OVERVIEW OF PROGRAMS

The Medical Assistance Division (MAD) of the state Human Services Department (HSD) is responsible for direct administration of the Medicaid program.  As part of this responsibility, the division administers the SALUD! Medicaid Managed Care program.

Eligibility is determined by local offices of the Income Support Division (ISD) and the Social Security Administration, except for those categories administered by the Children, Youth and Families Department and the Department of Health.

MEDICAID

Categories for Adults

Pregnant Women

Meet Aid to Families with Dependent Children (AFDC) requirements.

Eligible for full range of covered services.

Pregnant Women and Women of Childbearing Age

Income cannot exceed 185% of FPL.
No resource limit.

Pregnant women may be eligible for pregnancy-related services only.
Women of childbearing age may be eligible for family planning services.

Authorized providers make presumptive eligibility determinations for pregnancy-related services only.

Breast or Cervical Cancer

Must be under age 65, uninsured and have met the screening criteria as set forth in the Centers for Disease Control and Prevention’s (CDC) National Breast and Cervical Cancer Early Detection Program (NBCCEDP).

The New Mexico Department of Health is responsible for verifying that women referred for treatment have met screening requirements that include an income test and diagnostic testing by a contracted CDC provider that results in a diagnosis of breast or cervical cancer including pre-cancerous conditions.

The Department of Health is responsible for income screening.

Medical Assistance for Refugees

There are four scenarios under which Refugee Medical Assistance can be approved:
·         Applicant meets AFDC standard of need when the earned income disregard is applied;
·         Applicant meets all criteria for refugee cash assistance but wishes to receive only refugee medical assistance;
·         Four month refugee medical assistance extension when eligibility for refugee cash assistance is lost due to earned income; or
·         Spend down category

Provides Medicaid coverage for low-income refugees.

Coverage is limited to a maximum of eight months from the date the individual enters the U.S.

Emergency Medical Services for Undocumented Aliens

Must meet all eligibility criteria for an existing Medicaid category except for their alien status.

Coverage for emergency services is provided.

The individual must receive bona fide emergency medical services and have been referred to the local Income Support Division (ISD) office by the provider.  If s/he is found eligible by ISD, s/he must notify the provider so that claim can be submitted to the department’s utilization review (UR) contractor.  Coverage is available only for emergencies approved by the UR contractor and only for the duration of the specific emergency.

Categories for Families/Children

Children under age 19

Income cannot exceed 185% of FPL.

Full Medicaid coverage up to age 19.

Newborn babies

Born to mothers eligible for and receiving Medicaid, or to mothers determined to have been eligible for and receiving Medicaid at the time of birth.

Full Medicaid coverage for one year.

Babies are eligible for one year as long as the mother remains eligible for Medicaid (or would be eligible if she were still pregnant) and the child remains with the mother.

Both mother and child must continue to reside in New Mexico.

Foster Care and Adoption Subsidy

To be eligible on the basis of income, a child in substitute care placement must have an income below the maximum Category 002 standard of need for one person.

Provides Medicaid for children in state substitute care programs and in adoption subsidy situations.

The Children, Youth and Families Department makes eligibility determinations for these categories.

TANF

JUL Medicaid for families with dependent children

TANF criteria with certain exceptions.
No resource limit.

TANF program is known as New Mexico Works (NMW).

Continuous Medicaid coverage

Must have been receiving JUL Medicaid for one month out of last 6 months.

Provides continuous Medicaid coverage for four months when Medicaid for Families with Dependent Children eligibility is lost due to increased child support.

Transitional Medicaid

Must have been receiving JUL Medicaid.

Provides twelve months of Medicaid for families who lose eligibility forMedicaid for Families with Dependent Children due to increased earnings or loss of the earned income disregard.

Category 033

Otherwise eligible for JUL Medicaid, except that income derived from a stepparent, grandparent, or sibling results in Medicaid for Families with Dependent Children ineligibility.

Medically Needy/Spend Down

Only refugees are eligible under this category

Elderly/Disabled

Supplemental Security Income (SSI)
·         Aged
·         Blind
·         Disabled

Eligibility for Medicaid is based on eligibility for SSI.
The maximum monthly income benefits are $552 for an individual and $829 for a couple.
Resource limits are $2,000 for an individual and $3,000 for a couple.

The Social Security Administration (SSA) determines eligibility for these categories.

If the applicant is a minor child, a certain portion of the parents’ income is considered available to the child.
A burial fund of up to $1,500 is excludable.

Category 034

Otherwise eligible for SSI, except for income/resources deemed from a stepparent.

Institutional Care Medicaid
·         Aged
·         Blind
·         Disabled

Income limit is currently $1,636.
Resource limit is $2,000.

These categories are designated for individuals requiring institutional care in nursing facilities (NF) designated as High NFs or Low NFs, Intermediate Care Facilities for the Mentally Retarded (ICF/MR) or acute care hospitals.

Individuals with less than $50 in income must apply for SSI.

For married applicants, special income and resource rules apply.  An amount up to $90,660 of the couple’s resources can be protected for the non-institutionalized spouse when one member of the couple begins institutionalization for a continuous period of at least 30 days on or after January 1, 2003.  Different resource criteria apply depending on when the applicant is institutionalized.

