Current through Register Vol. 35, No. 18, September 24, 2024
A.
Vision appliances: MAD covers specific vision care services that
are medically necessary for the diagnosis of and treatment of eye diseases. MAD
pays a provider for the correction of refractive errors that are required by
the condition of the MAP eligible recipient. All services must be furnished
within the limits of MAD benefits, within the scope and practice of the medical
professional as defined by state law and in accordance with applicable federal,
state and local laws and his or her New Mexico regulation and licensing
division's (RLD) practice board.
(1) Exam:
MAD covers routine eye exams. Coverage for a MAP eligible recipient over 22
years of age is limited to one routine eye exam in a 36-month period. Exam
coverage for a MAP eligible recipient under 21 years of age is limited to one
routine eye exam in a 12-month period. If a MAP eligible recipient has
transitioned from the early, periodic screening, diagnosis and treatment
(EPSDT) program at age 21, the date of service for his or her last exam starts
the 36-month period. An exam for an existing medical condition, such as
cataracts, diabetes, hypertension, and glaucoma will be covered for required
follow-up and treatment. The medical condition must be clearly documented on
his or her visual examination record and indicated by diagnosis on the claim
form.
(2) Corrective lenses: MAD
covers one set of corrective lenses for a MAP eligible recipient 21 years of
age and older not more frequently than once in a 36-month period. For a MAP
eligible recipient under 21 years of age, one set of corrective lenses is
covered no more frequently than once every 12 months. If a MAP eligible
recipient has transitioned from the EPSDT program at age 21, the date of
service for his or her last corrective lenses starts the 36-month period. For
either age group, MAD covers corrective lenses more frequently when an
ophthalmologist or optometrist recommends a change in prescription due to a
medical condition, including but not limited to cataracts, diabetes,
hypertension, glaucoma or treatment with certain systemic medications affecting
vision. The vision prescription must be appropriately recorded on the MAP
eligible recipient's visual examination record and indicated by a diagnosis on
the claim.
(a) For the purchase of
eyeglasses, the diopter correction must meet or exceed one of the following
diopter correction criteria:
(i) -1.00 myopia
(nearsightedness);
(ii) + 1.00 for
hyperopia (farsightedness);
(iii)
0.75 astigmatism (distorted vision), the combined refractive error of sphere
and cylinder to equal 0.75 will be accepted;
(iv)
±1.00 for presbyopia
(farsightedness of aging); or
(v)
diplopia (double vision) - prism lenses.
(b) When a MAP eligible recipient's existing
prescription is updated and the frequency of replacement lenses meets the
requirements in Paragraph (2) above, the lenses may be replaced when there is a
minimum 0.75 diopter change in the prescription. The combined refractive error
of sphere and cylinder to equal 0.75 will be accepted. An exception is
considered for the following:
(i) a MAP
eligible recipient over 21 years of age with cataracts;
(ii) an ophthalmologist or optometrist
recommends a change due to a medical condition; or
(iii) a MAP eligible recipient is under 21
years of age.
(3) Bifocal lenses: MAD covers bifocal lenses
with a correction of 0.25 or more for distance vision and 1 diopter or more for
added power (bifocal lens correction).
(4) Tinted lenses: MAD covers tinted lenses
with filtered or photochromic lenses if the examiner documents one or more of
the following disease entities, injuries, syndromes or anomalies in the
comments section of the visual examination record, and the prescription meets
the dioptic correction purchase criteria:
(a)
aniridia;
(b) albinism,
ocular;
(c) traumatic defect in
iris;
(d) iris coloboma,
congenital;
(e) chronic
keratitis;
(f) sjogren's
syndrome;
(g) aphakia, U.V. filter
only if intraocular lens is not U.V. filtered;
(h) rod monochromaly;
(i) pseudophakia; or
(j) other diagnoses confirmed by
ophthalmologist or optometrist that is documented in the MAP eligible
recipient's visual examination form.
