NMSA 1978, § 27-2-1 Short title
27-2-1. Short title
Sections 27-2-1 through 27-2-34 NMSA 1978 may be cited as the "Public Assistance Act".
1953 Comp., § 13-17-1, enacted by Laws 1973, ch. 376, § 1; 2013, ch. 139, § 1.
Public Assistance Act
NMSA 1978 ch. 27, art. 2
in effectNMSA 1978, § 27-2-2 Definitions
27-2-2. Definitions
As used in the Public Assistance Act:
A. "authority" or "department" means the health care authority;
B. "board" means the authority;
C. "director" means the secretary;
D. "local office" means the county or district office of the authority;
E. "medicaid advisory committee" means the body, established by federal law, that advises the New Mexico medicaid program on policy development and program administration;
F. "medicaid forward plan" means a health care coverage plan that leverages the medicaid program to provide a state-administered health care coverage option;
G. "public welfare" or "public assistance" means any aid or relief granted to or on behalf of an eligible person under the Public Assistance Act and rules issued pursuant to that act;
H. "applicant" means a person who has applied for assistance or services under the Public Assistance Act;
I. "recipient" means a person who is receiving assistance or services under the Public Assistance Act;
J. "federal act" means the federal Social Security Act, as may be amended from time to time, and regulations issued pursuant to that act; and
K. "secretary" means the secretary of health care authority.
1953 Comp., § 13-17-2, enacted by Laws 1973, ch. 376, § 2; 1977, ch. 252, § 21; 1978 Comp., § 27-2-2; 1987, ch. 78, § 1; 1991, ch. 155, § 1; 2023, ch. 198, § 1; 2024, ch. 39, § 67.
NMSA 1978, § 27-2-3 Standard of need; income determination
27-2-3. Standard of need; income determination
A. Consistent with the federal act and subject to the availability of federal and state funds, the board shall adopt a standard of need which shall establish a reasonable level of subsistence.
B. Consistent with the federal act, the board shall define by regulation exempt and nonexempt income and resources. Medical expenses shall not be deducted from either income or resources in determining eligibility.
1953 Comp., § 13-17-3, enacted by Laws 1973, ch. 376, § 3; 1975, ch. 187, § 3.
NMSA 1978, § 27-2-4 Eligibility requirements
27-2-4. Eligibility requirements
Consistent with the federal act, a person is eligible for public assistance grants under the Public Assistance Act if:
A. pursuant to Section 27-2-3 NMSA 1978, the total amount of the person's nonexempt income is less than the applicable standard of need;
B. nonexempt specific and total resources are less than the level of maximum permissible resources established by the department;
C. the person meets all qualifications for one of the public assistance programs authorized by the Public Assistance Act;
D. within two years immediately prior to the filing of an application for assistance, the person has not made an assignment or transfer of real property unless the person has received a reasonable return for the real property or, if the person has not received a reasonable return, the person is willing to attempt to obtain such return and, if that attempt proves futile, the person is willing to attempt to regain title to the property;
E. the person is not an inmate of any public nonmedical institution at the time of receiving assistance, except that an inmate may be eligible for medical assistance programs administered by the medical assistance division of the department; and
F. the person is a resident of New Mexico.
1953 Comp., § 13-17-4, enacted by Laws 1973, ch. 376, § 4; 1975, ch. 187, § 4; 2015, ch. 127, § 1.
NMSA 1978, § 27-2-6.1 Supplemental postnatal assistance
27-2-6.1. Supplemental postnatal assistance
The department shall establish a program of supplemental postnatal assistance for those developmentally or intellectually disabled persons who during pregnancy received temporary assistance for needy families but whose assistance was revoked upon relinquishment of the newly born child for adoption. The supplemental postnatal assistance provided for in this section shall be at the same rate as temporary assistance for needy families, but supplemental postnatal assistance shall not exceed a period of sixty days. The department shall promulgate rules to carry out the provisions of this section.
1978 Comp., § 27-2-6.1, enacted by Laws 1978, ch. 30, § 1; 2023, ch. 113, § 3.
NMSA 1978, § 27-2-7 General assistance program; qualifications and payments
27-2-7. General assistance program; qualifications and payments
A. Subject to the availability of state funds, public assistance shall be provided under a general assistance program to or on behalf of eligible persons who:
(1) are under eighteen years of age and meet all eligibility conditions for the New Mexico Works Act [27-2B-1 NMSA 1978] except the relationship to the person with whom they are living;
(2) are over the age of eighteen and are disabled, according to rules of the department, and are not receiving cash assistance or services pursuant to the New Mexico Works Act;
(3) meet the qualifications under other rules for the general assistance program as the department shall establish; or
(4) are lawful resident immigrants who would otherwise be eligible for cash assistance or services pursuant to the New Mexico Works Act except that they began residing in the United States after August 22, 1996.
