To comply with Title XIX of the Social Security Act, as
amended, MAD is required to serve certain groups of eligible recipients and has
the option of paying for services provided to other eligible recipient groups
42 CFR 435.1 . MAD is also required to pay for emergency services furnished to
non-citizens residing in New Mexico who are not lawfully admitted for permanent
residence but who otherwise meet the eligibility requirements. Coverage is
restricted to those services necessary to treat an emergency medical condition,
which includes labor and delivery services. See
8.325.10.3 NMAC.
A. Recipient eligibility determination: To be
eligible to receive MAD benefits, an applicant/ recipient must meet general
eligibility or resource and income requirements. These requirements vary by
category of eligibility and may vary between health care programs. See
8.200
NMAC for information on medicaid eligibility requirements.
(1) An otherwise eligible recipient who is
under the jurisdiction or control of the correctional system or resides in a
public institution is not eligible for medicaid.
(2) MAD eligibility determinations are made
by the following agencies:
(a) the staff of
the income support division (ISD) county offices determines eligibility for
medicaid categories of eligibility;
(b) the staff of the New Mexico children,
youth and families department (CYFD) determines eligibility for child
protective services, adoptive services and foster care children;
(c) the staff of the social security
administration determines eligibility for social security income (SSI);
and
(d) the staff of a federally
qualified health center, a maternal and child health services block grant
program, the Indian health service, and other designated agents make
presumptive eligibility determinations.
B. Recipient freedom of choice: Unless
otherwise restricted by specific health care program rules, an eligible
recipient has the freedom of choice to obtain services from in-state and border
providers who meet the requirements for MAD provider participation. Some
restrictions to this freedom of choice apply to an eligible recipient who is
assigned to a provider or providers in the medical management program ( 45 CFR
431.54 (e)). See 3
01.5 NMAC,
Medical Management. Some
restrictions to this freedom of choice may also apply to purchases of medical
devices, and laboratory and radiology tests and other services and items as
allowed by federal law (42
CFR
431.54 (d)).
C. Recipient identification: An eligible
recipient must present all health program identification cards or other
eligibility documentation before receiving services and with each case of
continued or extended services.
(1) A provider
must verify the eligibility of the recipient to assure the recipient is
eligible on the date the services are provided. Verification of eligibility
also permits the provider to be informed of any restrictions or limitations on
services associated with the recipient's eligibility; of the applicability of
co-payments on services; of the need for the eligible recipient's care to be
coordinated with or provided through a managed care organization, a hospice
provider, a PACE provider, a medical management provider, or similar health
care plan or provider. Additionally, information on medicare eligibility and
other insurance coverage may be provided.
(2) An eligible recipient whose health care
program coverage or benefits may be limited include:
(a) qualified medicare beneficiary (QMB)
recipient; and
(b) family planning
benefits.
