Current through Register Vol. 35, No. 6, March 26, 2024
A.
Medical
management eligibility: To be eligible for medical management through
CMS an applicant must meet all of the following requirements:
(1) the applicant must be a resident of
NM;
(2) the applicant must be
financially eligible; (income below 200% of the federal poverty level). 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; and
(3) the applicant must be medically eligible
as defined in the medical index and the treatment protocols and guidelines
adopted by the children's medical services program, and as determined by the
medical director.
B.
Adult cystic fibrosis eligibility: To be eligible for medical
coverage and care coordination services through the adult cystic fibrosis
program, an applicant must meet all of the following requirements:
(1) the applicant must be 21 years of age or
older;
(2) the applicant must be
diagnosed as having cystic fibrosis by pilocarpine iontophoresis or by genetic
studies;
(3) the applicant must be
a resident of NM; and
(4) the
applicant must meet financial eligibility criteria (income below 200% of the
federal poverty level); 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.
C.
Clinic only eligibility: To be eligible for clinic services, an
applicant must meet the following requirements:
(1) the applicant must be under 21 years of
age, except for metabolic clinics where applicant may be any age;
(2) the applicant must be a resident of NM;
and
(3) the applicant must be
referred by a physician, physician's assistant, or pediatric nurse
practitioner.
D.
No fee for clinic: There is no charge for the children's medical service
sponsored clinic, however, there may be a charge for tests ordered by
physicians and completed outside of the clinics. Third party payment will be
sought if available.
E.
Care
coordination only eligibility: To the extent resources are available,
care coordination shall be provided for any child with special health care
needs, adult with cystic fibrosis, or individual at risk of having a child with
special needs, regardless of income.