(5) Polycarbonate lenses: MAD covers
polycarbonate lenses for:
(a) a MAP eligible
recipient for medical conditions which require prescriptions for high power
lenses;
(b) a MAP eligible
recipient with monocular vision;
(c) a MAP eligible recipient who works in a
high-activity physical job;
(d) a
MAP eligible recipient under 21 years of age; or
(e) a MAP eligible recipient 21 years and
older that has a developmental or intellectual disability.
(6) Balance lenses: MAD covers balance lenses
for a MAP eligible recipient under 21 years of age without a prior
authorization in the following situations:
(a)
lenses used to balance an aphakic eyeglass lens; or
(b) a MAP eligible recipient under 21years of
age is blind in one eye and the visual acuity in the eye requiring correction
meets the diopter correction purchase criteria.
(7) Frames: MAD covers frames for corrective
lenses. Coverage for a MAP eligible recipient 21 years of age and older is
limited to one frame in a 36-month period. If a MAP eligible recipient has
transitioned from the EPSDT program at age 21, the date of service of his or
her last frames starts the 36-month period. Coverage for a MAP eligible
recipient under 21 years of age is limited to one frame in a 12-month period
unless:
(a) an ophthalmologist or optometrist
has documented a medical condition that requires replacement; or
(b) other situations that will be reviewed on
a case-by-case basis.
(8) Contact lenses: MAD covers contact
lenses, either the original prescription or replacement, only with a prior
authorization. Coverage for an eligible adult recipient 21 years of age and
older is limited to one pair of contact lenses in a 24-month period, unless an
ophthalmologist or an optometrist recommends a change in prescription due to a
medical condition affecting vision. If a MAP eligible recipient is transition
from the EPSDT program at age 21, the date of service for his or her last
contact lenses starts as the 24-month period. A request for prior authorization
will be evaluated on dioptic criteria or visual acuity, the MAP eligible
recipient's social or occupational need for contact lenses, and special medical
needs. The criteria for authorization of contact lenses are as follows:
(a) the MAP eligible recipient must have a
diagnosis of keratoconus or diopter correction of +/- -6.00 or higher in any
meridian or at least 3.00 diopters of anisometropia; or
(b) monocular aphakics may be provided with
one contact lens and a pair of bifocal glasses.
(9) Replacement: Eyeglasses or contact lenses
that are lost, broken or have deteriorated to the point that, in the examiner's
opinion, they have become unusable to the MAP eligible recipient, may be
replaced. Two items must be documented in the provider's request for the
replacement in addition to being found in the MAP eligible recipient's visual
examination record: The MAP eligible recipient's eyeglasses or contact lens (or
lenses) must meet the diopter correction purchase criterion; and an explanation
of the loss, deterioration or breakage is provided. The following are the
criteria that an MAP eligible recipient must be meet for the replacement of his
or her eyeglasses or contact lenses:
(a) the
MAP eligible recipient is under 21 years of age; or
(b) the MAP eligible recipient is 21 years of
age and older and has a developmental or intellectual disability.
(10) Prisms: Prisms are covered if
medically indicated to prevent diplopia (double vision). Documentation is
required on the MAP eligible recipient's visual examination record.
(11) Lens tempering: MAD covers lens
tempering only on new glass lenses.
(12) Lens edging: MAD covers lens edging and
lens insertion.
(13) Minor repairs:
MAD covers minor repairs to eyeglasses.
(14) Dispensing fee: MAD pays a dispensing
fee to an ophthalmologist, optometrist, or optician for dispensing a
combination of lenses and new frames at the same time. This fee is not paid
when contact lenses are dispensed. The prescription and fitting of contact
lenses is paid to dispensing ophthalmologists and optometrists. Independent
technicians are not approved by MAD to prescribe and fit contact
lenses.
(15) Eye prosthesis: MAD
covers eye prostheses (artificial eyes); see Subsection D below.
B.
