New Mexico Administrative Code

The MAD will reimburse providers for the medicaid portion of the billed amount that providers paid to the New Mexico department of health (DOH). The following is the billing format. A. Each ICF-MR will pay DOH by check according to DOH regulations. B. A copy of the check(s) that …

A. A provider who is dissatisfied with the base year rate determination or the final settlement (in the case of a change of ownership) may request a reconsideration of the determination by addressing a request for reconsideration to: Director, Medical Assistance Division, P.O. Bo…

A. Provider's 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…

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

This 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.

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

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.

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…

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 title XIX program makes reimbursement for appropriately licensed and certified intermediate care facilities for the mentally retarded as outlined in this material.

New Mexico Health Care Authority.

A. Upon approval of New Mexico MAP provider participation agreements by MAD, providers who meet the following requirements are eligible to be reimbursed for furnishing waiver services to recipients: (1) standards established by the HCBS waiver program; and (2) provide services to…

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

A. Enrollment in the MFW program is contingent upon the applicant meeting the eligibility requirements as described in this rule, the availability of funding as appropriated by the New Mexico legislature, and the number of federally authorized unduplicated eligible recipients. On…

The services covered by the MFW program are intended to provide a home and community-based alternative to institutional care for an eligible recipient. In all services covered under the MFW the recipient has the right to privacy, dignity, and respect. The recipient further has th…

Only services listed as covered waiver services are covered under the waiver program. Ancillary services can be available to waiver recipients through the MAP state plan services. These ancillary services are subject to the limitations and coverage restrictions which exist for ot…

The CMS requires a person-centered individualized service plan (ISP) for each individual receiving services through a HCBS waiver program. The ISP is developed annually through an ongoing person-centered planning process. A. The case manager assists the recipient in identifying h…

All medicaid services, including services covered under the MFW, 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 ma…

Waiver service providers must submit claims for reimbursement to MAD's fiscal contractor for processing. Claims must be filed per the billing instructions in the medicaid policy manual. Providers must follow all medicaid billing instructions. See Section 8.302.2 NMAC. Once enroll…

A. Pursuant to 42 CFR Section 431.220(a)(1) and (2), Section 27-3-3 NMSA 1978 an eligible recipient may request a HSD administrative hearing to appeal an adverse action or adverse decision. See Section 8.352.2 NMAC for a description of the HSD administrative hearing process. In a…

A. Continuation of benefits may be provided to an eligible recipient who requests a HSD administrative hearing within the timeframe defined in Section 8.352.2 NMAC. B. The continuation of a benefit is only available to an eligible recipient that is currently receiving the appeale…

The rule applies to the general public.

An eligible recipient has the opportunity to register a grievance or complaint concerning the MFW program. An eligible recipient may register complaints with DOH via e-mail, mail or phone. Complaints will be referred to the appropriate DOH division or as appropriate referred to M…

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.

March 1, 2018 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 medical assistance program (MAP). These policies describe eligible providers, covered services, non-covered services, utilization review, and provider reimbursement.

A. Activities of daily living (ADLs): Those activities associated with an individual's daily functioning. The basic skills of everyday living such as toileting, bathing, dressing, grooming, and eating and the skills necessary to maintain the normal routines of the day, such as ho…

The New Mexico MAP pays for medically necessary services furnished to eligible recipients. To help New Mexico recipients receive services in a cost-effective manner, the New Mexico medical assistance division (MAD) has obtained a waiver of certain federal regulations to provide h…

New Mexico Health Care Authority.

A. 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 (PPA) by MAD or its designee, licensed pra…

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

The MAP category of eligibility criteria for DDW services is found in 8.290.400 NMAC.

The DDW program is limited to the number of federally authorized unduplicated eligible recipient (UDR) positions and program funding. All DDW covered services in an ISP must be authorized. DDW services must be provided in accordance with all requirements set forth by DDW service …

The DDW program is limited to the number of federally authorized unduplicated eligible recipient (UDR) positions and program funding. All DDW covered services in an ISP must be authorized by DOH. DDW services must be provided in accordance with all requirements set forth by DOH D…

Only those services listed in the DDW benefit package may be reimbursed through the DDW. Room, board and ancillary services are not covered under DDW services. An eligible recipient may access, as medically necessary, all medicaid state plan benefits in addition to their DDW serv…

A. CMS requires a person-centered service plan for every individual receiving HCBS. The ISP must be developed annually through an ongoing person-centered planning process. The ISP development must:(1) Involve those whom the participant wishes to attend and participate in developi…

All MAD services, including services covered under the DDW, are subject to utilization review for medical necessity and program compliance. Reviews may be performed before services are furnished, after services are furnished and before payment is made, or after payment is made; s…

DDW service providers must submit claims for reimbursement to MAD's fiscal contractor for processing. A DDW provider must follow 8.302.2 NMAC, MAD billing instructions, utilization review instructions, and supplements. Reimbursement to providers of waiver services is made at a pr…

The rule applies to the general public.

An eligible recipient may request a HSD administrative hearing to appeal a decision of MAD or its third party assessor contractor, that is an adverse action against the recipient. Prior to the fair hearing an eligible recipient may be offered an agency review conference. An agenc…

A continuation of an existing DDW benefit or benefits is automatically provided to an eligible recipient claimant pending the resolution of the agency review conference and any subsequent fair hearing. The continuation of a benefit is only available to a claimant that is currentl…

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.

December 1, 2018, 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 (MAP).