N.M. Admin. Code § 8.308.9.12

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

Section 8.308.9.12 - GENERAL COVERED SERVICES

A.Ambulatory surgical services: The benefit package includes surgical services rendered in an ambulatory surgical center setting as detailed in 8.324.10 NMAC.

B.Anesthesia services: The benefit package includes anesthesia and monitoring services necessary for the performance of surgical or diagnostic procedures as detailed 8.310.2 NMAC.

C.Audiology services: The benefit package includes audiology services as detailed in 8.310.2 and 8.324.5 NMAC with some limitations. For a ABP member 21 years and older, audiology services are limited to hearing testing or screening when part of a routine health exam and are not covered as a separate service. Audiologist services, hearing aids and other aids are not covered.

D.Client transportation: The benefit package covers expenses for transportation, meals, and lodging it determines are necessary to secure MAD covered medical or behavioral health examination and treatment for a MCO member in or out of his or her home community as detailed in 8.301.6, 8.324.7 and 8.310.2 NMAC.

E.Community intervener: The benefit package includes community intervener services. The community intervener works one-on-one with a deaf-blind member who is five-years of age or older to provide critical connections to other people and his or her environment. The community intervener opens channels of communication between the member and others, provides access to information, and facilitates the development and maintenance of self-directed independent living.

(1)Member eligibility: To be eligible for community intervener services, a member must be five-years of age or older and meet the clinical definition of deaf-blindness, defined as:

(a) the member has a central visual acuity of 20/200 or less in the better eye with corrective lenses, or a field defect such that the peripheral diameter of visual field subtends an angular distance no greater than 20 degrees, or a progressive visual loss having a prognosis leading to one or both these conditions;

(b) the member has a chronic hearing impairment so severe that most speech cannot be understood with optimum amplification or the progressive hearing loss having a prognosis leading to this condition; and

(c) the member for whom the combination of impairments described above cause extreme difficulty in attaining independence in daily life activities, achieving psychosocial adjustment, or obtaining a vocation.

(2)Provider qualifications: The minimum provider qualifications for a community intervener are as follows:

(a) is at least 18 years of age;

(b) is not the spouse of the member to whom the intervener is assigned;

(c) holds a high school diploma or a high school equivalency certificate;

(d) has a minimum of two years of experience working with individuals with developmental disabilities;

(e) has the ability to proficiently communicate in the functional language of the deaf-blind member to whom the intervener is assigned; and

(f) completes an orientation or training course by any person or agency who provides direct care services to deaf-blind individuals.

F.Dental services: The benefit package includes dental services as detailed in 8.310.2 NMAC.

G.Diagnostic imaging and therapeutic radiology services: The benefit package includes medically necessary diagnostic imaging and radiology services as detailed in 8.310.2 NMAC.

H.Dialysis services: The benefit package includes medically necessary dialysis services as detailed in 8.310.2 NMAC. Dialysis benefits are limited to the first three months of dialysis pending the establishment of medicare eligibility unless the member does not qualify for medicare benefits as determined by the social security administration. A dialysis provider shall assist a member in applying for and pursuing final medicare eligibility determination. If the member does not qualify for medicare benefits, the MCO is responsible for covering dialysis services.

I.Durable medical equipment and medical supplies: The benefit package includes covered vision appliances, hearing aids and related services and durable medical equipment and medical supplies and oxygen as detailed in 8.324.5 NMAC. For an ABP eligible recipient 21 years of age and older, see 8.309.4 NMAC for service limitations.

J.Emergency and non-emergency transportation services:

(1) The benefit package includes transportation service such as ground ambulance and air ambulance in an emergency and when medically necessary, and taxicab and handivan, commercial bus, commercial air, meal and lodging services as indicated for medically necessary physical and behavioral health services, as detailed in 8.324.7 NMAC. MAD covers the most appropriate and least costly transportation alternatives only when a member does not have a source of transportation available and the member does not have access to alternative free sources. The MCO shall coordinate efforts when providing transportation services for a member requiring physical or behavioral health services.

(2) The benefit package also includes non-medical transportation as detailed in 8.314.5 NMAC.

K.Experimental or investigational services: The benefit package includes medically necessary services which are not considered unproven, investigational or experimental for the condition for which they are intended or used as determined by MAD as detailed in 8.310.2 NMAC.

L.Health home services: The benefit package includes CareLink NM (or its successor) health home services as detailed in 8.310.10 NMAC for qualified beneficiaries in areas these services are available through by MAD-approved providers.

M.Home healthagencyservices and other nursing care: The benefit package includes home health agency services as detailed in 8.325.9 and 8.320.2 NMAC. For an ABP eligible recipient 21 years of age and older, see 8.309.4 NMAC for service limitations.

(1) A MCO may also cover private duty nursing services and in home rehabilitation services as needed to provide medically necessary services to members even though those services are not rendered through a home health agency.

(2) In addition to home health agency services, a MCO is also required to provide in home services under the EPSDT program through private duty nursing and EPSDT personal care (which is not to be confused with the personal care option services covered as a community benefit). See 8.308.9.15 NMAC regarding EPSDT services.

