New Mexico Administrative Code
Title 8 - SOCIAL SERVICES
Chapter 325 - SPECIALTY SERVICES
Part 9 - HOME HEALTH SERVICES
Section 8.325.9.12 - ELIGIBLE RECIPIENTS

Universal Citation: 8 NM Admin Code 8.325.9.12

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

A. Recipients must have a medical need to receive care at home to be eligible for home health agency services and must be certified as such by their attending physicians. A medical need to receive care at home means that the recipient has a condition caused by illness or injury which renders him/her unable to leave the home to obtain necessary medical care and treatment (i.e., is essentially homebound) or that the medical need for care at home is more appropriate and cost-effective and will prevent or delay institutionalization. Recipients do not need to be bedridden to be considered as having a medical need to receive care at home. Recipients may be considered eligible to receive care at home if they meet one or more of the following criteria:

(1) recipients who cannot leave their residences without the use of wheelchairs, crutches, walkers or assistance from another individual;

(2) recipients who because of severe physical or mental illness or injury must comply with doctor's orders and avoid all stressful physical activity;

(3) recipients who cannot leave their residences because of danger caused by a mental condition;

(4) recipients who have just returned to their residence after hospital stays for severe illness or surgical procedures and whose activities are restricted by their physicians because of pain, suffering, medical limitation or danger of infection.;

(5) recipients who are at high risk during pregnancy, infancy or childhood and for whom home health care is more appropriate to their needs.

(6) recipients are not eligible to receive care at home just because they:
(a) cannot drive,

(b) have multiple medical problems or

(c) live in an isolated area.

B. Infrequent periods away from residence: Recipients can leave their residences occasionally for medical treatment or personal errands and be eligible to receive home health care.

C. Determination of medical need to receive care at home: MAD or its designee reviews information submitted by the provider and determines whether recipients are considered eligible for home health service. Coverage is granted when the home health agency can demonstrate that care at home is appropriate to the medical needs of the recipient, the needed service is not otherwise available, and not receiving care would result in lack of access to health care services, institutionalization of the recipient and greater costs to the medicaid program.

D. Documentation of medical need to receive care at home: The home health agency is responsible for documenting on the written plan of care evidence of the recipient's medical need for home health care.

Disclaimer: These regulations may not be the most recent version. New Mexico may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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