N.M. Admin. Code § 8.291.400.14

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

Section 8.291.400.14 - PREGNANT INDIVIDUALS ELIGIBLE FOR EXTENDED OR CONTINUOUS ELIGIBILITY (42 CFR 435.170)

A. Extended eligibility for pregnant individuals: For a pregnant individual who was eligible and enrolled for mandatory or optional coverage under the state plan on the date their pregnancy ends (regardless of the reason the pregnancy ends), HSD provides full medicaid coverage through the last day of the month in which the 12-month postpartum period ends.

B. Continuous eligibility for pregnant individuals: For a pregnant individual who was eligible and enrolled for mandatory or optional coverage under the state plan and who, because of a change in circumstance (e.g., income, household, composition, aging out etc.), will not otherwise remain eligible, HSD provides full medicaid coverage through the last day of the month in which the 12-month postpartum period ends.

(1) The following populations are provided continuous eligibility effective April 1, 2022:

(a) Current medicaid recipients who are pregnant as of April 1, 2022 or who enroll based on pregnancy or become pregnant after April 1, 2022.

(b) Current medicaid recipients who are receiving medicaid while pregnant and who are no longer pregnant as of April 1, 2022, but who are still within a 12-month postpartum period; and

(c) Individuals who apply for medicaid after their pregnancy ends, who received medicaid-covered services while pregnant on or after April 1, 2022 if such services were received during an approved period of retroactive eligibility.

(2) The following applies to certain categories or individuals:

(a) An individual approved on the other adult category who becomes pregnant may remain on the adult category and receive services under the alternative benefit plan (ABP). The ABP is considered full benefits for the purpose of the 12-month extended postpartum period. An individual on the other adult category who becomes pregnant may also transition to another full coverage medicaid category such as pregnant women or parent/caretaker and will remain eligible until their 12-month postpartum period expires.

(b) Children turning age 19 aging out of a children's medicaid category will remain on a children's medicaid category until their 12-month postpartum period expires.

(c) An individual covered on the parent/caretaker category during a 12-month postpartum period and who has increased earnings or spousal support above the parent/caretaker category limit will remain on the parent/caretaker category until their 12-month postpartum period expires and then can transition to a four or 12-month transitional medical assistance period.

(d) An individual who becomes pregnant during the 12-month postpartum period is entitled to 12-months continuous coverage through the end of the second pregnancy and the 12-month postpartum period following.

(e) The extended 12-month postpartum period applies to individuals receiving medicaid who are lawfully residing children under age 21 and pregnant individuals referred to as "CHIPRA 214".

C. Renewals: Medicaid renewals are conducted at the end of the individual's 12-month postpartum period. Individuals remain enrolled in the eligibility group in which the individual was enrolled during pregnancy through the end of the 12-month postpartum period as described in Subsection C of 8.291.400.14 NMAC.

D. There is not extended or continuous medicaid eligibility for a pregnant individual covered during a presumptive eligibility period under section 1920 of the ACT.

E. An individual's eligibility may not be terminated during a continuous eligibility period, regardless of any changes in circumstances, unless:

(1) the individual or their representative requests a voluntary termination of eligibility;

(2) the individual ceases to be a resident of New Mexico;

(3) eligibility was determined incorrectly at the most recent determination or redetermination of eligibility because of HSD error or fraud, abuse, or perjury attributed to the individual; or

(4) the individual dies.

N.M. Admin. Code § 8.291.400.14

Adopted by New Mexico Register, Volume XXXIII, Issue 07, April 5, 2022, eff. 4/5/2022