N.M. Admin. Code § 8.290.600.12 - ONGOING BENEFITS
A. A complete
redetermination of eligibility must be performed annually by the ISD caseworker
for each open case.
B. Level of
care determinations are made by the utilization review contractor or a member's
selected or assigned managed care organization, as applicable to the centennial
care, community benefit program. Level of care reviews are required to be
completed at least annually except for certain community benefit members whose
chronic condition is not expected to improve. These individuals may be eligible
for an ongoing nursing facility (NF) level of care (LOC). To qualify for
ongoing NF LOC, the community benefit member must have met a NF LOC for the
previous three years. The ongoing NF LOC status must be reviewed and approved
annually by the managed care organization's medical director and must be
supported in documentation by the member's physician. The complete criteria for
an ongoing NF LOC can be found in the New Mexico medicaid nursing facility
level of care criteria and instructions document.
C.
90 day reconsideration
period: HSD will reconsider in a timely manner the waiver eligibility of
an individual who is terminated for failure to submit the renewal form or
necessary information, if the individual subsequently submits the renewal form
within 90 days after the date of termination without requiring a new
application per 42 CFR
435.916(C)(iii).
Notes
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