Hearing
appliances:
(1) Within specified
limitations, MAD covers the following services when furnished by primary care
provider (PCP), licensed audiologists or by licensed hearing aid dealers:
(a) hearing aid purchase, rental repairs,
hearing aid repair and handling, replacements, and the loan of equipment while
repairs or replacements are made:
(i) binaural
hearing aid fitting will be covered for a MAP eligible recipient with bilateral
hearing loss who is attending an educational institution, seeking employment,
is employed, or for a MAP eligible recipient with a current history of binaural
fitting; or
(ii) binaural hearing
aid fitting will be considered on a case-by-case basis for a MAP eligible
recipient determined to be legally blind;
(b) hearing aid accessories and supplies,
including the batteries required after the initial supply furnished at the time
the hearing aid is dispensed; and
(c) hearing aid insurance against loss and
breakage for up to four years for all purchased hearing aids; hearing aid
insurance is required when the aid is dispensed; four years of hearing aid
insurance is required for:
(i) a MAP eligible
recipient under 21 years of age;
(ii) a MAP eligible recipient residing in a
nursing facility (NF); or
(iii) a
MAP eligible recipient who has a developmental or intellectual
disability;
(d)
replacement of hearing aids is limited to the provisions of the MAP eligible
recipient's hearing aid insurance; the provider is responsible for obtaining
insurance for every hearing aid purchased for a MAP eligible
recipient.
C.
DME, oxygen and medical supplies: MAD covers DME that meets the
MAD definition of DME, the medical necessity criteria, and MAD prior
authorization requirements. MAD covers the repair, maintenance, delivery of
durable medical equipment, and the disposable and non-reusable items essential
for the use of the equipment, subject to the limitations specified in this
rule. All items purchased or rented must be ordered by a provider who has an
approved MAD PPA. Coverage for DME is limited for a MAP eligible recipient in
an institutional setting when the institution is to provide the necessary
items. An institutional setting is a hospital, NF, intermediate care facility
for individuals with intellectual disabilities (ICF-IID), and a rehabilitation
facility. A MAP eligible recipient who is receiving services from a home and
community-based waiver is not considered an institutionalized eligible
recipient. MAD does not cover duplicates of items, for example, a MAP eligible
recipient is limited to one wheelchair, one hospital bed, one oxygen delivery
system, or one of any particular type of equipment. A back-up ventilator is
covered.
(1) DME is defined by MAD as:
(a) equipment that can withstand repeated
use;
(b) primarily and customarily
used to serve a medical purpose;
(c) not useful to an eligible recipient in
the absence of an illness or injury; and
(d) appropriate for use at home.
(2) Equipment used in a MAP
eligible recipient's residence must be used exclusively by the MAP eligible
recipient for whom it was approved.
(3) To meet the medical necessity criterion,
DME must be necessary for the MAP eligible recipient's treatment of an illness,
injury, or to improve the functioning of a specific body part.
(4) Replacement of equipment is limited to
the same extent as it is limited by medicare regulation. When medicare does not
specify a limitation, equipment is limited to one item every three years unless
there are changes in the MAP eligible recipient's medical necessity or as
otherwise indicated in this rule.
(5) Medical supplies: MAD covers medical
supplies that are necessary for an ongoing course of treatment within the
limits specified in this section. As distinguished from DME, medical supplies
are disposable and non-reusable items.
(a) A
provider or medical supplier that routinely supplies an item to a MAP eligible
recipient must document that the order for additional supplies was requested by
the MAP eligible recipient or his or her authorized representative and the
provider or supplier must confirm that the MAP eligible recipient does not have
in excess of a 15-calendar day supply of the item before releasing the next
supply order. A provider must keep documentation in its files available for
auditing that shows compliance with this requirement.
(b) MAD coverage for DME and medical supplies
is limited for a MAP eligible recipient in an institutional setting when the
institution is to provide the necessary items. An institutional setting is a
hospital, NF, ICF-IID, and a rehabilitation facility.
(6) Covered services and items: MAD covers
the following items without prior authorization for both an institutionalized
and non-institutionalized MAP eligible recipient:
(a) trusses and anatomical supports that do
not need to be made to measure;
(b)
family planning devices;
(c)
repairs to DME and replacement parts if a MAP eligible recipient owns the
equipment for which the repair is necessary and the equipment being repaired is
a covered MAD benefit; some replacement items used in repairs may require prior
authorization; see Section 13 of this rule;
(d) repairs to augmentative and alternative
communication devices require prior authorization;
(e) monthly rental includes monthly service
and repairs; and
(f) replacement
batteries and battery packs for augmentative and alternative communication
devices owned by the MAP eligible recipient.