B. General assistance program payments may be made directly to the recipient or to the vendor of goods or services provided to the recipient. The department may by rule limit the grants that are made to general assistance recipients.
C. Whenever the department makes an adjustment in the standard of need for the New Mexico Works Act, subject to the availability of state funds, it shall make a commensurate adjustment in the standard of need for the general assistance program.
1953 Comp., § 13-17-10, enacted by Laws 1973, ch. 376, § 10; 1977, ch. 201, § 1; 1998, ch. 8, § 27; 1998, ch. 9, § 27.
NMSA 1978, § 27-2-7.1 Eligible person entitled to information
27-2-7.1. Eligible person entitled to information
A recipient shall be provided with information about expiration of medicaid or general assistance benefits when the recipient or the recipient's guardian, custodian or other authorized representative files a request for such information with the human services department [health care authority department]. The department shall respond to the request within five business days of receipt of the request made on a form the department shall devise and make available to a recipient. The response shall be by physical mail, electronic mail or facsimile or by access into a department-authorized web site.
Laws 2007, ch. 88, § 1.
NMSA 1978, § 27-2-9 Payment for hospital care
27-2-9. Payment for hospital care
A. Consistent with the federal act, the department shall provide necessary hospital care for recipients of public assistance other than those eligible under the general assistance program authorized by Section 10 [27-2-7 NMSA 1978] of the Public Assistance Act. The rate of payment for in-patient hospital services shall be based either on the reasonable cost or the customary cost of such services, whichever is less. In determining reasonable cost under this section, the board shall adopt regulations establishing a formula consistent with the federal act. The department shall apply that formula to determine the amount to which each hospital is entitled as reimbursement for providing in-patient hospital services.
B. To receive reimbursement for providing in-patient hospital services, a hospital shall file annually with the department such information as the department may reasonably require to determine reasonable costs or the hospital's customary cost of in-patient hospital services.
C. Any hospital entitled to reimbursement for in-patient hospital services shall be entitled to a hearing, pursuant to regulations of the board consistent with applicable state law, if the hospital disagrees with the department's determination of the reimbursement the hospital is to receive.
1953 Comp., § 13-17-12, enacted by Laws 1973, ch. 376, § 13.
NMSA 1978, § 27-2-9.1 Administration of shelter care supplement
27-2-9.1. Administration of shelter care supplement
A. A shelter care supplement shall be provided to those persons who are recipients of supplemental security income under Title 16 of the federal Social Security Act and who reside in shelter care homes licensed by the authority.
B. The authority is authorized to determine eligibility, compute payment, make payments and otherwise administer the shelter care supplement program.
C. The amount of the shelter care supplement payment shall be established by the secretary subject to the availability of general funds.
Laws 1979, ch. 401, § 1; 1983, ch. 174, § 1; 2024, ch. 39, § 68.
NMSA 1978, § 27-2-10 Food stamp program
27-2-10. Food stamp program
The income support division of the human services department [health care authority department]:
A. is authorized to establish a food stamp program to carry out the federal Food Stamp Act, as may be amended from time to time, and regulations issued pursuant to that act, subject to the continuation of the federal food stamp program and the availability of federal funds; and
B. shall by January 30 of each calendar year notify the taxation and revenue department of the location of food stamp offices in New Mexico for inclusion in a notice sent with an income tax refund or other notice to a taxpayer whose income is within one hundred thirty percent of federal poverty guidelines.
1953 Comp., § 13-17-13, enacted by Laws 1973, ch. 376, § 14; 2005, ch. 138, § 2.
NMSA 1978, § 27-2-11 Scope of assistance programs
27-2-11. Scope of assistance programs
Any public assistance program conducted by the department under the federal act is effective in all political subdivisions if the federal act so requires.
1953 Comp., § 13-17-14, enacted by Laws 1973, ch. 376, § 15.
NMSA 1978, § 27-2-12 Medical assistance programs
27-2-12. Medical assistance programs
A. Consistent with the federal act and subject to the appropriation and availability of federal and state funds, the medical assistance division of the department may by rule provide medical assistance, including the services of licensed doctors of oriental medicine, licensed chiropractic physicians, licensed dental therapists and licensed dental hygienists in collaborating practice, to persons eligible for public assistance programs under the federal act.
