N.M. Admin. Code § 8.280.400.11

Current through Register Vol. 35, No. 23, December 10, 2024

Section 8.280.400.11 - APPLICANT AND RECIPIENT REQUIREMENTS

Applicants must live within the designated PACE service area and meet all of the criteria listed below at the time of application and enrollment.

A. Applicants must be 55 years of age or older. Applicants/recipients must be determined blind or disabled if under the age of 65 years.

(1) To be considered blind, an applicant/recipient must have central visual acuity of 20/200 or less with corrective lenses or must be considered blind for practical purposes.

(2) To be considered disabled, an applicant/recipient must be unable to engage in any substantial gainful activity, because of any medically determinable physical, developmental, or mental impairment which has lasted, or is expected to last, for a continuous period of at least 12 months.

(3) If a determination of blindness or disability has not been made, the income support division worker will submit medical reports to the disability determination unit.

B. Level of care requirements must be met in addition to all other requirements. An applicant or recipient must be eligible for institutional nursing facility level of care as determined by the medical assistance division (MAD) utilization review contractor. An institutional level of care must be recommended for the applicant or recipient by a PACE physician licensed to practice medicine or osteopathy in the state of New Mexico. Institutions are defined as acute care hospitals, nursing facilities (either high NF or low NF as defined by medicaid regulations) and intermediate care facilities for individuals with intellectual disabilities (ICF/IID). Level of care determinations are performed by the MAD utilization review contractor. Level of care for approved recipients will be determined on an annual basis.

C. An interview is not required in accordance with 8.281.400.11 NMAC.

D. Upon enrollment, applicants must be able to live in a community setting without jeopardizing their individual health and safety. The ability to live safely in the home and community is determined by the PACE organization's interdisciplinary team.

N.M. Admin. Code § 8.280.400.11

8.280.400.11 NMAC - Rp, 8 NMAC 4.PAC.420, 12-1-06, Adopted by New Mexico Register, Volume XXIX, Issue 24, December 27, 2018, eff. 1/1/2019, Amended by New Mexico Register, Volume XXXII, Issue 02, January 26, 2021, eff. 2/1/2021, Amended by New Mexico Register, Volume XXXII, Issue 24, December 28, 2021, eff. 1/1/2022