N.M. Admin. Code § 8.308.14.9 - CO-PAYMENTS IN THE MEDICAID MANAGED CARE PROGRAM

The medical assistance division (MAD) imposes co-payment provisions on certain members, certain categories of eligibility and on certain services. The member's HSD contracted managed care organization (MCO) is required to impose co-payments as directed by MAD at 8.302.2 NMAC and in accordance with federal regulations.

General requirements regarding co-payments:

A. The MCO or its contracted providers may not deny services for a member's failure to pay the co-payment amounts.

B. The MCO must take measures to educate and train both its contracted providers and members on co-payment requirements.

C. The MCO shall not impose co-payment provisions on certain services that, in accordance with federal regulations, are always exempt from co-payment provisions. See 42 CFR 447.56, limitations on premiums and cost sharing and 8.302.2 NMAC.

D. The MCO shall not impose co-payment provisions on certain member categories of eligibility that, in accordance with federal and state regulations and rules, are exempt from cost-sharing provisions.

E. Payments to MCO contracted providers: In accordance with 42 CFR 447.56, limitations on premiums and cost sharing,the MCO must reduce the payment it makes to a contracted provider by the amount of the member's applicable co-payment obligation, regardless of whether the provider has collected the payment.

F. At the direction of MAD, the MCO must report all co-payment amounts collected.

G. The MCO may not impose more than one type of co-payment for any service, in accordance with 42 CFR 447.52.

H. The MCO must track, by month, all co-payments collected from each individual member in the household to ensure that the household does not exceed the aggregate limit (cap). The cap is five percent of countable household income for all individual members in a household, calculated as applicable for a quarter. The MCO must be able to provide each household member, at his or her request, with information regarding co-payments that have been applied to claims for the member.

I. The MCO must report to the provider when a co-payment has been applied to the provider's claim and when a co-payment was not applied to the provider's claim. The MCO shall be responsible for assuring the provider is aware that:

(1) the provider shall be responsible for refunding to the member any co-payments the provider collects after the member has reached the co-payment cap (five percent of the member's household income, calculated on a quarterly basis) which occurs because the MCO was not able to inform the provider of the exemption from co-payment due to the timing of claims processing;

(2) the provider shall be responsible for refunding to the member any co-payments the provider collects for which the MCO did not deduct the payment from the provider's payment whether the discrepancy occurs because of provider error or MCO error; and

(3) failure to refund a collected co-payment to a member and to accept full payment from the MCO may result in a credible allegation of fraud, see 8.351.2 NMAC.

Notes

N.M. Admin. Code § 8.308.14.9

8.308.14.9 NMAC - N, 1-1-14; A, 6-15-14, Amended by New Mexico Register, Volume XXV, Issue 19, October 15, 2014, eff. 10/15/2014, Adopted by New Mexico Register, Volume XXVIII, Issue 18, September 26, 2017, eff. 10/1/2017