B. Subject to appropriation and availability of federal, state or other funds received by the state from public or private grants or donations, the medical assistance division of the department may by rule provide medical assistance, including assistance in the payment of premiums for medical or long-term care insurance, to children up to the age of twelve if not part of a sibling group; children up to the age of eighteen if part of a sibling group that includes a child up to the age of twelve; and pregnant women who are residents of the state of New Mexico and who are ineligible for public assistance under the federal act. The department, in implementing the provisions of this subsection, shall:
(1) establish rules that encourage pregnant women to participate in prenatal care; and
(2) not provide a benefit package that exceeds the benefit package provided to state employees.
1953 Comp., § 13-17-15, enacted by Laws 1973, ch. 376, § 16; 1991, ch. 144, § 1; 1993, ch. 158, § 1; 2003, ch. 343, § 1; 2006, ch. 2, § 1; 2019, ch. 107, § 15.
NMSA 1978, § 27-2-12.2 Medical assistance program; eligibility of married individuals
27-2-12.2. Medical assistance program; eligibility of married individuals
For the purpose of determining medical assistance for institutional care program eligibility under the Public Assistance Act, the community spouse resource allowance for a community spouse as defined and authorized by the federal Medicare Catastrophic Coverage Act of 1988 shall be a minimum of thirty thousand dollars ($30,000).
Laws 1987, ch. 16, § 1; 1989, ch. 74, § 1.
NMSA 1978, § 27-2-12.3 Medicaid reimbursement; equal pay for equal physicians', dentists', optometrists', podiatrists' and psychologists' services
27-2-12.3. Medicaid reimbursement; equal pay for equal physicians', dentists', optometrists', podiatrists' and psychologists' services
The human services department [health care authority department] shall establish a rate for the reimbursement of physicians, dentists, optometrists, podiatrists and psychologists for services rendered to medicaid patients that provides equal reimbursement for the same or similar services rendered without respect to the date on which such physician, dentist, optometrist, podiatrist or psychologist entered into practice in New Mexico, the date on which the physician, dentist, optometrist, podiatrist or psychologist entered into an agreement or contract to provide such services or the location in which such services are to be provided in the state; provided, however, that the requirements of this section shall not apply when the human services department [health care authority department] contracts with entities pursuant to Section 27-2-12.6 NMSA 1978 to negotiate a rate for the reimbursement for services rendered to medicaid patients in the medicaid managed care system.
1978 Comp., § 27-2-12.2, enacted by Laws 1987, ch. 269, § 1; 1996, ch. 70, § 1.
NMSA 1978, § 27-2-12.4 Long-term care facilities; noncompliance with standards and conditions; sanctions
27-2-12.4. Long-term care facilities; noncompliance with standards and conditions; sanctions
A. In addition to any other actions required or permitted by federal law or regulation, the authority shall impose a hold on state medicaid payments to a long-term care facility thirty days after the authority makes an on-site visit that the long-term care facility is not in substantial compliance with the standards or conditions of participation promulgated by the United States department of health and human services pursuant to which the facility is a party to a medicaid provider agreement, unless the substantial noncompliance has been corrected within that thirty-day period or the facility's medicaid provider agreement is terminated or not renewed based in whole or in part on the noncompliance. The written notice shall cite the specific deficiencies that constitute noncompliance.
B. The authority shall remove the payment hold imposed under Subsection A of this section when after an on-site visit, the authority certifies in writing that the long-term care facility is in substantial compliance with the standards or conditions of participation pursuant to which the facility is a party to a medicaid provider agreement.
C. The authority shall not reimburse any long-term care facility during the payment hold period imposed pursuant to Subsection A of this section for any medicaid recipient-patients who are new admissions and who are admitted on or after the day the hold is imposed and prior to the day the hold is removed.
D. If a long-term care facility is certified in writing to be in noncompliance pursuant to Subsection A of this section for the second time in any twelve-month period, the authority shall cancel or refuse to execute the long-term care facility's medicaid provider agreement for a two-month period, unless it can be demonstrated that harm to the patients would result from this action or that good cause exists to allow the facility to continue to participate in the medicaid program. The provisions of this subsection are subject to appeal procedures set forth in federal regulations for nonrenewal or termination of a medicaid provider agreement.
E. A long-term care facility shall not charge medicaid recipient-patients, their families or their responsible parties to recoup any payments not received because of a hold on medicaid payments imposed pursuant to this section.
F. This section shall not be construed to affect any other provisions for medicaid provider agreement termination, nonrenewal, due process and appeal pursuant to federal law or regulation.
