHIX, eligibility pending appeal is governed by the provisions of 45 CFR section 155.525.
[8.100.970.8 NMAC - Rp, 8.100.970.8 NMAC, 11/27/2013; A/E, 11/1/2021; A, 4/1/2022]
A. Initiation of the hearing process:
(1) A request for a fair hearing can be made by the claimant or an authorized representative orally or in writing.
(2) If a claimant requests a fair hearing orally, the department shall take such actions as are necessary to initiate the fair hearing process.
(3) The fair hearings bureau shall promptly send written acknowledgement to the claimant and the authorized representative upon its receipt of a written or oral hearing request.
B. Time limits:
(1) A household or its authorized representative shall request a fair hearing no later than close of business on the 90th day following the date of the notice of adverse action. If the 90th day falls on a weekend, holiday or other day the department is closed, a request received the next business day will be considered timely.
(2) The department shall assure that the fair hearing is conducted, a fair hearing decision is reached and the claimant and the authorized representative are notified of the decision within the specified program time limit set forth below, except in instances where the time limit may be extended pursuant to Subsection B of 8.100.970.10 NMAC or Subsection G of 8.100.970.12 NMAC.
(a) SNAP program: The final fair hearing decision shall be issued to the claimant and the authorized representative within 60 days from the date the department receives the hearing request unless extended pursuant to Subsection B of 8.100.970.10 NMAC or Subsection G of 8.100.970.12 NMAC.
(b) Cash assistance programs: The final fair hearing decision shall be issued to the claimant and the authorized representative within 90 days from the date that the department receives the hearing request unless extended pursuant to Subsection B of 8.100.970.10 NMAC or Subsection G of 8.100.970.12 NMAC.
(c) LIHEAP: The final fair hearing decision shall be issued to the claimant and the authorized representative within 60 days from the date that the department receives the hearing request unless extended pursuant to Subsection B of 8.100.970.10 NMAC or Subsection G of 8.100.970.12 NMAC.
(d) Medical assistance programs: The final fair hearing decision shall be issued to the claimant and the authorized representative within 90 days from the date that the department receives the hearing request unless extended pursuant to Subsection B of 8.100.970.10 NMAC or Subsection G of 8.100.970.12 NMAC. Fair hearing decisions regarding the termination, modification, reduction or suspension of services is governed by all applicable federal and state laws and regulations, including 8.352 NMAC, et seq.
(e) NMHIX matters: The final fair hearing decision shall be issued to the claimant and the authorized representative within 90 days from the date of the appeal request. Fair hearing decisions regarding adverse actions by NMHIX are governed by all applicable federal and state laws and regulations, including 45 CFR 155 Subpart F. In the case of an appeal request submitted under 45 CFR 155.540 that the department determines meets the criteria for an expedited appeal, the department must issue the fair hearing decision notice as expeditiously as reasonably possible.
C. Jurisdiction of the fair hearings bureau:
(1) An applicant for, or recipient of, a department administered public assistance program may request a fair hearing, and the department’s fair hearings bureau shall have jurisdiction over the matter, if:
(a) an application for benefits or services is denied in whole or in part, or not processed timely;
(b) assistance or services are reduced, modified, terminated, suspended or not provided, or the form of payment is changed;
(c) a good cause request for not participating in the work program or CSED is denied in whole or in part;
(d) the department refuses or fails to approve a work program participation plan, or the supportive services related to it, that have been developed by a participant; or
(e) the claimant is aggrieved by any other action affecting benefit level or participation in an assistance program administered by HSD.
(2) An applicant for, or enrollee in, health insurance coverage or insurance affordability programs through the New Mexico health insurance exchange may request a fair hearing, and the department’s fair hearings bureau shall have jurisdiction over the matter, if the applicant or enrollee is appealing:
(a) An eligibility determination made in accordance with 45 CFR Subpart D, including:
( i ) an initial determination of eligibility, including the amount of advance payments of the premium tax credit and level of cost-sharing reductions, made in accordance with the standards in 45 CFR section 155.305(a) through (h); and
(ii) a redetermination of eligibility, including the amount of advance payments of the premium tax credit and level of cost-sharing reductions, made in accordance with 45 CFR section 155.330 and 155.335;
(iii) a determination of eligibility for an enrollment period, made in accordance with 45 CFR section 155.305(b); and
(b) A failure by NMHIX to provide timely notice of an eligibility determination in accordance with 45 CFR section 155.310(g), 45 CFR section 155.330(e)(1)(ii), 45 CFR section 155.335(h)(1)(ii), or 45 CFR section 155.610( i ).