(7) Covered services for a
non-institutionalized MAP eligible recipient: MAD covers certain medical
supplies, nutritional products and DME provided to a non-institutionalized MAP
eligible recipient without prior authorization. Monthly allowed quantities of
items are limited to the same extent as limited by medicare regulation. When
medicare does not specify a limitation, an item is limited to a reasonable
amount as defined by MAD and published in its DME and medical supplies billing
instructions which are available on the HSD/MAD website. MAD covers the
following for a non-institutionalized MAP eligible recipient:
(a) needles, syringes and intravenous (IV)
equipment including pumps for administration of drugs, hyper-alimentation or
enteral feedings;
(b) diabetic
supplies, chemical reagents, including blood, urine and stool testing
reagents;
(c) gauze, bandages,
dressings, pads, and tape;
(d)
catheters, colostomy, ileostomy and urostomy supplies and urinary drainage
supplies;
(e) parenteral
nutritional support products prescribed by a PCP on the basis of a specific
medical indication for a MAP eligible recipient who has a defined and specific
pathophysiologic process for which nutritional support is considered
specifically therapeutic and for which regular food, blenderized food, or
commercially available retail consumer nutritional supplements would not meet
the MAP eligible recipient's medical needs;
(f) apnea monitors: prior authorization is
required if the monitor is needed for six months or longer; and
(g) disposable gloves (sterile or
non-sterile) are limited to 200 per month.
(8) Covered oxygen and oxygen administration
equipment: MAD covers the following oxygen and oxygen administration systems,
within these specified limitations:
(a) oxygen
contents, including oxygen gas and liquid oxygen;
(b) oxygen administration equipment purchase
with prior authorization; oxygen administration equipment may be supplied on a
rental basis for one month without prior authorization; rental beyond the
initial month requires a prior authorization;
(c) oxygen concentrators, liquid oxygen
systems and compressed gaseous oxygen tank systems. MAD approves the most
economical oxygen delivery system available that meets the medical needs of the
MAP eligible recipient;
(d)
cylinder carts, humidifiers, regulators and flow meters;
(e) purchase of cannulae or masks;
and
(f) oxygen tents and croup or
pediatric tents.
(g) MAD does not
cover oxygen tank rental (demurrage) charges as separate charges when renting
gaseous tank oxygen systems. If MAD pays rental charges for a system, tank
rental is included in the rental payments. MAD follows the medicare rules for:
(i) limiting or capping reimbursement for
oxygen rental at 36 months;
(ii)
requirements for the provider to maintain and repair the equipment; and
(iii) to providing ongoing services
and disposable supplies after the capped rental;
(h) a NF is administratively responsible for
overseeing oxygen supplied to the MAP eligible recipient resident.
(9) Augmentative and alternative
communication devices: MAD covers medically necessary electronic or manual
augmentative communication devices for a MAP eligible recipient. Medical
necessity is determined by MAD or its designee. Communication devices whose
purpose is also educational or vocational are covered only when it has been
determined the device meets medical criteria. A MAP eligible recipient must
have the cognitive ability to use the augmentative communication device, and
not be able to functionally communicate verbally or through gestures.
(a) All of the following criteria must be met
before an augmentative communication device can be considered for prior
authorization. The communication device must be:
(i) a reasonable and necessary part of the
MAP eligible recipient's treatment plan;
(ii) consistent with the MAP eligible
recipient's symptoms, diagnosis or medical condition of the illness or injury
under treatment;
(iii) not
furnished for the convenience of the MAP eligible recipient, the family, the
attending practitioner or other practitioner or supplier;
(iv) necessary and consistent with generally
accepted professional medical standards of care;
(v) established as safe and effective for the
MAP eligible recipient's treatment protocol;
(vi) furnished at the most appropriate level
suitable for use in the MAP eligible recipient's home environment;
(vii) augmentative and alternative
communication devices are authorized every 60 months for a MAP eligible
recipient 21 years of age and older and every 36 months for a MAP eligible
recipient under 21 years of age, unless earlier authorization is dictated by
medical necessity; and
(viii)
repairs to, and replacement parts for augmentative and alternative
communication devices owned by the MAP eligible recipient.