G. As used in this section:
(1) "day" means a twenty-four hour period beginning at midnight and ending one second before midnight;
(2) "long-term care facility" means an intermediate care facility or skilled nursing facility that is licensed by the authority and is medicaid certified;
(3) "new admissions" means medicaid recipients who have never been in the long-term care facility or, if previously admitted, had been discharged or had voluntarily left the facility. The term does not include:
(a) persons who were in the long-term care facility before the effective date of the hold on medicaid payments and became eligible for medicaid after that date; and
(b) persons who, after a temporary absence from the facility, are readmitted to beds reserved for them in accordance with federal regulations; and
(4) "substantial compliance" means the condition of having no cited deficiencies or having only those cited deficiencies that:
(a) are not inconsistent with any federal statutory requirement;
(b) do not interfere with adequate patient care;
(c) do not represent a hazard to the patients' health or safety;
(d) are capable of correction within a reasonable period of time; and
(e) are ones that the long-term care facility is making reasonable plans to correct.
Laws 1987, ch. 214, § 1; 2024, ch. 39, § 69.
NMSA 1978, § 27-2-12.5 Medicaid-certified nursing facilities; retroactive eligibility; refunds; penalty
27-2-12.5. Medicaid-certified nursing facilities; retroactive eligibility; refunds; penalty
A. Medicaid payment for a medicaid-eligible patient shall be accepted by a medicaid-certified nursing facility from the first month of medicaid eligibility, regardless of whether the eligibility is retroactive. The nursing facility shall refund to the patient or responsible party all out-of-pocket money except for required medical-care credits paid to the nursing facility for that patient's care on and after the date of medicaid eligibility for services covered by the medicaid program. Within thirty days after notification by the human services department [health care authority department] of the patient's medicaid eligibility, the nursing facility shall make any necessary refund to the patient or responsible party required under this section.
B. In any cause of action brought against a nursing facility because of its failure to make a refund to the patient or responsible party as required under Subsection A of this section, the patient or responsible party may be awarded triple the amount of the money not refunded or three hundred dollars ($300), whichever is greater, and reasonable attorneys' fees and court costs.
Laws 1989, ch. 83, § 1; 1991, ch. 211, § 1.
NMSA 1978, § 27-2-12.6 Medicaid payments; managed care
27-2-12.6. Medicaid payments; managed care
A. The department shall provide for a statewide, managed care system to provide cost-efficient, preventive, primary and acute care for medicaid recipients by July 1, 1995.
B. The managed care system shall ensure:
(1) access to medically necessary services, particularly for medicaid recipients with chronic health problems;
(2) to the extent practicable, maintenance of the rural primary care delivery infrastructure;
(3) that the department's approach is consistent with national and state health care reform principles; and
(4) to the maximum extent possible, that medicaid-eligible individuals are not identified as such except as necessary for billing purposes.
C. The department may exclude nursing homes, intermediate care facilities for individuals with developmental or intellectual disabilities, medicaid in-home and community-based waiver services and residential and community-based mental health services for children with serious emotional disorders from the provisions of this section.
Laws 1994, ch. 62, § 22; 2023, ch. 113, § 4.
NMSA 1978, § 27-2-12.7 Medicaid; health care authority employees; standards of conduct; enforcement
27-2-12.7. Medicaid; health care authority employees; standards of conduct; enforcement
A. As used in this section:
(1) "business" means a corporation, partnership, sole proprietorship, firm, organization or individual carrying on a business;
(2) "authority" or "department" means the health care authority;
(3) "employee" means a person who has been appointed to or hired for an authority office connected with the administration of medicaid funds and who receives compensation in the form of salary;
(4) "employee with responsibility" means an employee who is directly involved in or has a significant part in the medicaid decision-making, regulatory, procurement or contracting process; and
(5) "financial interest" means an interest held by a person, the person's spouse or minor child that is:
(a) an ownership interest in business; or
(b) an employment or prospective employment for which negotiations have already begun.
B. No employee with responsibility shall, for twenty-four months following the date on which the employee ceases to be an employee, act as agent or attorney for another person or business in connection with a judicial or administrative proceeding, application, ruling, contract, claim or other matter relating to the medicaid program with respect to which the employee made an investigation, rendered a ruling or was otherwise substantially and directly involved during the last year the employee was an employee and that was actually pending under the employee's responsibility within that period.
C. The secretary, income support division director or medical assistance division director or their deputies shall not, for twelve months following the date on which that person ceases to be an employee, participate with respect to a judicial or administrative proceeding, application, ruling, contract, claim or other matter relating to the medicaid program and pending before the authority.
D. An employee with responsibility shall not participate in any manner with respect to a judicial or administrative proceeding, application, ruling, contract, claim or other matter relating to the medicaid program and involving the employee's spouse, minor child or a business in which the employee has a financial interest unless prior to the participation:
(1) full disclosure of the employee's relationship or financial interest is made in writing to the secretary; and
(2) a written determination is made by the secretary that the disclosed relationship or financial interest is too remote or inconsequential to affect the integrity of the services of the employee.