(3) Fair hearing requests submitted to the local county office shall be immediately forwarded to the fair hearings bureau for scheduling. The fair hearings bureau shall promptly inform the applicable local county office upon its receipt of a written or oral fair hearing request submitted directly to the fair hearings bureau to ensure timely scheduling of an ARC.
D. Denial or dismissal of request for hearing: The fair hearings bureau shall deny or dismiss, as applicable, a request for a fair hearing when:
(1) the request is not received by the close of business on the 90th day following the date of the notice of adverse action; in instances where the fair hearings bureau schedules a hearing prior to becoming aware of the lateness of the fair hearing request, the fair hearings bureau shall, upon learning of the late request, promptly dismiss the matter and provide notice thereof to all parties;
(2) the request for a fair hearing is withdrawn or canceled, either orally or in writing, by the claimant or claimant's authorized representative; if withdrawn orally, the claimant and the authorized representative shall be provided written verification of the withdrawal and given 10 calendar days from the date of the notification to request reinstatement of the hearing;
(3) the claimant fails to appear, without good cause, at a scheduled fair hearing;
(4) the same issue has already been appealed and a hearing decision made;
(5 ) there is no adverse action or delay of benefits or services for which a fair hearing may be requested; or
(6) the issue is one that the fair hearings bureau does not have jurisdiction as provided by federal or state laws and regulations;
(7) requests for fair hearings for medical assistance cases involving the termination, modification, reduction or suspension of services are governed by all applicable federal and state laws and regulations, including 8.352 NMAC, et seq;
(8) In matters involving NMHIX, an appeal will be dismissed if the appellant:
(a) withdraws the appeal request in writing or orally;
(b) fails to appear at a scheduled hearing without good cause;
(c) fails to submit a valid appeal request as specified in section 155.520(a)(4); or
(d) dies while the appeal is pending, except if the executor, administrator, or other duly authorized representative of the estate requests to continue the appeal.
E. Good cause for failing to appear:
(1) If the claimant or the claimant's authorized representative fails to appear for a fair hearing at the scheduled time and place, the claimant’s appeal will be considered abandoned and the fair hearings bureau shall dismiss the matter, unless the claimant or authorized representative presents good cause. A claimant or authorized representative may present good cause for failing to appear to the scheduled fair hearing at any time no later than close of business on the 10th calendar day immediately following the scheduled hearing date. If the 10th calendar day falls on a weekend, holiday or other day that the department is closed, a request received the next business day will be considered timely. If good cause is submitted timely and permitted, the fair hearings bureau shall reschedule the hearing or, where appropriate, reinstate a matter previously dismissed.
(2) If the department fails to appear due to circumstances beyond its control, the department may present good cause within 10 calendar days after the scheduled hearing. If good cause is submitted timely and permitted, the fair hearings bureau shall reschedule the fair hearing.
(3) Good cause includes, but is not limited to, a death in the family, disabling personal illness, or other significant emergencies. At the discretion of the hearing officer, other exceptional circumstances may be considered good cause.
[8.100.970.9 NMAC - Rp, 8.100.970.9 NMAC, 11/27/2013; A/E, 11/1/2021; A, 4/1/2022, 7/1/2024]
A. Notice of hearing: Unless the claimant or authorized representative requests an expedited scheduling of a fair hearing, the fair hearings bureau shall provide written notice of the scheduling of a fair hearing to all parties not less than 10 calendar days prior to date of the fair hearing, or not less than 15 calendar days prior to the date of the fair hearing if the hearing involves an adverse action by the New Mexico health insurance exchange (NMHIX). The notice of hearing shall include:
(1) the date, time and place of the hearing;
(2) the name, address and phone number of the hearing officer;
(3 ) information regarding the fair hearing process and the procedures to be followed by the respective parties;
(4) the right of the claimant and the authorized representative to receive a copy of the SOE and any document, not specifically prohibited by federal and state law and regulation, contained in the claimant's case record in order to prepare for the fair hearing in accordance with Subsection B of 8.100.970.8 NMAC;
(5) notice that the appeal will be dismissed if the claimant or the authorized representative fails to appear without good cause;
(6) information about resources in the community that may provide free legal assistance with the fair hearing process; and
(7) notice that the department will not pay for any costs of the claimant or authorized representative, including legal counsel, that are incurred in the preparation for, or attendance at, an ARC, fair hearing or judicial appeal.
