New Mexico Administrative Code
Title 8 - SOCIAL SERVICES
Chapter 206 - MEDICAID ELIGIBILITY - CYFD CHILDREN (CATEGORIES 006, 017, 037, 046, 047, 060, 061, 066 and 086)
Part 600 - BENEFIT DESCRIPTION
Section 8.206.600.13 - RETROACTIVE BENEFIT COVERAGE

Universal Citation: 8 NM Admin Code 8.206.600.13

Current through Register Vol. 35, No. 18, September 24, 2024

Up to three months of retroactive medicaid coverage can be furnished to applicants who have received medicaid-covered services during the retroactive period and would have met applicable eligibility criteria had they applied during the three months prior to the month of application 42 CFR Section 435.914. Retroactive coverage is not available prior to January 1, 1995, to applicants/ recipients of Category 060 and 061.

A. Application for retroactive benefit coverage: Application for retroactive medicaid can be made by checking "yes" in the "application for retroactive medicaid payments" box on the application/ redetermination of eligibility for medicaid assistance (MAD 381) form or by checking "yes" to the question "Does anyone in your household have unpaid medical expenses in the last three months?" on the application for assistance (ISD 100 S) form. Applications for retroactive medicaid benefits must be made by 180 days from the date of application for assistance. Medicaid-covered services which were furnished more than two years prior to application are not covered.

B. Approval requirements: To establish retroactive eligibility, the ISS must verify that all conditions of eligibility were met for each of the three retroactive months and that the applicant received medicaid-covered services. Each month must be approved or denied on its own merits. Retroactive eligibility can be approved on either the ISD2 system (for categories programmed on that system) or on the retroactive medicaid eligibility authorization (ISD 333) form.

C. Notice:

(1) Notice to applicant: The applicant must be informed if any of the retroactive months are denied.

(2) Recipient responsibility to notify provider: After the retroactive eligibility has been established, the ISS must notify the recipient that they are responsible for informing all providers with outstanding bills of the retroactive eligibility determination. If the recipient does not inform all providers and furnish verification of eligibility which can be used for billing and the provider consequently does not submit the billing within 120 days from the date of approval of retroactive coverage, the recipient is responsible for payment of the bill.

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