N.M. Admin. Code § 8.308.6.9 - MANAGED CARE ELIGIBILITY

A. General requirements: HSD determines eligibility for medicaid. An eligible recipient is required to participate in a HSD managed care program unless specifically excluded as listed below. Enrollment in a particular managed care organization (MCO) will be according to the eligible recipient's selection of a MCO at the time of application for eligibility, or during other permitted selection periods, or as assigned by HSD, if the eligible recipient makes no selection.

B. The following eligible recipients, as established by their eligibility category, are excluded from managed care enrollment:

(1) qualified medicare beneficiaries (QMB)-only recipients;

(2) specified low income medicare beneficiaries (SLIMB) only;

(3) qualified individuals;

(4) qualified disabled working individuals;

(5) refugees;

(6) participants in the program of all inclusive care for the elderly (PACE);

(7) children and adolescents in out-of-state foster care or adoption placements

(8) family planning-only eligible recipients and;

(9) residents in an intermediate care facility for individuals with intellectual disabilities (ICF/IID).

C. Native Americans may opt into managed care. If a Native American is dually eligible or in need of long-term care services, he or she is required to enroll in a MCO.

D. For those individuals who are not otherwise eligible for medicaid and who meet the financial and medical criteria established by HSD, HSD or its authorized agent may further determine eligibility for managed care enrollment through a waiver allocation process contingent upon available funding and enrollment capacity.

Notes

N.M. Admin. Code § 8.308.6.9

8.308.6.9 NMAC - N, 1-1-14, Adopted by New Mexico Register, Volume XXIX, Issue 08, April 24, 2018, eff. 5/1/2018, Amended by New Mexico Register, Volume XXIX, Issue 23, December 11, 2018, eff. 1/1/2019, Amended by New Mexico Register, Volume XXXII, Issue 15, August 10, 2021, eff. 8/10/2021