B. Postponement: A claimant or authorized representative is entitled to, and the fair hearings bureau shall grant, at least one postponement of a scheduled fair hearing. The department may request and be approved for one postponement at the discretion of the fair hearings bureau due to the unavailability of any department witness to appear at the scheduled fair hearing. Requests for more than one postponement are considered at the discretion of the fair hearings bureau, on a case-by-case basis. A request for postponement must be submitted not less than one business day prior to the scheduled fair hearing, unless otherwise allowed by the fair hearings bureau, and is subject to the following limitations:
(1) SNAP and LIHEAP cases: A postponement may not exceed 30 days and the time limit for action on the decision is extended for as many days as the fair hearing is postponed.
(2) Cash assistance cases: The fair hearing may be postponed, but must be rescheduled to assure a final decision is made no more than 90 days from the date of the request for fair hearing.
(3) Medical assistance cases: The fair hearing may be postponed, but must be rescheduled to assure a final decision is made no more than 90 days from the date of the request for fair hearing. Fair hearings for medical assistance cases involving the termination, modification, reduction or suspension of services are governed by all applicable federal and state laws and regulations, including 8.352 NMAC, et seq.
(4) NMHIX cases: The fair hearing may be postponed but must be rescheduled to assure a final decision is made not more than 90 days from the date of the appeal request.
(5) The fair hearings bureau shall issue notice of the rescheduling of a postponed fair hearing not less than 10 calendar days before the rescheduled date, unless oral agreements are obtained from all parties to reschedule the fair hearing with less notice in an effort to meet the required timeframes. Documentation of the oral agreement shall be maintained in the fair hearing record.
C. Expedited hearing:
(1) SNAP cases: Hearing requests from SNAP households, such as migrant farm workers that plan to move out of the state before the hearing decision would normally be made should be scheduled on an expedited basis.
(2) NMHIX cases: an appellant may request an expedited appeals process where there is an immediate need for health services because a standard appeal could jeopardize the appellant’s life, health, or ability to attain, maintain, or regain maximum function. If the request for an expedited appeal is denied, the appeal request must be handled under the standard process and the appellant must be promptly informed of the denial, through electronic or oral notification, if possible. If notification is oral, the appeals entity must follow up with the appellant by written notice. Written notice of the denial must include:
(a) the reason for the denial;
(b) an explanation that the appeal request will be transferred to the standard process; and
(c) an explanation of the appellant's rights under the standard process.
D. Group hearings: A hearing officer may respond to a series of individual requests for hearings by conducting a single group hearing. Group hearing procedures apply only to cases in which individual issues of fact are not disputed and where related issues of state or federal law, regulation or policy are the sole issues being raised. In all group hearings, the regulations governing individual hearings are followed. Each individual claimant is permitted to present the claimant’s own case or to be represented by an authorized representative. If a group hearing is scheduled, any individual claimant may withdraw from the group hearing and request an individual hearing. The confidentiality of client records is to be maintained in accordance with federal and state laws and regulations.
E. Agency review conference (ARC): Except in matters involving NMHIX, the department and the claimant are encouraged to meet for an ARC before the scheduled fair hearing to discuss the department’s action(s) that the claimant has appealed. The ARC is optional and does not delay or replace the fair hearing process. An ARC will be held within 10 calendar days from the date of the fair hearing request. If the claimant submits a hearing request to the field office, in person or by telephone, the ARC may, at the claimant’s option, be conducted at that time. An appeal may not be dismissed by the department for failure of the claimant or authorized representative to appear at a scheduled ARC.
(1) The department shall send a written notice of the scheduled ARC to the claimant and authorized representative. The claimant may choose to receive the notice by mail or in electronic format.
(2) An ARC may be attended by all parties responsible for and affected by the adverse action taken by the department, including but not limited to, the ISD field office staff, the CSED, a NMW representative and the claimant or its authorized representative.
(3) The purpose of the ARC is to informally review the adverse action taken by the department and to determine whether the dispute can be resolved in accordance with federal and state law and regulation. The ARC is optional and shall in no way delay or replace the fair hearing process, unless the outcome of the ARC is the claimant withdrawing the fair hearing request.
(4) For cases in which the household appeals a denial of expedited SNAP service, the ARC shall be scheduled within two business days, unless the household requests that it be scheduled at a later date or does not wish to have an ARC.
(5) A household may request an ARC in order to discuss an adverse action taken by the department against the household, regardless of whether or not a fair hearing is requested.