E. Violation of any of the provisions of this section by an employee is grounds for dismissal, demotion or suspension. A former employee who violates a provision of this section is subject to assessment by the authority of a civil money penalty of two hundred fifty dollars ($250) for each violation. The authority shall promulgate rules to provide for an administrative appeal of an assessment imposed.
Laws 1980, ch. 86, § 1; 1978 Comp., § 10-16-16, recompiled as 1978 Comp., § 27-2-12.7 by Laws 1997, ch. 112, § 10; 2024, ch. 39, § 70.
NMSA 1978, § 27-2-12.8 Mammograms for medicaid recipients
27-2-12.8. Mammograms for medicaid recipients
In providing coverage for mammograms under the medicaid program, the department shall ensure that:
A. patients will not be routinely solicited for mammograms; and that mammograms will only be performed based on nationally recognized standards; and
B. any fee for service payment that shall be made on behalf of the medicaid program for a mammogram of a medicaid recipient shall be consistent with and not exceed the usual and customary charge that reflects the reasonable fair market value of the cost of a mammogram.
Laws 1997, ch. 264, § 1.
NMSA 1978, § 27-2-12.9 Medicaid; personal spending allowances; increases
27-2-12.9. Medicaid; personal spending allowances; increases
For fiscal year 2001, the medicaid personal spending allowance shall be forty-five dollars ($45.00) per month for each eligible recipient. Thereafter, the medicaid personal spending allowance shall be increased at the beginning of each fiscal year by the annual percentage increase in the consumer price index for all urban consumers for all items for the preceding calendar year.
Laws 2000, ch. 9, § 1.
NMSA 1978, § 27-2-12.10 Clinical nurse specialists
27-2-12.10. Clinical nurse specialists
The department shall recognize clinical nurse specialists as mid-level providers in the medicaid program provided that the clinical nurse specialists comply with the requirements for licensure pursuant to the Nursing Practice Act [Chapter 61, Article 3 NMSA 1978] and that the services provided by the clinical nurse specialists are covered and reimbursable in accordance with Title 19 or Title 21 of the federal act.
Laws 2001, ch. 304, § 1.
NMSA 1978, § 27-2-12.11 Prescription drug waiver program; purpose; eligibility
27-2-12.11. Prescription drug waiver program; purpose; eligibility
Subject to the availability of state funds and consistent with the federal Social Security Act, the human services department [health care authority department] shall create a medicaid waiver program and may by regulation provide prescription drugs to persons whose incomes are less than one hundred eighty-five percent of the federal poverty level and who:
A. are sixty-five years of age or older; or
B. have been determined to be disabled under the criteria established under the federal social security administration's disability determination rules as applied by the department.
Laws 2003, ch. 34, § 1 and by Laws 2003, ch. 278, § 1.
NMSA 1978, § 27-2-12.12 Human services department [health care authority department]; managed care contract credentialing provisions
27-2-12.12. Human services department [health care authority department]; managed care contract credentialing provisions
The human services department [health care authority department] shall negotiate with medicaid contractors to ensure that the contractors' credentialing requirements are coordinated with other credentialing processes required of individual providers.
Laws 2003, ch. 235, § 4.
NMSA 1978, § 27-2-12.13 Medicaid reform; program changes
27-2-12.13. Medicaid reform; program changes
A. The department shall carry out the medicaid program changes as recommended by the medicaid reform committee that was established pursuant to Laws 2002, Chapter 96, as follows:
(1) develop a uniform preferred drug list for the state's medicaid prescription drug benefit and integrate all medicaid programs or services administered by the medical assistance division of the department to its use;
(2) work with other agencies to integrate the use of the uniform preferred drug list as described in Paragraph (1) of this subsection to other health care programs, including the department of health, the publicly funded health care agencies of the Health Care Purchasing Act [13-7-1 NMSA 1978], state agencies that purchase prescription drugs and other public or private purchasers of prescription drugs with whom the state can enter into an agreement for the use of a uniform preferred drug list;
(3) identify entities that are eligible to participate in the federal drug pricing program under Section 340b of the federal Public Health Service Act. The department shall make a reasonable effort to assist the eligible entities to enroll in the program and to purchase prescription drugs under the federal drug pricing program. The department shall ensure that entities enrolled in the federal drug pricing program are reimbursed for drugs purchased for use by medicaid recipients at acquisition cost and that the purchases are not included in a rebate program;
(4) work toward the development of a prescription drug purchasing cooperative to combine the buying power of the state's medicaid program, the publicly funded health care agencies of the Health Care Purchasing Act, the department of health, the corrections department and other potential public or private purchasers, including other states, to obtain the best price for prescription drugs. The administration and price negotiation of the prescription drug purchasing cooperative shall be consolidated under a single agency as determined by the governor;
(5) in consultation and collaboration with the department of health and medicaid providers and contractors, develop a program to expand the use of community health promoters. The community health promoters shall assist selected medicaid recipients in understanding the requirements of the medicaid program; ensuring that recipients are seeking and receiving primary and preventive health care services; following health care providers' orders or recommendations for medication, diet and exercise; and keeping appointments for examinations and diagnostic examinations;
