Current through Register Vol. 35, No. 18, September 24, 2024
A.
Notice:
(1) MAD or its UR contractor shall issue a
"notice of action" to an individual when it intends to take an adverse action
against an individual. When the notice of action relates to a reduction or
termination of a service, LOC, or another benefit the individual already
receives, the notice of action shall be sent not less than 10 calendar days
prior to the date of MAD's or its UR contractor's intended adverse
action.
(2) The MCO appeal process
is governed by and set forth in detail in 8.308.15 NMAC.
B.
Exceptions to a notice of
action: Notwithstanding the notice requirement set forth in the
preceding subsection, MAD, its UR contractor or the MCO may mail a notice of
action to the individual or the individual's authorized representative or
estate (in the event of an individual's death) no later than the actual date of
the intended adverse action when:
(1) MAD, its
UR contractor or the MCO has confirmed the death of the individual;
(2) MAD, its UR contractor or the MCO has
received a clear written statement signed by the individual or the individual's
authorized representative that all or a portion of an authorized service is no
longer wanted;
(3) the individual
or the individual's authorized representative provides information to MAD, its
UR contractor or the MCO that indicates his or her understanding that such
information may require MAD, its UR contractor or the MCO to take the adverse
action;
(4) MAD, its UR contractor
or the MCO learns the individual is residing in an institution, which renders
the individual ineligible for MAP enrollment and MAD services;
(5) MAD, its UR contractor or the MCO cannot
determine the physical location of either the individual, or if designated, his
or her authorized representative;
(6) MAD, its UR contractor or the MCO has
established that the individual has been accepted for medicaid services outside
of the state; or
(7) the primary
care provider for the individual has prescribed a change in his or her
LOC.
C.
Time
limits: An individual or his or her authorized representative must
adhere to the time limits for requesting both a continuation of a benefit and a
HSD administrative hearing.
(1) Requesting a
HSD administrative hearing: an individual who is not enrolled in a MCO has 90
calendar days from the date of the "notice of action" to request a HSD
administrative hearing. To be considered timely, the request must be received
by FHB, the individual's local income support division (ISD) office or by the
MAD director's office no later than the close of business on the 90th calendar
day immediately following the date of the notice of action. If the request for
a HSD administrative hearing is mailed by the individual, the request must be
postmarked by the 90th calendar day from the date of the notice of action. For
a member of a MCO, see 8.308.15 NMAC for detailed description of the MCO appeal
process.
(2) Continuation of a
benefit:
(a) An individual who is not a member
of a MCO, may request that the benefit that is the subject of an adverse action
continue while his or her HSD administrative hearing proceeds. A request for a
continuation of the benefit shall be accorded to any claimant who requests the
continuation within 10 calendar days of the mailing of the notice of action by
MAD or its UR contractor. The continuation of a benefit is only available to an
individual that is currently receiving the appealed benefit and will be the
same as the individual's current allocation, budget or LOC. MAD or its UR
contractor must provide information in its notice of action of an individual's
rights and limitations to continue a benefit during his or her HSD
administrative hearing process and of the responsibility to repay MAD for the
continued benefit if the HSD administrative hearing final decision is against
the individual.
(b) A member of a
MCO must follow his or her MCO appeal process. The member may request the
benefit that is the subject of an adverse action continue while his or her MCO
appeal process proceeds. A request for a continuation of a benefit shall be
accorded to any member who requests the continuation within 10 calendar days of
his or her MCO's mailing of the notice of action. The continuation of a benefit
is only available to a member that is currently receiving the appealed benefit.
The continuation of the benefit will be the same as the member's current
allocation, budget or LOC. The MCO must provide information in its notice of
action of a member's rights and limitations to continue a benefit during his or
her MCO appeal process and of the responsibility to repay the MCO for the
continued benefit if the MCO final appeal decision is against a member and, if
the member requests a HSD administrative hearing, its final decision is also
against the member as a claimant. The MCO appeal process is outlined in
8.308.15 NMAC.
(3) For a
member who is enrolled in a MCO and who is dissatisfied with the MCO's final
appeal process, the time limit to request a HSD administrative hearing is 30
calendar days following the MCO's final decision of his or her appeal.
(a) Upon requesting a HSD administrative
hearing within this time limit, the member is referred to as the claimant and
is governed by the remaining sections of this rule.
(b) If the member had a continuation of his
or her benefit during the MCO appeal process, the claimant automatically
maintains his or her continuation of the benefit throughout the remaining HSD
administrative hearing process. If the claimant or the claimant's authorized
representative opts to discontinue his or her benefit during the HSD
administrative hearing process, the claimant or the claimant's authorized
representative must contact the MCO to end services.
(4) The HSD administrative hearing is
concluded within 90 calendar days from the date the claimant or the claimant's
authorized representative requests a HSD administrative hearing unless the
claimant or the claimant's authorized representative agrees to extend the HSD
administrative hearing time frame in order to facilitate the process.
D.
Dismissal of a hearings
request: HSD authorizes FHB to issue a dismissal of a claimant or
member's request for a HSD administrative hearing when:
(1) the request is not received within the
time periods specified in the rules and notice of action, or if the claimant is
a MCO member and the member has not followed or exhausted the appeal process
available under the MCO;
(2) the
request is withdrawn or cancelled in writing by the individual or the
individual's authorized representative;
(3) the sole issue presented concerns a
federal or state statue, regulation or rule requiring an adjustment of benefits
for all or certain classes of individuals, including, but not limited to, a
termination, modification, reduction, or suspension of a service;
(4) the same issue involving the individual
has already been subject to a final decision by the MAD director following a
HSD administrative hearing;
(5) the
sole issue presented is regarding a New Mexico administrative code (NMAC) rule
rather than the application of the rule to the claimant or the member;
or
(6) the claimant, the member, or
the authorized representative fails to appear telephonically or in person at a
scheduled hearing without good cause at which time a HSD administrative hearing
may be considered abandoned and therefore dismissed. However, if the claimant
or the claimant's authorized representative presents to the ALJ good cause for
failure to appear within 10 calendar days after the date of the scheduled HSD
administrative hearing, the HSD administrative hearing may be rescheduled. Good
cause includes a death in the family, a disabling personal illness or another
significant emergency or at the discretion of the ALJ, as appropriate, another
exceptional circumstance. If the ALJ determines that the claimant or the
claimant's authorized representative has shown good cause, the HSD
administrative hearing will be rescheduled.
(7) When an ALJ dismisses a claimant's
request for a HSD administrative hearing, that decision becomes HSD's
administrative hearing final decision. A claimant may elect to then file a
state district court judicial appeal.