F. Summary of evidence (SOE): An SOE shall be prepared by the department or NMHIX, if applicable, and submitted to the fair hearings bureau and the claimant and authorized representative no less than 10 calendar days prior to the date of the fair hearing. Failure to provide the SOE within the prescribed timeframe may result in its exclusion or a postponement or continuance of the hearing at the discretion of the hearing officer pursuant to Subsection B of 8.100.970.10 NMAC and Subsection D of 8.100.970.12 NMAC. Unless the hearing request is withdrawn by the claimant or authorized representative, an SOE shall be prepared and submitted in accordance with this paragraph, regardless of the results of an ARC. The SOE shall contain at least the following information:
(1) identifying information, including but not limited to, claimant's name, at least the last four digits of the claimant’s social security number, the claimant’s individual identification number, case identification number or reference identification number, the claimant’s last known address, and the type of assistance involved, if applicable;
(2) the issue(s) on appeal that outlines the adverse action taken by the department against the household;
(3) documentation in support of the department’s adverse action, including any facts, information and department findings related to the fair hearing issue(s);
(4) applicable federal and state laws and regulations, internal department policy documents, and any additional supportive legal documentation; and
(5) results of the ARC, if completed at the time of submission of the SOE.
G. Availability of information: The department staff shall:
(1) allow the claimant and the authorized representative to examine the case record and provide the claimant and the authorized representative a copy of the SOE and any document, not specifically prohibited by federal and state laws and regulations, contained in the claimant's case record in order to prepare for the fair hearing in accordance with Subsection B of 8.100.970.8 NMAC; and
(2) provide accommodations for a disability or a language or speech interpreter in accordance with Paragraph (6) of Subsection E of 8.100.970.8 NMAC and 45 CFR section 155.505(f), as applicable.
[8.100.970.10 NMAC - Rp, 8.100.970.10 NMAC, 11/27/2013; A/E, 11/1/2021; A, 4/1/2022]
A. Rights during the fair hearing: The claimant or authorized representative shall be given an opportunity to:
(1) examine the SOE and case record prior to, and during, the hearing in accordance with Subsection B of 8.100.970.8 NMAC;
(2) present his or her case or have it presented by an authorized representative;
(3) introduce witnesses;
(4) establish all pertinent facts and circumstances;
(5) advance any arguments without undue interference; and
(6) question or refute any testimony or evidence, including an opportunity to confront and cross-examine the department’s witnesses.
B. Hearing officer: Fair hearings are conducted by an impartial official who:
(1) does not have any personal stake or involvement in the case;
(2) was not directly involved in the initial determination of the action which is being contested;
(3) was not the immediate supervisor of the worker who took the action that is being contested and, in hearings involving adverse actions by NMHIX, has not been directly involved in the eligibility determination or any prior appeal decisions in the same matter;
(4) may not discuss the merits of any pending fair hearing with anyone outside the fair hearings bureau, unless all parties or their authorized representatives are present.
C. Disqualification and withdrawal: If the appointed hearing officer had any involvement with the department action(s) being appealed, including giving advice or consulting on the issue(s) presented, or is related in any relevant degree to the claimant, the claimant’s authorized representative, or ISD worker that took the action being appealed, the appointed hearing officer shall be disqualified as the hearing officer for that case. In addition, an appointed hearing officer shall, prior to the date of the fair hearing, withdraw from participation in any proceedings that the hearing officer determines that he cannot afford a fair and impartial hearing or where allegations of bias have arisen and have not been resolved prior to the deadline for a fair hearing decision to be issued pursuant to Paragraph (2) of Subsection B of 8.100.970.9 NMAC.
D. Authority and duties of the hearing officer: The authority and duties of the hearing officer are to:
(1) explain how the fair hearing will be conducted to participants at the start of the hearing;
(2) administer oaths and affirmations;
(3) insure that all relevant issues are considered during the fair hearing;
(4) request, receive and make part of the fair hearing record all evidence necessary to decide the issues being raised;
(5) regulate the content, conduct and the course of the hearing to ensure an orderly hearing; if a claimant, the claimant’s authorized representative, any witness or other participant in the fair hearing refuses to cooperate or comply with rulings on the procedures and issues as determined by the hearing officer, or acts in such a manner that an orderly fair hearing is not possible, the hearing officer may take appropriate measures to ensure that order is fully restored so that the claimant’s opportunity to fairly present his or her case is safeguarded; such measures shall include, but not be limited to, excluding or otherwise limiting the presentation of irrelevant evidence, or terminating the fair hearing and making the recommendation based on the record that has been made up to the point that the fair hearing was terminated;
(6) limit cross-examination that is repetitive or harassing;
(7) request, if appropriate, and except in matters involving NMHIX, an independent medical assessment or professional evaluation from a source mutually satisfactory to the claimant and the department; and
(8) provide a fair hearing record and report and recommendation for review and final decision by the appropriate division director; and
(9) in matters involving adverse action by NMHIX, provide a written final decision.