(3) Services in the home are also a benefit under community based services. See 8.308.12. NMAC Community Benefit.

(4) For an ABP eligible recipient 21 years of age and older, see 8.309.4 NMAC for service limitations.

N.Hospice services: The benefit package includes hospice services as detailed in 8.325.4 NMAC.

O.Hospital outpatient service: The benefit package includes hospital outpatient services for preventive, diagnostic, therapeutic, rehabilitative or palliative medical or behavioral health services as detailed in 8.311.2 NMAC.

P.Inpatient hospital services: The benefit package includes hospital inpatient acute care, procedures and services for the member as detailed in 8.311.2 NMAC. The MCO shall comply with the maternity length of stay in the Health Insurance Portability and Accountability Act (HIPAA) of 1996. Coverage for a hospital stay following a normal, vaginal delivery may not be limited to less than 48 hours for both the member and her newborn child. Health coverage for a hospital stay in connection with childbirth following a caesarean section may not be limited to less than 96 hours for the member and her newborn child.

Q.Laboratory services: The benefit package includes laboratory services provided according to the applicable provisions of Clinical Laboratory Improvement Act (CLIA) as detailed in 8.310.2 NMAC.

R.Nursing facility services: The benefit package includes nursing facility services as detailed in 8.312.2 NMAC. Nursing facility services are not a benefit for an ABP eligible recipient except as a short term "step-down" hospital discharge prior to going home.

S.Nutrition services: The benefit package includes nutritional services based on scientifically validated nutritional principles and interventions which are generally accepted by the medical community and consistent with the physical and medical condition of the member as detailed in 8.310.2 NMAC.

T.Physical health services:

(1) Primary care and specialty care services are found in the following 8.310.2, 8.310.3, 8.320.2, and 8.320.6 NMAC. The services are rendered in a hospital, clinic, center, office, school-based setting, and when facilities and settings are parent approved, including the home.

(2) The benefits specifically include:

(a) labor and delivery in a hospital;

(b) labor and delivery in an eligible recipient's home;

(c) labor and delivery in a midwife's unlicensed birth center;

(d) labor and delivery in a department of health licensed birth center; and

(e) other related birthing services performed by a certified nurse midwife or a direct-entry midwife licensed by the state of New Mexico, who is either validly contracted with and fully credentialed by the MCO or validly contracted with HSD and participates in MAD birthing options program as detailed in 8.310.2 NMAC.

(f) The MCO shall operate a proactive prenatal care program to promote early initiation and appropriate frequency of prenatal care consistent with the standards of the American college of obstetrics and gynecology.

(g) The MCO shall participate in MAD's birthing options program.

U.Podiatry: The benefit package includes podiatric services furnished by a provider, as required by the condition of the member as detailed in 8.310.2 NMAC.

V.Prosthetics and orthotics: The benefit package includes prosthetic and orthotic services as detailed in 8.324.5 NMAC.

W.Rehabilitation services: The benefit package includes inpatient and outpatient hospital, and outpatient physical, occupational and speech therapy services as detailed in 8.323.5 NMAC. For an ABP eligible recipient 21 years of age and older, see 8.309.4 NMAC for service limitations

X.Private duty nursing: The benefit package includes private duty nursing services for a member under 21 years of age. See Subsection M of 8.308.9.12 NMAC.

Y.Swing bed hospital services: This benefit package includes services provided in hospital swing beds to a member expected to reside in such a facility on a long-term or permanent basis as defined in 8.311.5 NMAC. Swing bed hospital services are not a benefit for an ABP eligible recipient except as a short term "step-down" hospital discharge prior to going home.

Z.Tobacco cessation services: The benefit package includes cessation services as described in 8.310.2 NMAC and education.

AA.Transplant services: The following transplants are covered in the benefit package as long as the procedures are not considered experimental or investigational: heart transplants, lung transplants, heart-lung transplants, liver transplants, kidney transplants, autologous bone marrow transplants, allogeneic bone marrow transplants and corneal transplants as detailed in 8.310.2 NMAC. See 8.325.6 NMAC for guidance whether MAD has determined if a transplant is experimental or investigational.

BB.Vision and eye care services: The benefit package includes specific vision care services that are medically necessary for the diagnosis of and treatment of eye diseases for a member as detailed in 8.310.2 NMAC. All services must be furnished within the scope and practice of the medical professional as defined by state law and in accordance with applicable federal, state and local laws and rules. For an ABP eligible recipient 21 years and older, the service limitations are listed below:

(1) Routine vision care is not covered.

(2) MAD does not cover refraction or eyeglasses other than for aphakia following removal of the lens.

CC.Other services: When an additional benefit service is approved by MAD, the MCO shall cover that service as well.

N.M. Admin. Code § 8.308.9.12

8.308.9.12 NMAC - N, 1-1-14, Adopted by New Mexico Register, Volume XXIX, Issue 08, April 24, 2018, eff. 5/1/2018