(10) Rental of DME: MAD covers the
rental of DME.
(a) MAD does not cover routine
maintenance and repairs for rental equipment as it is the provider's
responsibility to repair or replace the MAP eligible recipient's equipment
during the rental period.
(b) Low
cost items, defined as those items for which the MAD allowed payment is less
than $150, may only be purchased. For these items, the purchased DME becomes
the property of the MAP eligible recipient for whom it was approved.
(c) MAD covers the rental and purchase of
used equipment. The equipment must be identified and billed as used equipment.
The equipment must have a statement of condition or warranty, and a stated
policy covering liability.
(11) Delivery of equipment and shipping
charges: MAD covers the delivery of a DME item only when the equipment is
initially purchased or rented and the round trip delivery is over 75 miles. A
provider may bill delivery charges as a separate additional charge when the
provider customarily charges a separate amount for delivery to its clients who
are not a MAP eligible recipient of the service. MAD does not pay delivery
charges for equipment purchased by medicare, for which MAD is responsible only
for the coinsurance and deductible. MAD covers the shipping charges for DME and
medical supplies when it is more cost effective or practical to ship items to
the MAP eligible recipient rather than have him or her travel to pick up items.
Shipping charges are defined as the actual cost of shipping an item from a
provider to a MAP eligible recipient by a means other than that of provider
delivery. MAD does not pay shipping charges for an item purchased by medicare
for which MAD is only responsible for the coinsurance and deductible.
(12) Wheelchairs and seating systems:
(a) MAD covers customized wheelchairs and
seating systems made for a specific MAP eligible recipient, including a MAP
eligible recipient who is institutionalized. Written prior authorization is
required by MAD or its designee. MAD or its designee cannot give verbal
authorizations for customized wheelchairs and seating systems. A customized
wheelchair and seating system is defined as one that has been uniquely
constructed or substantially modified for a specific MAP eligible recipient and
is so different from another item used for the same purpose that the two items
cannot be grouped together for pricing purposes. There must be a customization
of the frame for the wheelchair base or seating system to be considered
customized.
(b) Repairs to a
wheelchair owned by a MAP eligible recipient residing in an institution are
covered.
(c) A customized or
motorized wheelchair required by a MAP eligible recipient who is
institutionalized to pursue educational or employment activity outside the
institution may be covered, but must be reviewed on a case-by-case basis by MAD
or its designee.
D. Prosthetics and orthotics supplies: MAD
covers medically necessary prosthetics and orthotics supplied by a MAD provider
to a MAP eligible recipient only when specified requirements or conditions are
satisfied. Prosthetic devices are replacements or substitutes for a body part
or organ, such as an artificial limb or eye prosthesis. Orthotic devices
support or brace the body, such as trusses, compression custom-fabricated
stockings and braces. MAD covers prosthetics and orthotics only when all the
following conditions are met:
(1) the device
has been ordered by the MAP eligible recipient's PCP or other appropriate
practitioner and is medically necessary for MAP eligible recipient's mobility,
support or physical functioning;
(2) the need for the device is not satisfied
by the existing device the MAP eligible recipient currently has;
(3) the device is covered by MAD and all
prior approval requirements have been satisfied;
(4) coverage of compression stockings for a
MAP eligible recipient 21 years and older is limited to stockings that are
custom-fabricated to meet his or her medical needs;
(5) coverage of orthopedic shoes for a MAP
eligible recipient 21 years and older is limited to the shoe that is attached
to a leg brace;
(6) replacement of
items is limited to one item every three years, unless there is a change in the
MAP eligible recipient's medical necessity; and
(7) therapeutic shoes furnished to a diabetic
is limited to one of the following within one calendar year:
(a) no more than one pair of custom-molded
shoes (including inserts provided with such shoes) and two additional pairs of
inserts; and
(b) no more than one
pair of depth shoes and three pairs of inserts (not including the
non-customized removable inserts provided with such shoes).