New Mexico Administrative Code

A. The MCO shall cover the following behavioral health services listed below. When an additional behavioral health service is approved by MAD, the MCO shall cover that service as well. See 8.321.2 NMAC for detailed descriptions of each service. MAD makes available on its websitei…

This rule applies to the general public.

The MCO shall cover community benefit services for a member who meets the specific eligibility requirements for each MCO community benefit service as detailed in 8.308.12 NMAC. When an additional community benefit service is approved by MAD, the MCO shall cover that service as we…

The MAD category of eligibility "other adults" has an alternative benefit plan (ABP). The MCO shall cover the ABP specific services for an ABP member. Services are made available through a MCO under a benefit plan similar to services provided by commercial insurance plans. ABP be…

An ABP member who self-declares they have a qualifying condition is evaluated by their MCO for determination if they meet an ABP qualifying condition. An ABP exempt member may select to no longer utilize their ABP benefits package. Instead, the ABP exempt member will utilize thei…

Beginning January 1, 2019, the benefit is available to approximately 300 eligible pregnant medicaid managed care enrolled members and their children who reside in Bernalillo County (other HSD-designated counties may be included at a later time and with a distinct enrollment limit…

MAD does not cover some services. For the following services that are covered in another MAP category of eligibility, reimbursement shall be made by MAD or its contractor. However, the MCO is expected to coordinate these services, when applicable, and ensure continuity of care by…

A. In this section, emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence o…

A. The MCO may not arbitrarily deny or reduce the amount, duration, or scope of a required service solely because of diagnosis, type of illness, or condition of the member. B. The services supporting members with ongoing or chronic conditions or who require long-term services and…

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 division programs.

A. Alternative benefits plan services with limitations (ABP): The medical assistance division (MAD) category of eligibility "other adults" has an alternative benefit plan (ABP). The HSD contracted managed care organization (MCO) covers ABP specific services for an ABP member. Ser…

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.

This part defines the benefit package for which a MCO shall be paid a fixed per-member-per-month capitated payment rate. The MCO shall cover the services specified in 8.308.9 NMAC. The MCO shall not delete a benefit from the MCO benefit package. A MCO is encouraged to offer value…

New Mexico Health Care Authority.

An ABP eligible recipient who self-declares he or she has a qualifying condition is evaluated by the MAD utilization review (UR) contractor for determination of whether he or she meets the qualifying condition. An ABP-exempt eligible recipient may select to no longer utilize his …

The ABP benefits and services are detailed in Sections 12 through 17 of this rule. The ABP-exempt benefits and services are detailed in Section 19 of this rule.

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 pharmacy and related services, as detailed in 8.324.4 NMAC.

The benefit package includes reproductive health services as detailed in 8.310.2 NMAC.

The benefit package includes the current national standards for preventive health services including behavioral health preventive services. Standards are derived from several sources, including the United States preventive services task force, the centers for disease control and …

The benefit package includes telemedicine services as detailed in 8.310.2 NMAC.

The benefit package includes the behavioral health services as detailed in 8.321.2 NMAC.

The benefit package includes the delivery of the federally mandated EPSDT program services [42 CFR Section 441.57] provided by a primary care provider (PCP) as detailed in 8.320.2 NMAC. These include the ABP benefit services found in Sections 12 through 17 of this rule. A. Genera…

An ABP eligible recipient with a qualifying condition may select ABP-exempt utilizing the standard medicaid state plan benefits. All services, services limitations and co-payments that apply to full benefit medicaid recipients are available to APB-exempt recipients. An ABP-exempt…

This rule applies to the general public.

Health care to an ABP eligible recipient is furnished by a variety of providers and provider groups. Refer to the MAD NMAC specific service rules for detailed description of unique provider requirements. For general information, see 8.310.2 and 8.310.3 NMAC.

MAD does not cover certain procedures, services, or miscellaneous items. Refer to the NMAC specific service rules for detailed description of unique noncovered services. For general information, see 8.310.2 NMAC for physical health noncovered services, 8.320.2 NMAC for EPSDT nonc…

All MAD services are subject to UR for medical necessity and program compliance. Refer to the NMAC specific service rule for detailed description of the service's prior authorization and utilization review requirements. For general information, see 8.310.2 and 8.310.3 NMAC.

Services provided may be subject to cost sharing requirements. Please see 8.302.2 NMAC for more information on any required recipient co-payments.

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 NMSA 1978, Section 27-1-12 et …

Permanent.

January 1, 2014, 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 division programs.

[RESERVED]

To reduce the impact of poverty on people living in New Mexico by providing support services that help families break the cycle of dependency on public assistance.

The medical assistance division (MAD) category of eligibility "other adults" has an alternative benefit plan (ABP). MAD covers ABP specific services for an ABP eligible recipient. Services are made available through MAD under a benefit plan similar to services provided by commerc…

New Mexico Health Care Authority (HCA).

A. Health care to eligible recipients in a health home is furnished by a variety of providers and provider groups. The reimbursement and billing for these services is administered by medical assistance division (MAD). Upon approval of a New Mexico provider participation agreement…

A. A provider agency who furnishes MAD services to an eligible recipient must comply with all federal and state laws, rules, regulations, and executive orders relevant to the provision of services as specified in the MAD PPA. A provider agency also must comply with all appropriat…

An eligible recipient: A. is 21 years of age and older who meets the HCA criteria for serious mental illness (SMI); or B. is under 21 years of age who meets the HCA criteria for serious emotional disturbance (SED); or C. meets the criteria for substance use disorder (SUD).

Health home services through CareLink NM are coordinated with the eligible recipient and their family and a CareLink NM provider agency as appropriate. CareLink NM services identify available community-based resources and actively manage appropriate referrals and access to care, …

Non-covered CareLink NM services are subject to the limitations and coverage restrictions that exist for other MAD services. See 8.310.2 and 8.321.2 NMAC for general non-covered services. Specific to CareLink NM services, the following apply: A. CareLink NM services rendered duri…

All MAD services are subject to utilization review (UR) for medical necessity and program compliance. Reviews can be performed before services are furnished, after services are furnished, before payment is made, or after payment is made. The provider agency must contact MAD or it…

CareLink NM services are reimbursed through a per-member-per-month (PMPM) payment to the provider agency. CareLink NM dedicated services are those outlined in 8.310.10.13 NMAC. MAD covered services provided to an eligible recipient including behavioral and physical health service…

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 Title XIX of the Social Security Act as amended or by state statute. See Sections 27-2-12 et seq. NMSA …

Permanent.