Current through Register Vol. 35, No. 6, March 26, 2024
A.
The provider who furnishes services to medicaid recipients will comply with all
specified medicaid participation requirements. See 8.302.1 NMAC,
General Provider Policies. The provider will verify that
individuals are eligible for medicaid, medicare, or other health insurance at
the time services are furnished. The provider will verify whether or not an
individual is self-pay at the time services are provided. The provider will
maintain records which are sufficient to fully disclose the extent and nature
of the services provided to recipients. See 8.302.1 NMAC, General
Provider Policies. The provider will provide the coordination which
will enable the client to utilize PACE as the single source for primary care.
This will assist the enrollee in the coordination of care by
specialists.
B.
Outreach and
marketing: The provider will have a written plan which accomplishes the
following outreach and marketing objectives.
(1) Strategies of how prospective
participants are provided adequate program descriptions.
(a) The program descriptions shall be written
in a culturally competent format at a language level understandable by the
participant (sixth grade). The format should be sensitive to the culture and
language common to the service area.
(b) Program descriptions should include the
services available through the program. The services include, but are not
limited to, the following: enrollment and disenrollment, procedures to access
services, after hours call-in system, provisions for emergency treatment,
restrictions against using medical providers and/or services not authorized by
the interdisciplinary team, and any other information necessary for prospective
participants to make informed decisions about enrollment. Prior to enrollment,
each participant will be informed of what individualized initial assessment and
treatment plan has been developed by the interdisciplinary team.
(2) Development of outreach and
enrollment materials (including marketing brochures, enrollment agreements,
website and disenrollment forms). These materials should be submitted in draft
form to MAD for approval prior to publication. Distribution prior to approval
is prohibited.
(3) Submit an active
and ongoing marketing plan, with measurable enrollment objectives and a system
for tracking its effectiveness. The plan shall also include, but not be limited
to, the sequence and timing of promotional and enrollment activities and the
resources needed for implementation.
(4) Ensure that prohibited marketing
activities are not conducted by its employees or its agents. Prohibited
practices are:
(a) discrimination of any kind
while maintaining the PACE program requirements;
(b) statements or activities that could
mislead or confuse potential participants, or misrepresent the contractor, CMS,
or the state medicaid agency;
(c)
inducing enrollment through gifts or payments; the Procurement Code, Sections
13-1-28
through
13-1-199
NMSA 1978, imposes civil and misdemeanor criminal penalties for its violation;
in addition, the New Mexico criminal statutes impose felony penalties for
bribes, gratuities and kickbacks; and
(d) subcontracting outreach efforts to
individuals or organizations whose sole responsibility involves direct contact
with elderly to solicit enrollment.
