N.M. Admin. Code § 8.300.1.10

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

Section 8.300.1.10 - RELATIONSHIP TO MEDICARE

MAD covers medically necessary health services furnished to eligible recipients who meet specific income, resource and eligibility standards. Medicare is a federal program which offers health insurance coverage to eligible recipients 65 years of age or older, to those who have received disability benefits for 24 consecutive months, to those who have end stage renal disease, and to other eligible recipients, as specified by other provisions of the Social Security Act.

A. The state of New Mexico has entered into an agreement with the social security administration to pay medicaid eligible recipient premiums for medicare part B, and under some circumstances, medicare part A premiums.

B. After medicare has made payment for services, the medicaid program pays for the medicare co-insurance and deductible amounts for all eligible medicaid recipients subject to the following medicaid reimbursement limitations.

(1) Medicaid payment for the co-insurance and deductible is limited such that the payment from medicare, plus the amount allowed by medicaid for the co-insurance and deductible, shall not exceed the medicaid allowed amount for the service. When the medicare payment exceeds the amount that medicaid would have allowed for the service, no payment is made for the co-insurance or deductible. The claim is considered paid in full. The provider may not collect any remaining portion of the medicare co-insurance or deductible from the eligible recipient or their personal representative. For services for which medicare part B applies a fifty percent co-insurance rate, medicare co-insurance and deductible amounts may be paid at an amount that allows the provider to receive more than medicaid allowed amount, not to exceed a percentage determined by HCA.

(2) The medicaid program will pay toward the medicare co-insurance and deductible to the extent that the amount paid by medicare and the allowed medicare co-insurance and deductible together do not exceed the medicaid allowed amount. The medicaid program will pay the medicare co-insurance and deductible when the medicaid program does not have a specific amount allowed for the service.

N.M. Admin. Code § 8.300.1.10

2/1/95; 8.300.1.10 NMAC - Rn, 8 NMAC 4.MAD.011 & A, 5/1/04; A, 9/15/08, Adopted by New Mexico Register, Volume XXXV, Issue 12, June 25, 2024, eff. 7/1/2024