E. Appointment of hearing officer: A hearing officer is appointed by the fair hearings bureau upon receipt of the request for hearing.
F. Process: Formal rules of evidence and civil procedure do not apply to the fair hearing process. All relevant evidence is admissible, subject to the hearing officer's authority to limit evidence that is repetitive or unduly cumulative. Evidence that is not available to the claimant may not be presented to the hearing officer or used in making the final fair hearing decision, unless the unavailability of evidence was in accordance with federal and state laws and regulations.
(1) Confidentiality: The confidentiality of client records is to be maintained in accordance with federal and state laws and regulations. Confidential information that is protected from release and other documents or records that the claimant will not otherwise have an opportunity to contest or challenge shall not be introduced at the fair hearing or affect the hearing officer's recommendation.
(2) Administrative notice: The hearing officer may take administrative notice of any matter for which judges of this state may take judicial notice.
(3) Privilege: The rules of privilege apply to the extent that they are requested and recognized in civil actions in New Mexico.
(4) Medical issues: In a case involving medical care or a medical condition, the claimant waives confidentiality and both parties shall have the right to examine any medical documents that are admitted into evidence.
(5) When the evidence presented at the fair hearing does not adequately address the relevant medical issues, additional medical information may be obtained at the discretion of the hearing officer. The additional medical information may include, but is not limited to, a medical evaluation or analysis obtained at the department’s expense, from a source satisfactory to the claimant.
G. Motions: Motions shall be decided by the hearing officer without a hearing, unless permitted by the hearing officer upon written request of the department, the claimant or the authorized representative.
H. Burden of proof: The department has the burden of proving the basis for its action, proposed action or inaction by a preponderance of the evidence.
I. Record of the fair hearing: A record of each fair hearing shall be made by the hearing officer, in accordance with the following.
(1) The fair hearing proceedings, including testimony and exhibits, shall be recorded electronically.
(2) The hearing officer’s electronic recording shall be the official transcript of the fair hearing, and shall be retained by the fair hearings bureau in accordance with all federal and state laws and regulations.
(3) The record of the fair hearing includes: the recorded fair hearing, including testimony and exhibits, any pleadings filed in the proceeding, any and all papers and requests filed in the proceeding, the report and recommendation of the hearing officer, except in matters involving NMHIX; and, the final fair hearing decision made by the division director, or the hearing officer in matters involving NMHIX. The fair hearing record will be maintained in the department’s secure electronic data management system, but may be made available to the claimant or the authorized representative for copying and inspection at a reasonable time.
(4) If a final fair hearing decision is appealed, a written verbatim transcript of the fair hearing shall be prepared by the department and a copy of the transcript shall be provided to the claimant or authorized representative, free of charge.
[8.100.970.11 NMAC - Rp, 8.100.970.11 NMAC, 11/27/2013; A/E, 11/1/2021; A, 4/1/2022]
A fair hearing is conducted in an orderly manner and in an informal atmosphere. The fair hearing is not open to the public. The fair hearing is conducted by telephone, unless the claimant or the authorized representative makes a special request for the fair hearing to be held in person and the request is justified by special circumstances, as determined by the hearing officer on a case-by-case basis. In cases involving NMHIX, the fair hearings shall also be conducted in accordance with 45 CFR 155.535(c)-(f).
A. Opening the fair hearing: The fair hearing is opened by the hearing officer who will explain the telephonic fair hearing procedures to all present at the fair hearing. The hearing officer will then explain their role in the proceedings, and that the final fair hearing decision on the issue(s) appealed will be made by the appropriate department division director after review of the hearing officer's report and recommendation, including the fair hearing record. On the record, the individuals present are asked to identify themselves, the order of testimony is explained, the oath is administered to all witnesses who will testify during the hearing, the issue is identified, and all pleadings, papers, and requests, including but not limited to, the SOE and any evidence being presented, will be identified and entered into the record with any objections handled in accordance with applicable federal and state laws and regulations.
