New Mexico Administrative Code

HSD is committed to aggressive prevention, detection, monitoring, and investigation to reduce provider or member fraud, waste and abuse. This rule applies to all individuals and entities participating in or contracting with HSD or a MCO for provision or receipt of medicaid servic…

New Mexico Health Care Authority.

A. HSD newborn enrollment criteria. (1) When a child is born to a member enrolled in a MCO, the hospital or other providers will complete a MAD form 313 (notification of birth) or its successor, prior to or at the time of discharge. HSD shall ensure that upon receipt of the MAD f…

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.

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.

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 eligi…

New Mexico Health Care Authority.

A. Member disenrollment initiated by a MCO The MCO shall not, under any circumstances, disenroll a member. The MCO shall not request disenrollment because of a change in the member's health status, because of his or her utilization of medical or behavioral health services, his or…

The mass transfer process is initiated when HSD determines that the transfer of MCO members from one MCO to another is in the best interests of the program. A. Triggering a mass transfer: The mass transfer process may be triggered by two situations: (1) a maintenance change, such…

A. Each member shall receive an identification card (ID) that provides his or her MCO membership information within 20 calendar days of notification of enrollment with the MCO. B. The MCO shall re-issue a member ID card within 10 calendar days of notice if the member reports a lo…

HSD shall review and approve the content, comprehension level, and language(s) of all marketing materials directed at a member before use by a MCO. The MCO shall comply with all federal regulations regarding medicare-advantage and medicaid marketing. See 42 CFR. Parts 422, 438.

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.

A. General: A medical assistance division (MAD) eligible recipient is required to enroll in a HSD managed care organization (MCO) unless he or she is:(1) a Native American who opts into managed care. If a Native American is dually eligible or in need of long-term care services, h…

New Mexico Health Care Authority.

A. All written materials will be available in English and all languages spoken by approximately five percent or more of the MCO's membership, as determined by the HSD contracted managed care organization (MCO) or HSD. Upon consent from the appropriate native American tribal leade…

The MCO shall provide each member or the member's authorized representative with written information concerning his or her rights and responsibilities. A. These include the right:(1) to be treated with respect and with due consideration for his or her dignity and privacy; (2) to …

The MCO shall provide a member with access to electronic or hard copy versions of his or her personal health records.

The MCO shall provide health education to its members. Health education is intended to advise or inform the MCO members about issues related to healthy lifestyles, situations that affect or influence health status, behaviors that affect or influence health status or methods of me…

The MCO shall have a member portal on its website that is available to all members and potential members, and contains accurate, up-to-date information about the MCO to include, services provided, the preferred drug list, the provider directory, member handbook, frequently asked …

The MCO shall operate a call center with a toll-free phone line to respond to member questions, concerns, inquiries and complaints from a member and his or her provider. The line shall be equipped to handle calls from an individual with limited English proficiency, as well as cal…

The MCO shall convene advisory boards that meet quarterly and are representative of its membership. The advisory board shall advise the MCO on issues concerning service delivery, quality of its covered services, and other member issues as needed or as directed by HSD.

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).

New Mexico Health Care Authority.

New Mexico administrative code (NMAC) rules and related documents contain a detailed description of the services covered by MAD, the limitations and exclusions to covered services, and non-covered services. The NMAC rules are the official source of information on covered and non-…

A. The MCO shall provide medically necessary services consistent with the following: (1) a determination that a health care service is medically necessary does not mean that the health care service is a covered benefit; benefits are to be determined by HSD; (2) in making the dete…

A. Ambulatory surgical services: The benefit package includes surgical services rendered in an ambulatory surgical center setting as detailed in 8.324.10 NMAC. B. Anesthesia services: The benefit package includes anesthesia and monitoring services necessary for the performance of…

The benefit package includes case management services necessary to meet an identified service need of a member. The following are specific case management programs available when a member meets the requirements of a specific service. A. Case management services for adults with de…

The benefit package includes pharmacy and related services, as detailed in 8.324.4 NMAC. A. The MCO may determine its formula for estimating acquisition cost and establishing pharmacy reimbursement. B. The MCO shall include on the MCO's formulary or PDL all multi-source generic d…

The benefit package includes the delivery of the federally mandated EPSDT services ( 42 CFR Part 441, Subpart B) provided by a primary care provider (PCP) as detailed in 8.320.2 NMAC. The MCO shall provide access to early intervention programs and services for a member identified…

The benefit package includes reproductive health services as detailed in 8.310.2 NMAC. The MCO shall implement written policies and procedures approved by HSD which define how a member is educated about his or her rights to family planning services, freedom of choice, to include …

The MCO shall follow current national standards for preventive health services, including behavioral health preventive services. Standards are derived from several sources, including the U.S. preventive services task force, the centers for disease control and prevention; and the …

The benefit package includes telemedicine services as detailed in 8.310.2 NMAC. A. The MCO must: (1) promote and employ broad-based utilization of statewide access to Health Insurance Portability and Accountability Act (HIPAA)-compliant telemedicine service systems including, but…