MAD covers services and procedure furnished by a provider
located within 100 geographical miles of the New Mexico border, even though the
road miles may be greater than 100 miles, to the same extent and using the same
coverage rules as for an in-state provider. See
8.302.4.9 NMAC, out of
state and border area providers. When it is the general practice for
an eligible recipient in a New Mexico locality to access medical services in a
location more than 100 geographical miles from the New Mexico border, MAD will
treat that out-of-state location as a border area. MAD covers services and
procedures furnished by a provider more than 100 geographical miles from the
New Mexico border, excluding Mexico, to the extent and using the same coverage
rules as for in-state provider when one or more of the following conditions are
met.
A. An eligible recipient is
out-of-state at the time the services are needed and the delivery of services
is of an emergent or urgent nature or if the eligible recipient's health would
be endangered by traveling back to New Mexico. Services must be medically
necessary to stabilize the eligible recipient's health and prevent significant
adverse health effects, including preventable hospitalization. Claims for such
services are subject to pre-payment or post-payment reviews to assure the
emergent or urgent need or medical necessity of the services.
B. On-going-services provided by a medical
assistance program within the state continue to be necessary when the eligible
recipient is visiting another state.
C. Care is medically necessary for an
eligible recipient that is placed by the state of New Mexico in foster care in
an out-of-home placement or in an institution. Care is medically necessary for
an eligible recipient that was adopted from New Mexico and resides
out-of-state. If the agreement with the other state requires that state's
medicaid program pay for covered services, MAD will only consider payment when
a service is not covered by the other state and the eligible recipient would be
eligible for that service if living in New Mexico.
D. Durable medical equipment, medical
supplies, prosthetics or orthotics are purchased from out-of-state
vendors.
E. Clinical laboratory
tests, radiological interpretations, professional consultations or other
services are performed by out-of-state laboratories but do not require the
eligible recipient to leave the state.
F. Medical services or procedures considered
medically necessary are not available in the state of New Mexico. All services
that are not available in New Mexico require prior authorization when provided
by an out-of-state provider. An out-of-state service may be limited to the
closest provider or an otherwise economically prudent choice of provider
capable of rendering the service.
G. Services, such as personal assistance, are
needed by an eligible recipient out-of-state if that recipient is eligible to
receive services through a medicaid home and community-based services waiver
program and is traveling to another state.
