N.M. Admin. Code § 8.291.400.13

Current through Register Vol. 35, No. 21, November 5, 2024

Section 8.291.400.13 - PRESUMPTIVE ELIGIBILITY

Presumptive eligibility (PE) provides medicaid benefits under one of the eligible groups outlined in Subsection B of 8.291.400.10 NMAC, starting with the date of the PE determination and ending with the last day of the following month or, if an ongoing application is submitted at the time the PE is granted or at any time during the approved PE period, the PE will remain open until the ongoing application is approved or denied.

A. Only one PE approval is allowed per pregnancy or per 12-month period for other ACA related categories.

B. Determinations can only be made by individuals employed by eligible entities and certified as presumptive eligibility determiners (PEDs) by the medical assistance division (MAD).

(1) Processing PE information: PEDs must notify MAD within 24 hours of the determination of presumptive eligibility.

(2) PE: The PED must process the presumptive eligibility and encourage clients to submit an ongoing application for medicaid eligibility. If the client elects to do so, the PED must assist the client with the submission of an application for medical assistance.

(3) Provider eligibility: Entities who may participate in the PE program must be:

(a) a qualified hospital that participates as a provider under the medicaid state plan or a medicaid 1115 demonstration who notifies the medicaid agency of its election to make presumptive eligibility determinations and agrees to make PE determinations consistent with state policies and procedures; or

(b) an entity or provider that has not been disqualified by the medicaid agency for failure to make PE determinations in accordance with applicable state policies and procedures or for failure to meet any standards that may have been established by the medicaid agency; or

(c) a federally qualified health center (FQHC), an Indian health service (IHS) facility, a state of New Mexico agency, a school, or a head start agency or a primary care provider who is contracted with at least one HSD contracted MCO; or

(d) other entities HSD has determined as an eligible presumptive participant.

C. PE approval limitations:

(1) all MAD authorized PE determiners can approve PE for children and pregnant women ACA categories;

(2) hospitals opting to participate in the PE program and correctional facilities (state prisons and county jails), health facilities operated by the Indian health service, a tribe, or tribal organization or an urban Indian organization can approve PE for all ACA related categories.

D. If, at the time of a PE approval, the client agrees to submit an application for ongoing coverage, the PED must submit the application within ten days of the PE approval.

E. A pregnant individual who has been approved for PE can receive ambulatory prenatal care during the PE approval period as defined in 8.291.400.13 NMAC.

(1) For PE, an approved PED must accept self-attestation of pregnancy.

(2) The needs and income of the unborn child(ren) are considered when determining the woman's countable family size.

N.M. Admin. Code § 8.291.400.13

8.291.400.13 NMAC - Rp, 8.291.400.13 NMAC, 1-1-14, Adopted by New Mexico Register, Volume XXVIII, Issue 18, September 26, 2017, eff. 10/1/2017, Amended by New Mexico Register, Volume XXXIII, Issue 07, April 5, 2022, eff. 4/5/2022