B. Order of testimony: The order of testimony is as follows:
(1) Presentation of the department’s case: The department or NMHIX will present its case and the evidence, including testimony and exhibits, in support of the adverse action taken against the household, and:
(a) the claimant or authorized representative may cross-examine the department representative;
(b) the hearing officer may ask further clarifying questions; and
(c) if the department calls other witnesses, the order of examination of each witness is as follows:
( i ) direct testimony by the witness(es);
(ii) cross-examination by the claimant or the authorized representative; and
(iii) examination or further clarifying questions by the hearing officer or, if requested, follow up questions from the department representative.
(2) Presentation of the claimant’s/appellant’s case: The claimant or the authorized representative will present its case and the evidence, including testimony and exhibits, in support of its position, and:
(a) the department may cross-examine the claimant or the authorized representative;
(b) the hearing officer may ask further clarifying questions; and,
(c) if the claimant calls other witnesses, the order of examination of each witness is as follows:
( i ) direct testimony by the witness(es);
(ii) cross-examination by the department representative; and
(iii) examination or further clarifying questions by the hearing officer or, if requested, follow up questions from the claimant or the authorized representative.
(3) The claimant may offer evidence on the points at issue without undue interference, may request proof or verification of evidence or statements submitted by the department or its witnesses, and may present evidence in rebuttal.
(4) The hearing officer may ask the parties to summarize and present closing arguments.
C. Written closing argument: If the claimant or the department is represented by legal counsel, the hearing officer may request that the closing argument be submitted in writing to the fair hearings bureau.
D. Continuance: The hearing officer may continue the hearing upon the request of either party, or on the hearing officer’s own motion, for admission of additional testimony or evidence. A party seeking a continuance in order to obtain additional evidence must make a showing that the evidence was not available at the time of the hearing despite a reasonable attempt having been made to obtain it. The granting of a continuance is at the discretion of the hearing officer is subject to the same limitations set forth in Subsection B of 8.100.970.10 NMAC. The reason(s) for the continuance and if any oral agreements were reached in regards to the continuance shall be stated for the hearing record. The fair hearings bureau shall issue notice of the rescheduling of a continued fair hearing not less than 10 calendar days before the rescheduled date, unless oral agreements are obtained from all parties to reschedule the fair hearing with less notice in an effort to meet the required timeframes.
E. Additional documentary evidence: If the hearing officer requests additional documentary evidence based on testimony heard during the fair hearing, the hearing officer may close the fair hearing but keep the record open subject to production of the additional evidence being submitted by a party or parties.
(1) The hearing officer shall set a date and time for production of the requested evidence, not to exceed 10 calendar days; the party producing the additional evidence shall submit copies to the hearing officer and each party.
(2) Within 10 calendar days of its receipt of the additional evidence, the non-producing party may submit a written response to the hearing officer and each party that will become part of the fair hearing record; or, the hearing officer may continue the hearing until such a date and time that the non-producing party may respond to the additional evidence on the record.
(3) The hearing officer shall close the record at the close of business on the 10th calendar day following its receipt of the additional evidence.
(4) The hearing officer may only request additional evidence pursuant to this paragraph if it will not result in a violation of the limitations set forth in Subsection B of 8.100.970.10 NMAC.
F. Re-opening a fair hearing: The hearing officer, at the hearing officer’s discretion, may re-open a fair hearing when the evidentiary record fails to address an issue that is relevant to resolution of a fair hearing request. The fair hearing can only be re-opened if the parties have agreed to an extension of the timeframes in accordance with Paragraph (2) of Subsection B of 8.100.970.9 NMAC and the limitations set forth in Subsection B of 8.100.970.10 NMAC. Written notice of the date, time and place of the re-opened fair hearing is sent to the parties, not less than 10 days before the date of the re-opened hearing, or not less than 15 days in matters involving NMHIX, unless oral agreements are obtained from all parties to reschedule the fair hearing with less notice in an effort to meet the required timeframes.
[8.100.970.12 NMAC - Rp, 8.100.970.12 NMAC, 11/27/2013; A/E, 11/1/2021; A, 4/1/2022]
The final fair hearing decision shall be made by the appropriate department division director after review of the fair hearing record and the hearing officer's report and recommendation.
A. Hearing officer recommendation: The hearing officer reviews the record of the fair hearing and all appropriate regulations, and evaluates the testimony and evidence admitted during the hearing. The hearing officer submits the complete record of the fair hearing, along with the hearing officer’s report and recommendation, in a standard format to the appropriate division director(s) within 15 days of the hearing, or sooner, to ensure the timeframes set forth in Paragraph (2) of Subsection B of 8.100.970.9 NMAC are met.
