New Mexico Administrative Code

We ensure that New Mexicans attain their highest level of health by providing whole-person, cost-effective, accessible, and high-quality health care and safety-net services.

The New Mexico medical assistance division (MAD) pays for medically necessary health services furnished to eligible recipients and members. To help New Mexico eligible recipients and members receive necessary services, MAD pays for services furnished in nursing facilities.

New Mexico Health Care Authority.

The human services department will reimburse nursing facilities (effective October 1, 1990, the skilled nursing facility/intermediate care facility SNF/ICF distinction is eliminated; see 8.312.3.16 NMAC) the lower of the following, effective July 1, 1984: A. billed charges; and B…

A. Adequate cost data: (1) Providers receiving payment on the basis of reimbursable cost must provide adequate cost data based on financial and statistical records which can be verified by qualified auditors. The cost data must be based on an approved method of cost finding and o…

Prospective per diem rates will be established as follows and will be the lower of the amount calculated using the following formulas, or the ceiling: A. Base year: Rebasing of the prospective per diem rate will take place every three years. Therefore, the operating years under t…

The following categories are used to establish ceilings for calculating prospective per diem rates: 1) state-owned and operated NF, 2) non-state-owned and operated NF. The department determines the status of each provider for exclusion from or inclusion in any one category. Ceili…

In order to insure that the medicaid program does not pay for costs associated with unnecessary beds as evidenced by under-utilization, allowable facility costs will be calculated by imputing a ninety percent occupancy rate. This provision will apply to: A. any new facility certi…

A. Since rebasing of the prospective per diem rate will take place every three years, the department recognizes that certain circumstances may warrant an adjustment to the base rate. Therefore, the provider may request such an adjustment for the following reasons: (1) additional …

As mandated by Section 1919 of the Social Security Act, the following changes are made effective October 1, 1990: A. Elimination of SNF/ICF Distinction: Effective October 1, 1990, the SNF and ICF distinctions will be eliminated and all participating providers will become NFs. In …

When medicaid payment is made to reserve a bed while the recipient is absent from the facility, the reserve bed day payment shall be in an amount equal to fifty percent of the regular payment rate.

A. A provider who is dissatisfied with the base year rate determination or the final settlement (in the case of a change in ownership) may request a reconsideration of the determination by addressing a request for reconsideration to: director, medical assistance division, human s…

A. Providers' cost reports submitted by participating providers as a basis for reimbursement as required by law are available to the public upon receipt of a written request to the medical assistance division. Information thus disclosed is limited to cost report documents require…

The rule applies to the general public.

If any provision of this regulation is held to be invalid, the remainder of the regulations shall not be affected thereby.

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.

September 1, 2021, unless a later date is cited at the end of a section.

The objective of this rule 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.

A. Accrual basis of accounting: Under the accrual basis of accounting, revenue is recorded in the period when it is earned, regardless of when it is collected. The expenditures for expense and asset items are recorded in the period in which they are incurred, regardless of when t…

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 makes reimbursement for appropriately licensed and certified nursing facility (NF) services as outlined in this material.

New Mexico Health Care Authority, Medical Assistance Division.

A. Upon approval of New Mexico medical assistance program provider participation agreements by New Mexico medical assistance division (MAD), intermediate care facilities for the mentally retarded (ICF-MR) which meet the following conditions for participation are eligible to be re…

See Section MAD-967.5, Appeals for Denial, Termination, or Non-Renewal of Provider Participation.

See Section MAD-967, Sanctions for Non-Compliance and Section MAD-968, Intermediate Remedies.

A. Providers who furnish services to HCA/MAD program eligible recipients must comply with all specified HCA/ MAD participation requirements. See Section MAD-701, General Provider Policies. B. Providers must verify that individuals are eligible for medicaid at the time services ar…

Medicaid does not reimburse ICFs-MR for furnishing services, unless they provide at least the following, see 42 CFR 483.440(a): A. room and board; B. continuous active treatment program, including aggressive, consistent implementation of a program of specialized and generic train…

Medicaid covers the costs of ICF-MR services identified as allowable. See 8.313.3 NMAC, Cost Related Reimbursement of Intermediate Care Facilities for the Mentally Retarded, Section III.G. Pharmacy services furnished in the ICF-MR are reimbursed separately and are subject to spec…

A. Medicaid does not cover the costs of ICF-MR services that are not allowable. See 8.313.3 NMAC, Cost Related Reimbursement of Intermediate Care Facilities for the Mentally Retarded. B. Medicaid does not pay for residents with a primary diagnosis of mental retardation who are re…

A. As a condition for participation in medicaid, each ICF-MR must establish and maintain an acceptable system of accounting for a resident's personal funds when a Title XIX (medicaid) recipient requests that their personal funds be cared for by the facility. See 42 CFR 483.10(c).…

Medical necessity, level of care or length of stay determinations, and on-site review activities are carried out in accordance with the MAD utilization review policy and procedures, authorized under Title XIX of the Social Security Act. See 8.350.3 NMAC, Abstract Submission for L…

All HCA/MAD program 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 Authoriz…

This rule applies to the general public.

Medicaid pays to hold or reserve a bed for a resident of an ICF-MR for the following reasons: 1) to allow the resident to make home and community visits, e.g., vacations; 2) to adjust to a new living environment; or 3) for hospitalizations.A. Coverage of reserve bed days: Without…

Intermediate care providers must submit claims for reimbursement on the long term care turn around documents (TAD) or its successor. See Section MAD-702, Billing for Medicaid Services. Once enrolled, providers receive instructions on documentation, billing, and claims processing.…

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

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

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

The mission of the New Mexico medical assistance division (MAD) is to maximize the health status of HCA/MAD program 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 recipients, including services furnished by intermediate care facilities for the mentally retarded 42 CFR 440.150. This section describes eligible providers, covered services, ser…

Health Care Authority, Medical Assistance Division.

The HCA will reimbursement ICF/ MR facilities the lower of the following, effective September 1, 1990: A. billed charges; B. the prospective rate as constrained by the ceilings established by the HCA as described in this plan.

A. Adequate cost data: (1) Providers receiving payment on the basis of reimbursable cost must provide adequate cost data based on financial and statistical records which can be verified by qualified auditors. The cost data must be based on an approved method of cost finding and o…

Prospective per diem rates will be established as follows and will be the lower of the amount calculated using the following formulas, or any applicable ceiling: A. Base year: (1) For implementation year one (effective September 1, 1990), the providers base year will be for cost …

Ceilings on the four major cost centers will be established as follow: A. Direct patient care: No ceiling will be imposed on this cost center. B. A&G and R&B: The per diem costs for administration and general and for room and board will be grouped together for the establishment o…

Since rebasing of the prospective per diem rate will take place every three years, the HCA recognizes that certain circumstances may warrant an adjustment to the base rate. Therefore, the provider may request such an adjustment for the following reasons: A. Additional costs incur…

Reserve bed days will be paid using the provider's level III rate.