New Mexico Administrative Code

The New Mexico medical assistance program (medicaid) is the payer of last resort. When resources are available from third parties, HSD administers a specific program to ensure that these resources are used to pay for the medical services furnished to eligible recipients. See 42 C…

New Mexico Health Care Authority.

Health care to eligible recipients is furnished by a variety of providers and provider groups. The reimbursement and billing for these services is administered by MAD. Upon approval of a New Mexico MAD provider participation agreement by MAD or its designee, licensed practitioner…

A. A provider who furnishes services to a medicaid or other health care program eligible recipient must comply with all federal and state laws, regulations and executive orders relevant to the provision of services as specified in the MAD provider participation agreement. A provi…

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…

Services furnished by an out-of-state or border provider are subject to the limitations and coverage restrictions which exist for other services rendered in-state as stated in the relevant administrative, provider, and other services sections of the MAD program policy manual. In …

All out-of-state hospital, and other residential service claims are subject to prepayment review or periodic re-authorization by MAD or its designee for medical necessity and length of stay, in addition to requiring authorization for the initial placement.

All MAD services are subject to utilization review for medical necessity and program compliance. Reviews can be performed before services are furnished, after services are furnished, and before payment is made, or after payment is made. See 8.302.5 NMAC, Prior Authorization and U…

Services furnished within the state or border areas are subject to the rules for instate providers even if the billing or administrative office is outside the state.

Reimbursement to an out-of-state or border area provider is made at the same rate as for an in-state provider except as otherwise stated in the relevant specific providers and services sections of the MAD program rules manual. A. Unless payment for a service is made using a diagn…

The rule applies to the general public.

The New Mexico medicaid program and other health care programs are administered pursuant to regulations promulgated by the federal department of health and human services under the Social Security Act as amended, or by state statute. See Section 27-2-12 et seq. NMSA 1978. Section…

Permanent.

July 1, 2024, unless a later date is cited at the end of a section.

The objective of this rule is to provide instruction for the service portion of the New Mexico medical assistance programs.

To reduce the impact of poverty on people living in New Mexico and to assure low income and individuals with disabilities in New Mexico equal participation in the life of their communities.

Border area services are those that are rendered within 100 miles of the New Mexico state border (Mexico excluded). Out-of-state services are those that are rendered in an area more than 100 miles from the New Mexico border (Mexico excluded). To help New Mexico eligible recipient…

New Mexico Health Care Authority.

This rule applies to the general public.

The New Mexico medicaid program and other health care programs are administered pursuant to regulations promulgated by the federal department of health and human services under Title XIX of the Social Security Act as amended or by state statute. See Section 27-1-12 et seq., NMSA …

Permanent.

May 1, 2018, unless a later date is cited at the end of a section.

The objective of this rule is to provide instructions for the service portion of the New Mexico medical assistance programs (MAP).

A. General requirements: (1) Care coordination services are provided and coordinated with the eligible recipient member and his or her family, as appropriate. Care coordination involves, but is not limited to, the following: planning treatment strategies; developing treatment and…

New Mexico Health Care Authority.

This rule applies to the general public.

The New Mexico medicaid program and other health care programs are administered pursuant to regulations promulgated by the federal department of health and human services under Title XIX of the Social Security Act as amended or by state statute. See Section 27-1-12 et seq., NMSA …

Permanent.

May 1, 2018, unless a later date is cited at the end of a section.

The objective of this rule is to provide instructions for the service portion of the New Mexico medical assistance programs (MAP).

To transform lives. Working with our partners, we design and deliver innovative, high quality health and human services that improve the security and promote independence for New Mexicans in their communities.

Transition of care refers to movement of an eligible recipient or a manage care organization (MCO) member from one health care practitioner or setting to another as their condition and health care needs change. The MCO shall have the resources, the policies and the procedures in …

New Mexico Health Care Authority.

The MCOs shall offer the ABCB approach to its members who meets the NF LOC and are determined through a CNA or reassessment to need MCO CB services. Although a member's assessment for the amount and types of services may vary, ABCB services are not provided 24 hours per day. A me…

All ABCB agencies must apply and be approved to be a MAD provider and must then contract with any or all approved MCOs. A complete listing of all CB provider qualifications and responsibilities are detailed in the MAD MCO policy manual. ABCB providers must meet all Federal requir…

A member must meet NF LOC and be determined through a CNA or reassessment to need MCO CB services.

A. Adult day health: adult day health services provide structured therapeutic, social and rehabilitative services designed to meet the specific needs and interests of a member that are incorporated into the member's care plan. (1) Adult day health services are provided by a licen…

MAD and the member's MCO do not cover certain procedures, services, or miscellaneous items. See specific MAD NMAC rules, sections of this rule, and the MAD MCO manual for additional information on benefit coverage and limitations.

The MCO shall offer the SDCB approach to a member who meets a NF LOC and is determined through a CNA or reassessment to need CB services. Self-direction affords a member the opportunity to have choice and control over how his or her CB services are provided and who provides the s…

A. The FMA, member or his or her EOR shall verify that a potential provider meets all applicable qualifications prior to rendering a service. If a provider or employee is unable to pass a nationwide criminal history screening pursuant to NMSA 1978, 29-12-2 et seq. or is listed in…

A member must meet NF LOC, be determined through a CNA or reassessment to need MCO CB services, and be approved by the member's MCO for the SDCB approach.

MAD and the member's MCO cover certain procedures, services, and miscellaneous items. For those services that are the same in ABCB and SDCB, detailed descriptions are found in 8.308.12.13 NMAC. Other services may be available to a member in the SDCB approach and detailed descript…

MAD and the member's MCO do not cover certain procedures, services, or miscellaneous items. Services and goods that are not covered by the SDCB approach include, but are not limited to the following: A. services covered by third-parties; MAD or the MCO is the payer of last resort…

This rule applies to the general public.

A member who meets a NF LOC and who qualifies for MCO CB must first access services through his or her MCO's ABCB approach. After 120 calendar days, the member may continue his or her CB services provided through the MCO's ABCB or may select the MCO's SDCB approach. The member's …