B. Content of recommendation: The hearing officer specifies the reason(s) for all factual conclusions, identifies the supporting evidence, references the relevant federal and state laws and regulations, along with appropriate department policy and procedural guidance, and responds to the arguments of the parties in a written report and recommendation. The hearing officer shall submit a recommendation:
(1) in favor of the claimant when the adverse action taken by the department is not supported by a preponderance of the evidence available as a result of the fair hearing;
(2) in favor of the department when the preponderance of the evidence, available as a result of the fair hearing, supports the adverse action taken by the department is in accordance with federal and state laws and regulations; or
(3) any other result supported by the fair hearing record.
C . Review of recommendation: The fair hearing record and report and recommendation are reviewed by the appropriate department division director(s) or designee to ensure conformity with applicable federal and state laws and regulations.
D. Final decision: The hearing officer's recommendation may be adopted or rejected, in whole or in part, in a final written decision by the appropriate department division director. The final fair hearing decision shall be based solely on the fair hearing record as defined in Paragraph (3) of Subsection I of 8.100.970.11 NMAC. The final fair hearing decision must summarize the facts of the case, specify the reasons for the decision, and identify the supporting evidence and relevant federal and state laws and regulations. No person who participated in the original action under appeal may participate in arriving at the final fair hearing decision. The final fair hearing decision becomes part of the fair hearing record.
E. Notice to claimant: The claimant, the authorized representative and the department shall be notified in writing of the final fair hearing decision and its effect on the benefits. If a claimant has an authorized representative, the authorized representative is mailed a copy of the final fair hearing decision. When a final fair hearing decision is adverse to the claimant, the decision shall include:
(1) a statement that the claimant has exhausted all administrative remedies available;
(2) the claimant's right to pursue judicial review of the final fair hearing decision; and
(3) information on how to file an appeal of the final fair hearing decision, the timeframe for filing an appeal and where the appeal may be filed.
F. Fair hearing decisions involving adverse actions by NMHIX: The provisions of Subsections A through E of 8.100.970.13 NMAC do not apply to fair hearings involving adverse actions by NMHIX. For hearings involving adverse actions by NMHIX, there shall be no recommendation by the hearing officer. The hearing officer shall instead issue a written final fair hearing decision, which shall become part of the fair hearing record, and which shall:
(1) be based exclusively on:
(a) the information used to determine the appellant’s eligibility as well as any additional relevant evidence presented during the course of the appeals process, including at the hearing; and
(b) the eligibility requirements under Subpart D or G of 45 CFR Part 155, as applicable.
(2) state the decision, including a plain language description of the effect of the decision on the appellant’s eligibility;
(3) summarize the facts relevant to the appeal;
(4) identify the legal basis, including the regulations that support the decision;
(5) state the effective date of the decision;
(6) provide an explanation of the appellant’s right to pursue the appeal before the HHS appeals entity, including the applicable timeframe, if the appellant remains dissatisfied with the eligibility determination; and
(7) indicate that the decision of the fair hearing officer is final, unless the appellant pursues a second-tier appeal before the United States department of health and human services.
[8.100.970.13 NMAC - Rp, 8.100.970.13 NMAC, 11/27/2013; A/E, 11/1/2021; A, 4/1/2022]
Unless stayed by court order, the department’s final fair hearing decision is binding on all issues that have been the subject of the fair hearing as to that claimant. The local county office is responsible for assuring that decisions are implemented within the timeframes specified below. The final fair hearing decision serves as advanced notice for changes in benefits or services.
A. Decision favorable to the department: If assistance or benefits have been continued pending the outcome of the fair hearing and the decision is favorable to the department, the department shall take immediate action to adjust the payment and submit a claim for the excess benefit amount(s) paid pending the outcome of the fair hearing.
B. Decision favorable to the claimant:
(1) Cash assistance programs: When a fair hearing decision is favorable to the claimant, the department authorizes corrective payment. For incorrectly denied cases, corrected benefits are issued retroactively in the following manner:
(a) to the date of adverse action or to the 30 th day from the application date, whichever is earlier; or
(b) to the first day of the month that the case is actually eligible for benefits;
(c) for ongoing cases, the corrected cash assistance payments are retroactive to the first day of the month that the incorrect action became effective.
(2) SNAP: Decisions that result in an increased benefit shall be reflected in the claimant's next authorized allotment. The final fair hearing decision serves as verification for increased benefits.