(6) require that the managed care organizations provide or strengthen disease management programs for medical assistance recipients through closer coordination with and assistance to primary care and safety net providers and seek to adopt uniform key health status indicators. The department shall ensure that the managed care organizations make reasonable efforts and actively seek the expanded participation in disease management programs of primary care providers and other health care providers, particularly in underserved areas;
(7) ensure that case management services are provided to assist medicaid recipients in accessing needed medical, social and other services. The department shall require that managed care organizations provide or strengthen case management services through closer coordination with and assistance to primary care and safety net providers. The case management services shall be targeted to specific classes of individuals or individuals in specific areas where medicaid costs or utilization demonstrate a lack of health care management or coordination;
(8) design a pilot disease management program for the fee-for-service population. The department shall ensure that the disease management program is based on key health status indicators, accountability for clinical benefits and demonstrated cost savings;
(9) continue the personal care option with increased consumer awareness of consumer-directed services as a choice in addition to consumer-delegated services;
(10) expand the program of all-inclusive care for the elderly to a rural or urban area with a population less than four hundred thousand to the extent resources are available;
(11) in conjunction with the department of health, the children, youth and families department and the state agency on aging [aging and long-term services department], coordinate the state's long-term care services, including health and social services and assessment and information and referral development for recipients through an appropriate transition process;
(12) develop a fraud and abuse detection and recovery plan that ensures cooperation, sharing of information and general collaboration among the medicaid fraud control unit of the attorney general, the managed care organizations, medicaid providers, consumer groups and the department to identify, prevent or recover medicaid reimbursement obtained through fraudulent or inappropriate means;
(13) work with other agencies to identify other state-funded health care programs and services that may be reimbursable under medicaid and to ensure that the programs and services meet the requirements for federal funding;
(14) in conjunction with Indian health service facilities or tribally operated health care facilities pursuant to Section 638 of the Indian Self-Determination and Education Assistance Act, medicaid managed care organizations and medicaid providers, ensure that Indian health service facilities and tribally operated facilities are utilized to the extent possible for services that are eligible for a one hundred percent federal medical assistance percentage match;
(15) review the payment methodologies for eligible federally qualified health centers that provide the maximum allowable medicaid reimbursement;
(16) ensure that primary care clinics engaged in medicaid-related outreach and enrollment activities are appropriately reimbursed under medicaid;
(17) assess a premium on selected medicaid recipients who meet criteria as determined by the department;
(18) assess tiered co-payments on emergency room services in amounts comparable to those assessed for the same services by commercial health insurers or health maintenance organizations, except that no co-payment shall be imposed if the patient is admitted as a hospital inpatient as a result of the emergency room evaluation. The emergency room provider shall make a good faith effort to collect the co-payment from the patient. The co-payment shall apply to medicaid recipients in the managed care system or the fee-for-service system;
(19) assess tiered co-payments on selected higher-cost prescription drugs to provide incentives for greater use of generic prescription drugs when there is a generic or lower-cost equivalent available;
(20) assess a co-payment on the purchase of selected prescription drugs that are not on the uniform preferred drug list as described in Paragraph (1) of this subsection;
(21) consider the impact of cost-sharing requirements on medicaid recipients' access to health care. The department shall ensure that premiums and co-payments described in Paragraphs (17) through (20) of this subsection are in compliance with federal requirements;
(22) provide vision benefits for adults that do not exceed one routine eye exam and one set of corrective lenses in a twelve-month period or more than one frame for corrective lenses in a twenty-four-month period, except as medically warranted;
(23) review its prescription drug policies to ensure that pharmacists have the flexibility for and are not discouraged from using generic prescription drugs when there is a generic or lower-cost equivalent available; and
(24) review its nursing home eligibility criteria to ensure that consideration of income, trusts and other assets are the maximum permissible under federal law.
B. The department shall, to the extent possible, combine or coordinate similar initiatives in this section or in other medicaid reform committee recommendations to avoid duplication or conflict. The department shall give preference to those initiatives that provide significant cost savings while protecting the quality and access of medicaid recipients' health care services.
C. The department shall ensure compliance with federal requirements for implementation of the medicaid reform committee's recommendations. The department shall request a federal waiver as may be necessary to comply with federal requirements.
