N.M. Admin. Code § 8.301.6.10 - COVERED SERVICES AND SERVICE LIMITATIONS

MAD reimburses eligible recipients or transportation providers for medically necessary transportation subject to the following:

A. Free alternatives: Alternative transportation services which may be provided free of charge, include volunteers, relatives or transportation services provided by nursing facilities or other residential centers. An eligible recipient must certify in writing that they do not have access to free alternatives.

B. Least costly alternatives: MAD covers the most appropriate and least costly transportation alternatives suitable for the eligible recipient's medical condition. If an eligible recipient can use private vehicles or public transportation, those alternatives must be used before the eligible recipient can use more expensive transportation alternatives.

C. Non-emergency transportation service: MAD covers non-emergency transportation services for an eligible recipient who does not have primary transportation and who is unable to access a less costly form of public transportation.

D. Long distance common carriers: MAD covers long distance services furnished by a common carrier if the eligible recipient must leave their home community to receive medical services. Authorization forms for direct payment to long distance bus common carriers by MAD are available through the eligible recipient's local county income support division (ISD) office.

E. Ground ambulance services: MAD covers services provided by ground ambulances when:

(1) an emergency which requires ambulance service is certified by a physician or is documented in the provider's records as meeting emergency medical necessity as defined as:

(a) an emergency condition that is a medical or behavioral health condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in placing the health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, serious impairment to body function or serious dysfunction of any bodily organ or part; and

(b) "medical necessity" for ambulance services is established if the eligible recipient's condition is such that the use of any other method of transportation is contraindicated and would endanger the eligible recipient's health;

(2) scheduled, non-emergency ambulance services are ordered by a physician who certifies that the use of any other method of non-emergency transportation is contraindicated by the eligible recipient's medical condition; and

(3) MAD covers non-reusable items and oxygen required during transportation; coverage for these items are included in the base rate reimbursement for ground ambulance.

F. Air ambulance services: MAD covers services provided by air ambulances, including private airplanes, if an emergency exists and the medical necessity for the service is certified by the physician.

(1) An emergency condition is a medical or behavioral health condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in placing the health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, serious impairment to body function or serious dysfunction of any bodily organ or part.

(2) MAD covers the following services for air ambulances:

(a) non-reusable items and oxygen required during transportation;

(b) professional attendants required during transportation; and

(c) detention time or standby time up to one hour without physician documentation; if the detention or standby time is more than one hour, a statement from the attending physician or flight nurse justifying the additional time is required.

G. Lodging services: MAD covers lodging services if recipients are required to travel to receive medical services more than four hours one way and an overnight stay is required due to medical necessity or cost considerations. If medically justified and approved, lodging is initially set for up to five continuous days. For a longer stay, the need for lodging must be re-evaluated by the fifth day to authorize up to an additional 15 days. Re-evaluation must be made every 15 days for extended stays, prior to the expiration of the existing authorization. Approval of lodging is based on the medical provider's statement of need. Authorization forms for direct payment to medicaid lodging providers by MAD are available through local county income support division (ISD) offices.

H. Meal services: Medicaid covers meals if a recipient is required to leave their home community for eight hours or more to receive medical services. Authorization forms for direct payment to medicaid meal providers by MAD are available through local county ISD offices.

I. Coverage for attendants: MAD covers transportation, meals and lodging in the same manner as for an eligible recipient, for one attendant if the medical necessity for the attendant is certified in writing by the eligible recipient's medical provider or the eligible recipient who is receiving medical service is under 18 years of age. If the medical appointment is for an adult recipient, MAD does not cover transportation services or related expenses of children under 18 years of age traveling with the adult recipient.

J. Coverage for medicaid waiver recipients: Transportation of a medicaid waiver recipient to a provider of a waiver service is only covered when the service is occupational therapy, physical therapy, speech therapy and behavioral therapy services.

K. Medicaid family planning waiver eligible recipients: MAD does not cover transportation service for recipients eligible for medicaid family planning waiver services.

Notes

N.M. Admin. Code § 8.301.6.10

2/28/98; 8.301.6.10 NMAC - Rn, 8 NMAC 4.MAD.605.1 & A, 3/1/11, Adopted by New Mexico Register, Volume XXXV, Issue 12, June 25, 2024, eff. 7/1/2024