(3) Medical assistance programs: When a fair hearing decision is favorable to the claimant and a case was incorrectly denied, corrected benefits are issued retroactively in the following manner:
(a) to the date of adverse action or to the 30th day from the application date, whichever is earlier; or
(b) to the first day of the month that the case is actually eligible for benefits;
(c) for ongoing cases, the corrected benefit is retroactive to the first day of the month that the incorrect action became effective;
(d) fair hearings for medical assistance programs involving the termination, modification, reduction or suspension of services are governed by applicable federal and state law and regulations, including 8.352 NMAC, et seq.
C. Implementation of decisions related to NMHIX: Unless stated by court order, the department’s final fair hearing decision is binding on all issues that have been the subject of the fair hearings as to that claimant. NMHIX, upon receiving notice of the final fair hearing decision, must promptly:
(1) Implement the decision effective:
(a) Prospectively, on the first day of the month following the date of the notice of appeal decision, or consistent with 45 CFR section 155.330(f)(2), (3), (4), or (5), if applicable; or
(b) Retroactively, to the coverage effective date the appellant did receive or would have received if the appellant had enrolled in coverage under incorrect eligibility determination that is the subject of the appeal, at the option of the appellant.
(2) Redetermine the eligibility or household members who have not appealed their own eligibility determinations but whose eligibility may be affected by the appeal decision, in accordance with the standards specified in 45 CFR section 155.305.
[8.100.970.14 NMAC - Rp, 8.100.970.14 NMAC, 11/27/2013; A/E, 11/1/2021; A, 4/1/2022]
A. Right of appeal: If a final fair hearing decision upholds the department’s or NMHIX’s original action, the claimant has the right to pursue judicial review of the final fair hearing decision and is notified of that right in the department’s final fair hearing decision. In matters involving NMHIX, the claimant may submit a second-tier appeal to the United States department of health and human services and is notified of that right in the department’s final fair hearing decision.
B. Timeliness:
(1) SNAP, LIHEAP, general assistance (GA), and medical assistance programs: Unless otherwise provided by law, within 30 days of the issuance of the department’s final fair hearing decision, the claimant may appeal the final fair hearing decision by filing a notice of appeal with the appropriate district court pursuant to the provisions of Section 39-3-1.1 NMSA 1978.
(2) NMW: Unless otherwise provided by law, within 30 days of the issuance of the department’s final fair hearing decision, the claimant may appeal the final fair hearing decision by filing a notice of appeal with the court of appeals pursuant to the provisions of Section 27-2B-13 NMSA 1978.
C. Jurisdiction and standard of review:
(1) The district court’s jurisdiction is defined by statute at Section 27-3-3 NMSA 1978 and Section 39-3-1.1 NMSA 1978. The court of appeals jurisdiction is defined by statute at Section 27-2B-13 NMSA 1978.
(2) The court of appeals or district court may set aside, reverse or remand the department’s final fair hearing decision if it determines that:
(a) the department acted fraudulently, arbitrarily or capriciously;
(b) the final fair hearing decision was not supported by substantial evidence; or,
(c) the department did not act in accordance with federal and state laws and regulations.
D. Benefits pending an appeal: If the court decides in favor of the claimant, the department must immediately act in accordance with the court’s final hearing decision. If the decision is in favor of the department, the department shall take any and all appropriate actions in accordance with Subsection A of 8.100.970.14 NMAC and 8.100.640 NMAC.
E. Effect of appeal: If the court of appeals decides in favor of the claimant, the HSD office of general counsel immediately notifies the county office as to the appropriate benefit issuance and adjustments, if any. If the decision is in favor of HSD, and a reduction has been pending the decision on appeal, an overpayment claim retroactive to the date the change should have been made is filed.
F. Appealing the appellant court’s decision:
(1) SNAP, LIHEAP, GA and medical assistance programs: A party to the appeal to district court may appeal the district court’s decision by filing a petition for writ of certiorari with the court of appeals, which may exercise its discretion to grant review. A party may seek further review by filing a petition for writ of certiorari with the supreme court. Section 39-3-1.1 NMSA 1978.
(2) NMW: A party may seek further review by filing a petition for writ of certiorari with the supreme court.
[8.100.970.15 NMAC - Rp, 8.100.970.15 NMAC, 11/27/2013; A/E, 11/1/2021; A, 4/1/2022]
History of 8.100.970 NMAC:
History of Repealed Material: 8 NMAC 3.ISD General Provisions, filed 12/30/1994 - Repealed effective 7/1/1997
8.100.970 NMAC Oversight - Program Participation Hearings, filed 3/26/2001 - Repealed effective 11/27/2013.