N.M. Admin. Code § 8.308.14.10

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

Section 8.308.14.10 - MEMBER RIGHTS AND RESPONSIBILITIES

A. When a MAD benefit has a co-payment assigned for a MAP category of eligibility, the eligible recipient will at the time of service make payment or make arrangements with the provider for payment at a later date.

B. A member shares the responsibility to track his or her co-payments for each quarter. The member has the right to request from his or her MCO at any time an account of his or her household's co-payment total per quarter. If the member believes he or she has met the household's out-of-pocket (OOP) limit, he or she may request that the provider wait to charge future co-payments if the member has contacted his or her MCO to determine if the OOP limit has been met.

C. If a member had reached his or her household OOP limit but was not aware of it at the time the member paid a co-payment, the provider must refund the member the co-payment.

(1) The provider must refund the member within 10 working days after the member requests a reimbursement of the paid co-payment or the member's MCO notifies the provider that the member's OOP limit has been met.

(2) The member may notify verbally or in writing his or her MCO of the provider's failure to refund the co-payment within the required timeframe.

(3) Failure of the MCO to intervene to have its contracted provider refund the co-payment within 10 working days of the member notifying the MCO constitutes a MCO adverse action and the member may file a MCO appeal and if applicable, a HSD administrative hearing. See 8.308.15 and 8.352.2 NMAC for detailed information.

(4) The member may also contact the HSD office of inspector general after he or she has complied with Paragraph (2) and (3) above to report the provider's refusal to refund the member's co-payment as such action may result in a credible allegation of fraud.

N.M. Admin. Code § 8.308.14.10

8.308.14.10 NMAC - N, 1-1-14, Adopted by New Mexico Register, Volume XXVIII, Issue 18, September 26, 2017, eff. 10/1/2017