D. As used in this section:
(1) "case management" means services that ensure care coordination among the patient, the primary care provider and other providers involved in addressing the patient's health care needs, including care plan development, communication and monitoring;
(2) "community health promoters" means persons trained to promote health and health care access among low-income persons and medically underserved communities;
(3) "disease management" means health care services, including patient education, monitoring, data collection and reporting, designed to improve health outcomes of medicaid recipients in defined populations with selected chronic diseases;
(4) "drug purchasing cooperative" means a collaborative procurement process designed to secure prescription drugs at the most advantageous prices and terms;
(5) "fee-for-service" means a traditional method of paying for health care services under which providers are paid for each service rendered;
(6) "managed care system" refers to the program for medicaid recipients required by Section 27-2-12.6 NMSA 1978;
(7) "medicaid" means the joint federal-state health coverage program pursuant to Title 19 or Title 21 of the federal act;
(8) "preferred drug list" means a list of prescription drugs for which the state will make payment without prior authorization or additional charge to the medicaid recipient and that is based on clinical evidence for efficacy and meets the department's cost-effectiveness criteria;
(9) "primary care clinics" means facilities that provide the first level of basic or general health care for an individual's health needs, including diagnostic and treatment services, and includes federally qualified health centers or federally qualified health center look-alikes as defined in Section 1905 of the federal act and designated by the federal department of health and human services, community-based health centers, rural health clinics and other eligible programs under the Rural Primary Health Care Act [24-1A-1 NMSA 1978];
(10) "primary care provider" means a health care practitioner acting within the scope of his license who provides the first level of basic or general health care for a person's health needs, including diagnostic and treatment services, initiates referrals to other health care practitioners and maintains the continuity of care when appropriate; and
(11) "waiver" means the authority granted by the secretary of the federal department of health and human services, upon the request of the state, that allows exceptions to the state medicaid plan requirements and allows a state to implement innovative programs or activities.
Laws 2003, ch. 315, § 1.
NMSA 1978, § 27-2-12.14 Brain injury; services authorized
27-2-12.14. Brain injury; services authorized
Subject to the availability of state funds and consistent with Title 19 of the federal Social Security Act, the department shall provide services to persons with brain injuries, with emphasis on long-term disability services provided through home- and community-based programs.
Laws 2005, ch. 243, § 1.
NMSA 1978, § 27-2-12.15 Medicaid, state children's health insurance program and state coverage initiative program medical home waiver; rulemaking; application for waiver or state plan amendment
27-2-12.15. Medicaid, state children's health insurance program and state coverage initiative program medical home waiver; rulemaking; application for waiver or state plan amendment
A. Subject to the availability of state funds and consistent with the federal Social Security Act, the department shall work with its contractors that administer the state's approved waiver programs to promote and, if practicable, develop a program called the "medical home program". The "medical home" is an integrated care management model that emphasizes primary medical care that is continuous, comprehensive, coordinated, accessible, compassionate and culturally appropriate. Care within the medical home includes primary care, preventive care and care management services and uses quality improvement techniques and information technology for clinical decision support. Components of the medical home model may include:
(1) assignment of recipients to a primary care provider, clinic or practice that will serve as a medical home;
(2) promotion of the health commons model of service delivery, whereby the medical home tracks recipients' primary care, specialty, behavioral health, dental health and social services needs as much as practicable;
(3) health education, health promotion, peer support and other services that may integrate with health care services to promote overall health;
(4) health risk or functional needs assessments for recipients;
(5) a method for reporting on the effectiveness of the medical home model and its effect upon recipients' utilization of health care services and the associated cost of utilization of those services;
(6) mechanisms to reduce inappropriate emergency department utilization by recipients;
(7) financial incentives for the provision of after-hours primary care;
(8) mechanisms that ensure a robust system of care coordination for assessing, planning, coordinating and monitoring recipients with complex, chronic or high-cost health care or social support needs, including attendant care and other services needed to remain in the community;
(9) implementation of a comprehensive, community-based initiative to educate recipients about effective use of the health care delivery system, including the use of community health workers or promotoras;
(10) strategies to prevent or delay institutionalization of recipients through the effective utilization of home- and community-based support services;
(11) a primary care provider for each recipient, who advocates for and provides ongoing support, oversight and guidance to implement an integrated, coherent, cross-disciplinary plan for ongoing health care developed in partnership with the recipient and including all other health care providers furnishing care to the recipient;
(12) implementation of evidence-based medicine and clinical decision support tools to guide decision-making at the point-of-care based upon recipient-specific factors;
(13) use of comparative effectiveness to make a cost-benefit analysis of health care practices;
(14) use of health information technology, including remote supervision, recipient monitoring and recipient registries, to monitor and track the health status of recipients;
(15) development and use of safe and secure health information technology to promote convenient recipient access to personal health information, health services and web sites with tools for patient self-management;
(16) implementation of training programs for personnel involved in the coordination of care for recipients;
(17) implementation of equitable financial incentive and compensation systems for primary care providers and other staff engaged in care management and the medical home model; and
(18) any other components that the secretary determines will improve a recipient's health outcome and that are cost-effective.
