Current through Register Vol. 35, No. 18, September 24, 2024
A. Except where
noted, the HSD income support division (ISD) determines eligibility in the
categories listed below:
(1) other adult
(Category 100);
(2) parent
caretaker (Category 200);
(3)
pregnant women (Category 300);
(4)
pregnancy-related services (Category 301);
(5) loss of parent caretaker due to earnings
from employment or due to spousal support (Categories 027 and 028);
(6) newborn (Category 031);
(7) children under age 19 (Categories 400,
401, 402, 403, 420, and 421);
(8)
children, youth, and families department medicaid (Categories 017, 037, 046,
04, 066, and 086); and
(9) family
planning (Category 029).
B.
Medicare savings program
(MSP): MSP assists an eligible recipient with the cost of medicare.
(1) Medicare is the federal government
program that provides health care coverage for individuals 65 or older; or
under 65 who have a disability. Individuals under 65 who have a disability are
subject to a waiting period of 24 months from the approval date of social
security disability insurance (SSDI) benefits before they receive medicare
coverage. Coverage under medicare is provided in four parts.
(a) Part A hospital coverage is usually free
to beneficiaries when medicare taxes are paid while working.
(b) Part B medical coverage requires monthly
premiums, co-insurance and deductibles to be paid by the beneficiary.
(c) Part C advantage plan allows a
beneficiary to choose to receive all medicare health care services through a
managed care organization.
(d) Part
D provides prescription drug coverage.
(2) The following MSP programs can assist an
eligible recipient with the cost of medicare.
(a)
Qualified medicare beneficiaries
(QMB) - Categories 041 and 044: QMB covers low income medicare
beneficiaries who have or are conditionally eligible for medicare Part A. QMB
benefits are limited to the following:
(i)
cost for the monthly medicare Part B premium;
(ii) cost of medicare deductibles and
coinsurance; and
(iii) cost for the
monthly medicare Part A premium (for those enrolling conditionally).
(b)
Specified low-income
medicare beneficiaries (SLIMB) - Category 045: SLIMB medicaid covers
low-income medicare beneficiaries who have medicare Part A. SLIMB is limited to
the payment of the medicare Part B premium.
(c)
Qualified individuals 1 (QI1s) -
Category 042: QI1 medicaid covers low-income medicare beneficiaries who
have medicare Part A. QI1 is limited to the payment of the medicare part B
premium.
(d)
Qualified
disabled working individuals (QDI) - Category 050: QDI medicaid covers
low income individuals who lose entitlement to free medicare Part A hospital
coverage due to gainful employment. QDI is limited to the payment of the
monthly Part A hospital premium.
(e)
Medicare Part D prescription drug
coverage - low income subsidy (LIS) - Category 048: LIS provides
individuals enrolled in medicare Part D with a subsidy that helps pay for the
cost of Part D prescription premiums, deductibles and co-payments. An eligible
recipient receiving medicaid through QMB, SLMB or QI1 is automatically deemed
eligible for LIS and need not apply. Other low-income medicare beneficiaries
must meet an income and resource test and submit an application to determine if
they qualify for LIS.
C.
Supplemental security income (SSI)
related medicaid:
(1)
SSI -
Categories 001, 003 and 004: Medicaid for individuals who are eligible
for SSI. Eligibility for SSI is determined by the social security
administration (SSA). This program provides cash assistance and medicaid for an
eligible recipient who is:
(a) aged (Category
001);
(b) blind (Category 003);
or
(c) disabled (Category
004).
(2)
SSI
medicaid extension - Categories 001, 003 and 004: MAD provides coverage
for certain groups of applicants or eligible recipients who have received
supplemental security income (SSI) benefits and who have lost the SSI benefits
for specified reasons listed below and pursuant to 8.201.400 NMAC:
(a) the pickle amendment and 503
lead;
(b) early
widow(er);
(c) disabled widow(er)
and a disabled surviving divorced spouse;
(d) child insurance benefits, including
disabled adult children (DAC);
(e)
nonpayment SSI status (E01);
(f)
revolving SSI payment status "ping-pongs"; and
(g) certain individuals who become ineligible
for SSI cash benefits and, therefore, may receive up to two months of extended
medicaid benefits while they apply for another MAD category of
eligibility.
