New Mexico Administrative Code

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 the Social Security Act as amended or by state statute. See Section 27-2-12 et seq NMSA 1978. Section 9…

Permanent.

June 1, 2016, 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.

The New Mexico title XIX program reimburses appropriately licensed and certified acute care hospitals for inpatient services as outlined in this part. Procedures and policies governing state licensure, certification of providers, utilization review and any other aspect of state r…

New Mexico Health Care Authority.

A. Upon approval of New Mexico medical assistance program provider participation agreements by MAD, small rural hospitals that meet the following requirements are eligible to be reimbursed for providing services as swing bed providers: (1) hospital is licensed and certified by th…

To participate as a swing bed hospital, the facility must comply with the following conditions: A. be licensed and certified as meeting all the requirements for participation as a hospital; B. meet the requirements for hospital providers of long term care services. See 42 CFR 405…

Providers who furnish services to medicaid recipients must comply with all specified medicaid participation requirements. See 8.302.1 NMAC, General Provider Policies. Providers must verify that individuals are eligible for medicaid at the time services are furnished and determine…

Medicaid covers hospital and nursing facility (low or high level) services which are medically necessary for the diagnosis and/or treatment of an illness or injury as indicated by the condition of the recipient.

Swing bed services are subject to the limitations and coverage restrictions which exist for other medicaid services. See 8.301.3 NMAC, General Noncovered Services.

All medicaid 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 a…

A. As a condition for participation in medicaid, each swing bed provider must establish and maintain an acceptable system of accounting for a resident's personal funds when a Title XIX (medicaid) recipient requests that his/her personal funds be cared for by the facility. See 42 …

All adult recipients must be informed of their right to make health decisions, including their right to accept or refuse medical treatment, as specific in the Patient Self-Determination Act. See 8.302.1.18 NMAC, General Provider Policies.

To allow recipients to visit family or friends for short periods of approved therapeutic leave or to allow trial placement to adjust to a new environment as part of a discharge plan, MAD pays the routine rate to hold or reserve the bed for the recipient's return. A. Coverage of r…

Swing bed providers must submit claims for reimbursement on the long term care turn around document (TAD) or its successor. See 8.302.2 NMAC, Billing for Medicaid Services. Once enrolled, providers receive instructions on documentation, billing, and claims processing. Swing bed h…

The rule applies to the general public.

The New Mexico medicaid program is administered pursuant to regulations promulgated by the federal department of health and human services under Title XIX of the Social Security Act, as amended and by the state health care authority pursuant to state statute. See Section 27-2-12 …

Permanent

February 1, 1995

The objective of these regulations is to provide policies for the service portion of the New Mexico medicaid program. These policies describe eligible providers, covered services, noncovered services, utilization review, and provider reimbursement.

[RESERVED]

The mission of the New Mexico medical assistance division (MAD) is to maximize the health status of medicaid-eligible individuals by furnishing payment for quality health services at levels comparable to private health plans.

The New Mexico medicaid program (medicaid) pays for medically necessary health services furnished to eligible recipients. To help New Mexico recipients receive necessary services, the New Mexico medical assistance division (MAD) pays for services furnished in general hospital set…

New Mexico Health Care Authority.

Health care to eligible recipients or members 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 (PPA) by MAD or its designee, lice…

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

A NF is required to provide the following to a MAP eligible recipient or member resident. A. Room and board. B. Professional nursing services 24 hours a day, seven days a week. Professional nursing services are those services which are performed directly by a RN or a licensed pra…

A. MAD covers NF services identified as allowable costs; see 8.312.3 NMAC. B. MAD covers physical, occupational and speech therapy services furnished to an eligible recipient or member residing in a NF in the following manner:(1) if the eligible recipient or member is also eligib…

NF services are subject to the limitations and coverage restrictions which exist for other MAD services. See also 8.310.2, 8.310.3, 8.312.3, 8.324.4 NMAC.

A. As a condition for MAD provider participation, each NF must establish and maintain an acceptable system of accounting for an eligible recipient or member resident's personal funds when an eligible recipient or member requests that their personal funds be cared for by the facil…

MAD pays to hold or reserve a bed for an eligible recipient or member resident in a NF to allow for the eligible recipient or member resident to make a brief home visit, for acclimation to a new environment, or for hospitalization according to the limits and conditions outlined b…

Medical necessity, LOC, and length of stay determinations are carried out in accordance with MAD UR instructions or the MAD MCO policy manual, as authorized under Title XIX of the Social Security Act; see 8.310.2 and 8.350.4 NMAC.

As part of the initial NF communication form for a new admission or as part of a subsequent specified review as determined by PASRR, or a significant change review as indicated by the minimum data set (MDS) for an eligible recipient or member resident with identified mental illne…

A. A long term care facility participating in the medicare and is an enrolled MAD provider is required to conduct a comprehensive, accurate, standardized, reproducible assessment of each eligible recipient or member resident's functional capacity. See Sections 4201 (a)(3) and 421…

The rule applies to the general public.

If an eligible recipient or member resident is required to pay a medical care credit, MAD or the MCO reimburses the NF for the difference between the NF's reimbursable rate and the medical care credit. The NF is responsible for collecting the amount reported as the medical care c…

Pursuant to the public health emergency declared by the governor of New Mexico in Executive Order 2020-004 on March 11, 2020, and any renewal and subsequent Executive Order, and the department of health and human services centers for medicaid and medicaid services COVID-19 Emerge…

All adult eligible recipient or member residents of nursing facilities must be informed of their right to make their own health decisions, including the right to accept or refuse medical treatment as specified in the Patient Self-Determination Act; see 8.302.1 NMAC.

An eligible recipient or member resident who believes that the NF has erroneously determined that they should be transferred or discharged may request a HCA administrative hearing. A NF must provide an eligible recipient or member resident notice of the proposed transfer or disch…

All MAD services are subject to utilization review for medical necessity, inspection of care, 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 8.310.2 NMAC. The …

A NF provider must submit claims for reimbursement on the long term care turn around document (TAD) or its successor; see 8.302.2 NMAC. A. MAD reimburses a NF at the lesser of the following: (1) the NF's billed charges; (2) the prospective reimbursement rates constrained by the c…

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 1…

Permanent.

August 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 programs.

A. "Authorized representative" means the individual designated to represent and act on the claimant's behalf. The eligible recipient or managed care organization (MCO) member's authorized representative must provide formal documentation authorizing the named individual or individ…