New Mexico Administrative Code
Title 7 - HEALTH
Chapter 30 - FAMILY AND CHILDREN HEALTH CARE SERVICES
Part 3 - CHILDREN'S MEDICAL SERVICES AND ADULT CYSTIC FIBROSIS
Section 7.30.3.7 - DEFINITIONS

A. "Application" means the written request, on forms prescribed by the division, for enrollment, and provision of supportive documentation of residence, income, age, and medical diagnosis for eligibility determination under children's medical services program.

B. "Assets" means savings accounts, stocks and bonds, checking accounts, accessible trust funds, and real property. Assets do not include loans which need to be repaid, or homestead acreage used for the production of income if this is the primary source of income, or personal property that is used in the production of income if related to the primary source of income.

C. "Care coordination" means coordination of resources across agency and professional lines to develop and attain the client's service plan with optimal client/family participation.

D. "Care coordinator" means the person employed by the children's medical services program to assist the family in planning, implementing, evaluating and coordinating with other health care professionals to establish and carry out a service plan for the client.

E. "Child" means a person below the age of 18.

F. "Children's medical services ("CMS") means a unit of the public health division in the New Mexico (NM) department of health that engages in:

G. "Client" means the individual who is applying for or receiving services from the children's medical services program and includes the person with legal authority to consent to medical care.

H. "Consultant" means a professional licensed by the appropriate specialty board, such as audiology, ophthalmology, orthodontia, speech or psychology, who provides statements of eligibility and approves care plans within the specialty area.

I. "Date of referral" means the calendar date a child or adult in need of services first requested services by telephone, mail, written referral, or application to a representative of the children's medical services program.

J. "Department" means the NM department of health.

K. "Diagnostic services" means the provision of professional services to determine whether or not the client has a diagnosis within the medical diagnostic categories established in the medical index.

L. "Division" means the public health division of the NM department of health, Post Office Box 26110, Santa Fe, New Mexico 87502.

M. "Eligible individual" means an individual below the age of 21 who is a resident of NM and has or is at increased risk for chronic medical conditions and who requires health and related services of a type or amount beyond that required by children generally; or an adult with cystic fibrosis; or an individual of any age who requires metabolic clinic services or genetic testing.

N. "Eligibility for clinic only" means eligibility only for services at any specialty clinics sponsored by the children's medical services program.

O. "Eligibility for medical management" means eligibility for purchase of health care services approved by the children's medical services program and payment of expenses related to medical care such as lodging, meals, and transportation as outlined in the service plan and approved by the children's medical services program.

P. "Eligibility for care coordination only" means eligibility only for care coordination services.

Q. "Enrollment" means a statement, on forms prescribed by the division, and signed by the client accepting services, and acknowledging that acceptance of these services does not restrict eligibility for any other benefits or services.

R. "Expenditure" means authorization of funds and payment for services to healthcare professionals, institutions, and others.

S. "Financial eligibility" means a household income below 200% of the federal poverty guidelines which are published annually. CMS is always the payor of last resort. Any and all third party payments must be fully utilized before CMS payments are made. Clients who have two or more other payor sources such as insurance, medicare, etc., do not meet financial eligibility for payment by the children's medical services program.

T. "Health" means a state of physical and mental well-being, not merely the absence of disease.

U. "Household" means those who dwell under the same roof and are related by blood or marriage, excluding those who constitute separate economic units as determined by the service coordinator and documented in the case record.

V. "Income" means earned and non-earned gross income of all persons who reside in the household of the client, and have financial responsibility for the client, and any contributions to the household from non-household members with financial responsibility. Irregular and unpredictable contributions in insignificant amounts are not considered income for the purposes of these regulations.

W. "Medicaid" means medical assistance eligibility, pursuant to Title XIX of the Social Security Act, by the medical assistance division of the NM human services department.

X. "Medical director" means a pediatrician certified by the American board of pediatrics, licensed to practice medicine in the state of NM, who assists the program manager in the determination of medical eligibility for the children's medical services program and approves service plans and payment for eligible children and adults.

Y. "Medical index" means a listing of medical diagnoses for which an eligible individual may receive coverage by the children's medical services program.

Z. "Medical report" means the written report of a provider giving the diagnosis of the individual and the treatment recommended and provided.

AA. "Prior approval" means the requirement of approval for expenditure of funds for services before the service is rendered by a provider.

BB. "Program manager" means the person or delegate responsible for the provision of services through the children's medical services program.

CC. "Provider" means any individual or entity furnishing health care under a provider agreement with the children's medical services program.

DD. "Residence" means place where client lives with the intent to make the place his permanent and principal home.

EE. "Service plan" means a statement, developed in partnership with the family/parent/guardian, of the identified health needs of the client, how they will be met, by whom, and within a specified time frame.

FF. "Third party" means any person or entity that is liable to pay all or part of the medical cost of injury, disease, or disability of a children's medical services client.

GG. "Youth" means a person at least 18 years of age and less than 21 years of age.