After being approved, a patient liability or “medical care credit” is calculated and is paid to the institution to defray the cost of institutional care.  A certain portion of the recipient’s income is allowed for personal needs ($49); non-covered medical expenses (up to $54 and actual health insurance premiums); and an allowance for maintenance of spouse and dependents at home.

Home and Community-Based Waivers
·         HIV/AIDS
·         Disabled and Elderly – Age 65 and Older
·         Disabled and Elderly – Blind
·         Disabled and Elderly – Disabled
·         Medically Fragile
·         Developmentally Disabled

Income and resource limits are the same as for Institutional Care Medicaid.

Recipients in these programs are individuals who qualify both financially and medically for institutional care but who remain in the community.

The Department of Health must determine that adequate care can be provided to the individual in the community at a lesser cost than in an institutional setting.

Qualified Medicare Beneficiaries (QMBs)

Income cannot exceed 100% of FPL (currently $739 for an individual and $995 for a married couple).
Resource limit is $4,000 for an individual and $6,000 for a couple (twice the SSI limit).

Entitles individuals to payment of Medicare premiums as well as the deductible and coinsurance amounts on Medicare-covered services. 

To be eligible, the applicant must already have, or be conditionally eligible for Medicare Part A. May not exist with any other Medicaid category.

Specified Low-income Medicare Beneficiaries (SLIMBSs)/Qualified Individuals (QI-1s)

SLIMB income must be greater than 100% but not exceeding 120% of FPL (currently $739.01 to $886 for an individual and $995.01 to $1,194 for a couple).
QI-1 income must be greater than 120% but not exceeding 135% of FPL (currently $886.01 to $997 for an individual and $1,194.01 to $1,344 for a couple).
Resource limit for both SLIMB and QI-1 is $4,000 for an individual and $6,000 for a couple (twice the SSI limit).

Individuals who qualify for this program have their Medicare Part B premiums paid by Medicaid.

The applicant must be enrolled in Medicare Part A.  Medicaid does not pay the Medicare Part A premium.  Since payment of the Medicare Part B premium in the only benefit, no Medicaid card is issued.

Qualified Disabled Working Individuals (QDs)

Income cannot exceed 200% of FPL (currently $1,477 for an individual and $1,990 for an applicant couple or an applicant with an ineligible spouse when income is deemed.
Resource limit is $4,000 for one person and $6,000 for a couple (twice the SSI limit).

Medicaid will pay for the Medicare Part A premium for individuals who qualify for this program.  No other benefits are provided and no Medicaid card is issued.

These individuals must have lost entitlement to free Part A due to substantial gainful employment.  They must, however, continue to meet the Social Security Administration’s definition of disability and be enrolled for premium Part A.

Working Disabled Individuals (WDIs)

Must meet the Social Security Administration’s criteria for disability without regard to “substantial gainful activity” or must be earning less than 250% of FPL after applicable disregards have been deducted.

Disabled individuals, who, because of earnings or excess income, do not qualify for Medicaid under any other programs for disabled individuals, may be eligible for this program.

The program will cover those individuals with a recent attachment to the work force.  An individual is considered to have a recent attachment to the work force if s/he 1) has enough earnings in a quarter to meet the SSA’s definition of a qualifying quarter, or 2) has lost SSI and Medicaid due to the initial receipt of Social Security Disability Insurance (SSDI) benefits, until Medicare entitlement.

Medicaid Extension:

The “Pickle Amendment” extends coverage to people who meet SSI eligibility criteria when Social Security cost-of-living increases are disregarded.

Public Law 100-203 extends Medicaid eligibility to widow(er)s between the ages of 60 and 64 who lose SSI eligibility due to receipt of or an increase in early widow(er)’s Title II benefits.  Eligibility terminates when the individual becomes eligible for Medicaid Part A.

Public Law 99-243, Section 6 extends Medicaid eligibility to certain disabled adult children (DAC) who lose SSI eligibility due to receipt of or increase in Title II DAC benefits.

The Omnibus Budget Reconciliation Act of 1990 extends Medicaid coverage to certain disabled widow(er)s and disabled surviving divorced spouses who lose SSI eligibility due to receipt of or increase in disabled widow(er)’s/disabled surviving divorced spouse’s Title II benefits.  Medicaid eligibility terminates when the individual becomes eligible for Medicare Part A.

The state has also opted to extend Medicaid eligibility to non-institutionalized individuals who lose SSI eligibility because the amount of their initial Title II benefit exactly equals the income ceiling for the SSI program.

Individuals who lose SSI eligibility for other reasons may qualify for up to two months of extended Medicaid eligibility to give them the opportunity to apply under one of the other categories of coverage.

The enactment of the 1997 Balanced Budget Act requires that children who lose SSI/Medicaid due to behavior-related disability criteria continue to receive Medicaid coverage.  The children will be eligible until they reach the age of 18 if they continue to meet all other SSI eligibility criteria.

CHIP

Children under age 19

Countable income of the family is between 185% and 235% of FPL.
No resource limit.

In order to be eligible for CHIP, a child cannot have other health insurance coverage.  A child whose health insurance was voluntarily dropped is ineligible for CHIP for six months, starting from the first month the health care coverage was dropped.

Children are eligible for a continuous period of twelve months regardless of changes in family income.

Authorized providers make presumptive eligibility determinations for this category.