(3)
Working disabled individuals (WDI) and medicare wait period - Category
074: There are two eligibility types:
(a) a disabled individual who is employed;
or
(b) a disabled individual who
has lost SSI medicaid due to receipt of SSDI and the individual does not yet
qualify for medicare.
D.
Long term care medicaid:
(1) medicaid for individuals who meet a
nursing facility (NF) level of care (LOC), intermediate care facilities for the
intellectually disabled (ICF-ID) LOC, or acute care in a hospital. SSI income
methodology is used to determine eligibility. An eligible recipient must meet
the SSA definition of aged (Category 081); blind (Category 083); or disabled
(Category 084).
(2)
Institutional care (IC) medicaid - Categories 081, 083 and 084: IC
covers certain inpatient, comprehensive and institutional and nursing facility
benefits.
(3)
Program of
all-inclusive care for the elderly (PACE) - Categories 081, 083 and 084:
PACE uses an interdisciplinary team of health professionals to provide dual
medicaid/medicare enrollees with coordinated care in a community setting. The
PACE program is a unique three-way partnership between the federal government,
the state, and the PACE organization. The PACE program is limited to specific
geographic service area(s). Eligibility may be subject to a wait list for the
following:
(a) the aged (Category
081);
(b) the blind (Category 083);
or
(c) the disabled (Category
084).
(4)
Home and
community-based 1915 (c) waiver services (HCBS) - Categories 090, 091, 092,
093, 094, 095 and 096: A 1915(c) waiver allows for the provision of long
term care services in home and community based settings. These programs serve a
variety of targeted populations, such as people with mental illnesses,
intellectual disabilities, or physical disabilities. Eligibility may be subject
to a wait list.
(a)
There are two HCBS
delivery models:(i) traditional agency
delivery where HCBS are delivered and managed by a MAD enrolled agency;
or
(ii) mi via self-directed where
an eligible recipient, or their representative, has decision-making authority
over certain services and takes direct responsibility to manage the eligible mi
via recipient's services with the assistance of a system of available supports;
self-direction of services allows an eligible mi via recipient to have the
responsibility for managing all aspects of service delivery in a
person-centered planning process.
(b)
HCBS waiver programs
include:(i) elderly (Category 091),
blind (Category 093) and disabled (Category 094);
(ii) medically fragile (Category
095);
(iii) developmental
disabilities (Category 096); and
(iv) self-directed model for Categories 090,
091, 093, 094, 095, 096 and 092).
E.
Emergency medical services for
non-citizens (EMSNC): EMSNC medicaid covers certain non-citizens who
either are undocumented or who do not meet the qualifying non-citizen criteria
specified in 8.200.410 NMAC. Non-citizens must meet all eligibility criteria
for one of the medicaid categories noted in 8.285.400 NMAC, except for
citizenship or qualified non-citizen status. Medicaid eligibility for and
coverage of services under EMSNC are limited to the payment of emergency
services from a medicaid provider.
F.
Refugee medical assistance (RMA) -
Categories 049 and 059: RMA offers health coverage to certain low-income
refugees during the first 12 months from their date of entry to the United
States (U.S.) when they do not qualify for other medicaid categories of
eligibility. An RMA eligible refugee recipient has access to a benefit package
that parallels the full coverage medicaid benefit package. RMA is funded
through a grant under Title IV of the Immigration and Nationality Act (INA). An
RMA applicant who exceeds the RMA income standards may "spend-down" below the
RMA income standards for Category 059 by subtracting incurred medical expenses
after arrival into the U.S.
G.
Breast and cervical cancer (BCC) - Category 052: BCC medicaid
provides coverage to an eligible uninsured woman, under the age of 65 who has
been screened and diagnosed by the department of health (DOH) as having breast
or cervical cancer to include pre-cancerous conditions. The screening criteria
are set forth in the centers for disease control and prevention's national
breast and cervical cancer early detection program (NBCCEDP). Eligibility is
determined using DOH notification and without a separate medicaid application
or determination of eligibility.
