N.M. Admin. Code § 8.200.430.13 - ASSIGNMENT OF SUPPORT
As a condition of MAP eligibility, HCA requires an applicant or a re-determining eligible recipient to assign their medical care support rights to HCA for medical support and any third party payments. The assignment authorizes HCA to pursue and make recoveries from liable third parties (42 CFR 433.146; Subsection G of 27-2-28 NMSA 1978.
A.
Assigning medical
support rights: The assignment to HCA of an eligible recipient's rights
to medical support and payments occurs automatically under New Mexico law when
the applicant or the re-determining eligible recipient signs the
application.
B.
Third party
liability (TPL): This section describes HCA's responsibility to identify
and collect from primarily responsible third parties and the eligible
recipient's responsibility to cooperate with HCA to uncover such payments. MAD
is the payer of last resort. If other third party resources are available,
these health care resources must be used before MAD makes a reimbursement. As a
condition of MAP eligibility, an applicant assigns their rights to physical and
behavioral health support and payments to HCA and promises to cooperate in
identifying, pursuing, and collecting payments from these resources. Third
party resources include the gross recovery by eligible recipient, including
personal injury protection benefits, before any reduction in attorney's fees or
costs, obtained through settlement or verdict, for personal injury negligence
or intentional tort claims or actions, up to the full amount of MAD payments
for treatment of injuries causally related to the occurrence that is the
subject of the claim or action.
(1) Required
TPL information: During the initial determination or re-determination of
eligibility for MAP enrollment, ISD must obtain information about TPL from
either the applicant or the re-determining eligible recipient.
(a) HCA is required to take all reasonable
measures to determine the legal liability of third parties, including health
insurers in paying for the physical and behavioral health services furnished to
an eligible recipient (42
CFR 433.138(a)).
(b) HCA uses the information collected at the
time of determination in order for MAD to pursue claims against third
parties.
(2)
Availability of health insurance: If an applicant or an eligible recipient has
health insurance, the applicant or the eligible recipient shall notify ISD. ISD
must collect all relevant information, including name and address of the
insurance company; individuals covered by the policy, effective dates, covered
services, and appropriate policy numbers.
(a)
An applicant or an eligible recipient with health insurance coverage or
coverage by a health maintenance organization (HMO) or other managed care plan
(plan) must be given a copy of the TPL recipient information letter.
(b) If there is an absent parent, ISD may
request the absent parent's name and social security number (SSN).
(c) ISD must determine if an absent parent,
relative, applicant or any member of the household is employed and has health
insurance coverage.
(3)
Eligible recipients with health insurance coverage: An applicant or an eligible
recipient must inform their MAD providers of their TPL. An applicant or an
eligible recipient must report changes to or terminations of insurance coverage
to ISD. If an applicant or an eligible recipient has health coverage through an
HMO or plan, payment from MAD is limited to applicable copayments required
under the HMO or plan and to MAD covered services documented in writing as
exclusions by the HMO or plan.
(a) If the HMO
or plan uses a drug formulary, the medical director of the HMO or plan must
sign and attach a written certification for each drug claim to document that a
pharmaceutical product is not covered by the HMO or plan. The signature is a
certification that the HMO or plan drug formulary does not contain a
therapeutic equivalent that adequately treats the physical or behavioral health
condition of the HMO or plan subscriber.
(b) Physical and behavioral health services
not included in the HMO or plan are covered by MAD only after review of the
documentation and on approval by MAD.
(c) An applicant or an eligible recipient
covered by an HMO or plan is responsible for payment of medical services
obtained outside the HMO or plan and for medical services obtained without
complying with the rules or policies of the HMO or plan.
(d) An applicant or an eligible recipient
living outside an HMO or plan coverage area may request a waiver of the
requirement to use HMO or plan providers and services. The applicant or the
eligible recipient for whom a coverage waiver is approved by MAD may receive
reimbursement for expenses which allow them to travel to an HMO or plan
participating provider, even when the provider is not located near the
applicant or the eligible recipient's residence.
(4) Potential health care resources: ISD must
evaluate the presence of a TPL source if certain factors are identified during
the MAD eligibility interview.
(a) When the
age of the applicant or the eligible recipient is over 65 years old medicare
must be explored. A student, especially a college student, may have health or
accident insurance through their school.
(b) An application on behalf of deceased
individual must be examined for "last illness" coverage through a life
insurance policy.
(c) Certain
specific income sources are indicators of possible TPL which include:
(i) railroad retirement benefits and social
security retirement or disability benefits indicating eligibility for Title
XVIII (medicare) benefits;
(ii)
workers' compensation (WC) benefits paid to employees who suffer an injury or
accident caused by conditions arising from employment; these benefits may
compensate employees for physical and behavioral health expenses and lost
income; payments for physical and behavioral health expenses may be made as
physical and behavioral health bills are incurred or as a lump sum
award;
(iii) black lung benefits
payable under the coal mine workers' compensation program, administered by the
federal department of labor (DOL), can produce benefits similar to railroad
retirement benefits if the treatment for illness is related to the diagnosis of
pneumoconiosis; beneficiaries are reimbursed only if services are rendered by
specific providers, authorized by the DOL; black lung payments are made monthly
and physical and behavioral health expenses are paid as they are incurred;
and
(iv) Title IV-D support
payments or financial support payments from an absent parent may indicate the
potential for physical and behavioral health support; if a custodial party does
not have health insurance that meets a minimum standard, the court in a
divorce, separation or custody and support proceeding may order the parent(s)
with the obligation of support to purchase insurance for the eligible recipient
child (45 CFR
303.31(b)(1); Paragraph (1)
of Subsection A of Section
40-4C-4 NMSA 1978; insurance can
be obtained through the parent's employer or union (Paragraph (2) of Subsection
A of Section
40-4C-4 NMSA 1978; parents may be
ordered to pay all or a portion of the physical and behavioral health expenses;
for purposes of physical l and behavioral health support, the minimum standards
of acceptable coverage, deductibles, coinsurance, lifetime benefits,
out-of-pocket expenses, co-payments, and plan requirements are the minimum
standards of health insurance policies and managed care plans established for
small businesses in New Mexico; see New Mexico insurance code.
(d) An applicant or an eligible
recipient has earned income: Earned income may indicate physical, behavioral
health and health insurance made available by an employer.
(e) Work history or military services: Work
history may indicate eligibility for other cash and physical and behavioral
benefits. Previous military service suggests the potential for veterans
administration (VA) or department of defense (DOD) health care, including the
civilian health and the medical program of the United States (CHAMPUS), for
individuals who reside within a 40-mile radius of a military health care
facility. An applicant or an eligible recipient who is eligible for DOD health
care must obtain certification of non-availability of medical services from the
base health benefits advisor in order to be eligible for CHAMPUS.
(f) An applicant or an eligible recipient's
expenses show insurance premium payments: Monthly expense information may show
that the applicant or the eligible recipient pays private insurance premiums or
is enrolled in an HMO or plan.
(g)
The applicant or the eligible recipient has a disability: Disability
information contained in applications or brought up during interviews may
indicate casualties or accidents involving legally responsible third
parties.
(h) The applicant or the
eligible recipient has a chronic disease: Individuals with chronic renal
disease are probably entitled to medicare. Applications for social security
disability may be indicative of medicare coverage.
(5) Communicating TPL information:
Information concerning health insurance or health plans is collected and
transmitted to MAD by ISD, child support enforcement division (CSED), SSA, and
the children, youth and families department (CYFD).
Notes
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