New Mexico Administrative Code

Medicaid recipients who meet the eligibility requirements as stated in the medical assistance division eligibility manual may be eligible to participate in the PACE program.

The PACE program is a partially capitated, community based service program. The PACE program will ensure access to a comprehensive benefit package of services to a frail population that meets nursing facility clinical criteria. The provider will provide all medicaid services that…

A. The following services are not the responsibility of the provider or medicaid: (1) any medicaid capitated or fee-for-service benefit which has not been authorized by the multidisciplinary team; (2) in inpatient facilities, private room and private duty nursing, unless medicall…

A. Prior to enrollment, an initial assessment and treatment plan for each participant is developed by the interdisciplinary team. B. Each participant will be reassessed by the interdisciplinary team on a semiannual basis and informed about a new treatment plan. C. The enrollee, e…

A. The effective date for the recipient's enrollment in the program is the first day of the calendar month following the signing of the enrollment agreement, if an approved level of care (LOC) and all financial and non-financial eligibility criteria have been approved by the inco…

All voluntary and involuntary disenrollments will be documented and available for review by the state medicaid agency. The provider will inform the ISD office when a participant is being disenrolled either voluntarily or involuntarily. Disenrollment is effective by the first day …

A. The provider will assist a participant who either voluntarily or involuntarily disenrolls from the PACE program to apply for other possible services, including medicare or private-pay services; and, B. The provider will work with the state medicaid agency to ascertain the indi…

There are no restrictions placed on a former participant's reinstatement into the PACE program, if the former participant continues to meet financial, non-financial and medical eligibility criteria.

The rule applies to the general public.

The ISD office will conduct a redetermination at least annually of all financial and non-financial criteria, per the standards of the medicaid eligibility requirements. See Subsection A of 8.280.600.12 NMAC, Ongoing Benefits, Regular Reviews. LOC is determined by the HCA's utiliz…

The provider will have written policies and procedures for ensuring the rights of participants as well as educating the participants to the PACE program. These policies and procedures should be presented in a culturally competent format at a language level understandable by the p…

The provider will have participant grievance procedures which provide the participants and their family members with a process for expressing dissatisfaction with the program services, whether medical or nonmedical in nature. The procedures will explain and permit an orderly reso…

A. The provider will have a written plan of quality assurance and improvement which provides for a system of ongoing assessment, implementation, evaluation, and revision of activities related to overall program administration and services. The plan will:(1) ensure that standards …

A. Standardized data: The provider will ensure the quality of the data according to MAD medium and frequency of reporting. B. Software: The provider shall make no use of computer software developed pursuant to the contract, except as provided in the contract or as specifically gr…

The provider is required to submit certain financial reports as follows. A. A budgeted versus actual financial report for the current and year-to-date periods on a monthly basis 45 days after the end of each month. During the first year of operation, the financial report will be …

All medicaid services, including services covered under the PACE program, 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 paym…

PACE program providers must submit claims for reimbursement on the UB 92 claim form or its successor. See 8.302.2 NMAC, 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 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.

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, including services furnished in nursing facilities. To help New Mexico recipients receive necessary services, the New Mexico medical assistance division (MAD)…

New Mexico Health Care Authority.

EPSDT includes a screening component called the "tot to teen healthcheck". EPSDT also includes diagnostic, treatment, and other necessary health care measures needed to correct or ameliorate physical and behavioral health disorders or conditions discovered during the tot to teen …

A. A MAP eligible recipient under 21 years of age, or his or her family, is provided with the following information: (1) benefits of preventive health care; (2) services available under EPSDT and where and how to access those services; (3) services provided under EPSDT are furnis…

Upon MAD's approval of a PPA, a licensed practitioner, agency or facility that meets applicable requirements is eligible to be reimbursed for furnishing covered services to a MAP eligible recipient. A provider must be enrolled before submitting a claim for payment to the appropri…

A. A provider who furnishes services to a MAP eligible recipient must comply with all federal, state, local laws, rules, regulations, executive orders and the provisions of the provider participation agreement (PPA). A provider must adhere to MAD program rules as specified in NMA…

A. Health care to New Mexico MAP eligible recipients is furnished by a variety of providers and provider groups. The reimbursement for these services is administered by MAD. Upon approval of a PPA or an electronic health record (EHR) incentive payment agreement by MAD or its desi…

MAD developed the tot to teen healthcheck, the screening segment of EPSDT services. The tot to teen healthcheck includes periodic screening and regularly scheduled assessments of the MAP eligible recipient's general physical growth and development as well as behavioral health and…

MAD special rehabilitation services are furnished through the New Mexico early childhood education and care department (ECECD) family infant toddler (FIT) program. FIT provides early intervention services for a MAP eligible that has or is at risk of having a developmental delay f…

MAD pays for case management services furnished to a medically at risk MAP eligible recipient under 21 years of age as an EPSDT service. The need for case management services must be identified in the tot to teen healthcheck screen or through other diagnostic evaluations or asses…

MAD pays for medically necessary personal care services (PCS) furnished to a MAP eligible recipient under 21 years of age as part of the EPSDT program when the services are part of his or her ISP for the treatment of correction, amelioration, or prevention of deterioration of a M…

MAD pays for private duty nursing (PDN) services as part of the EPSDT program, see 42 CFR Section 441.57. Services must be accessed through the tot to teen healthcheck screen. A MAP eligible recipient is under 21 years, who has been referred for PDN services shift care (not inter…

The rule applies to the general public.

MAD pays for medically necessary services, including outpatient services furnished to a MAP eligible recipient under 21 years of age by or under the supervision of licensed PT; OT; and master's level SLP. A MAP eligible recipient under 21 years of age who is eligible for a home a…

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 programs (MAP).

Electronic visit verification (EVV):A telephone and computer-based system that electronically verifies the occurrence of HSD selected services visits and documents the precise time the service begins and ends.

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 medical assistance division (MAD) pays for medically necessary health services including preventive, treatment and ameliorative services for a medical assistance program (MAP) eligible recipient under 21 years of age through the early and periodic screening, diagnostic and tr…

New Mexico Health Care Authority.

Health care to New Mexico MAP eligible recipients is furnished by a variety of providers and provider groups. The reimbursement for these services is administered by MAD. Upon approval of a provider participation agreement (PPA) by MAD or its designee, licensed practitioners, fac…

A. Upon approval of a New Mexico MAD PPA by MAD or its designee, local education agencies (LEAs), regional educational cooperatives (RECs), and other state-funded educational agencies (SFEAs) that meet specified requirements are eligible to be reimbursed for furnishing services t…

A. General responsibilities: (1) A provider who furnishes services to an eligible recipient must comply with all terms and conditions of his or her MAD PPA and the MAD New Mexico administrative code (NMAC) rules. (2) A provider must verify that an individual is an eligible recipi…

MAD covers the following services when medically necessary and rendered as part of an eligible recipient's IEP, IFSP, 504 plan, IHCP or other care plan by specified providers in school settings. A. For services in Subsections A - E of 8.320.6.13 NMAC, a provider must first develo…

A. The ITP must specify:(1) the eligible recipient's objectives and goals; and (2) the duration, the frequency of the service for the eligible recipient. B. The plan is developed by the LEA, REC or other SFEA in conjunction with the eligible recipient, his or her family, and appl…