B. For the purposes of this section, "primary care provider" means a medical doctor or physician assistant licensed under the Medical Practice Act [61-6-1 NMSA 1978] to practice medicine in New Mexico, an osteopathic physician licensed pursuant to Chapter 61, Article 10 NMSA 1978, an osteopathic physician's assistant licensed pursuant to the Osteopathic Physicians' Assistants Act [repealed], a pharmacist clinician licensed or certified to prescribe and administer drugs that are subject to the New Mexico Drug, Device and Cosmetic Act [26-1-1 NMSA 1978]; or a certified nurse practitioner as defined in the Nursing Practice Act [61-3-1 NMSA 1978] who provides first contact and continuous care and who has the staff and resources to manage the comprehensive and coordinated health care of each individual under the primary care provider's care.
Laws 2009, ch. 143, § 1; 2010, ch. 43, § 1.
NMSA 1978, § 27-2-12.16 Medicaid recipients; cost-sharing payments for emergency medical services when non-emergency services are indicated
27-2-12.16. Medicaid recipients; cost-sharing payments for emergency medical services when non-emergency services are indicated
A. Consistent with the federal act and subject to the appropriation and availability of federal and state funds, the department shall promulgate rules that require a recipient who chooses a high-cost medical service provided through a hospital emergency room to pay a co-payment, premium payment or other cost-sharing payment for the high-cost medical service if:
(1) the hospital from which the recipient seeks service:
(a) performs an appropriate medical screening and determines that the recipient does not have a condition requiring emergency medical services;
(b) informs the recipient that the recipient does not have a condition requiring emergency medical services;
(c) informs the recipient that if the hospital provides the non-emergency service, the hospital may require the recipient to pay a co-payment, premium payment or other cost-sharing payment in advance of providing the service;
(d) informs the recipient of the name and address of a non-emergency medicaid provider that can provide the appropriate medical service without imposing a cost-sharing payment; and
(e) offers to provide the recipient with a referral to the non-emergency provider to facilitate scheduling of the service;
(2) after receiving the information and assistance from the hospital described in Paragraph (1) of this subsection, the recipient chooses to obtain emergency medical services despite having access to medically acceptable, lower-cost non-emergency medical services; and
(3) the recipient's household income is at least one hundred percent of the federal poverty level.
B. The cost-sharing payment for a high-cost medical service made pursuant to this section shall be:
(1) for a child whose household income is one hundred to one hundred fifty percent of the federal poverty level, six dollars ($6.00);
(2) for an adult whose household income is one hundred to one hundred fifty percent of the federal poverty level, twenty-five dollars ($25.00);
(3) for a child whose household income is greater than one hundred fifty percent of the federal poverty level, twenty dollars ($20.00); and
(4) for an adult whose household income is greater than one hundred fifty percent of the federal poverty level, fifty dollars ($50.00).
C. The department shall not seek a federal waiver or other authorization to carry out the provisions of Subsection A of this section that would prevent a medicaid recipient who has a condition requiring emergency medical services from receiving care through a hospital emergency room or waive any provision under Section 1867 of the federal act.
D. The department shall not reduce hospital payments to reflect the potential receipt of a co-payment or other payment from a recipient receiving medical services provided through a hospital emergency room.
E. The secretary shall apply for a grant pursuant to Subsection 1903(y) of the federal Deficit Reduction Act to establish a program to provide for non-emergency services to serve as an alternative to emergency rooms as providers of health care. This program shall establish partnerships with local community hospitals and shall focus on providing alternatives to emergency services for primary care for rural and underserved areas where medicaid recipients do not have regular access to primary care. As used in this section, "primary care" means the first level of basic physical or behavioral health care for an individual's health needs, including diagnostic and treatment services.
Laws 2009, ch. 263, § 1.
NMSA 1978, § 27-2-12.17 Qualified state long-term care insurance partnership program; establishment; rulemaking
27-2-12.17. Qualified state long-term care insurance partnership program; establishment; rulemaking
A. Consistent with the federal act and subject to the appropriation and availability of federal and state funds, the secretary shall amend the state medicaid plan to establish a qualified state long-term care insurance partnership program pursuant to Section 1917(b) of the federal act. The program shall:
(1) provide incentives for an individual to obtain or maintain qualified insurance to cover the cost of long-term care; and
(2) provide a mechanism for an individual to qualify for medical assistance for institutional care or a medical assistance home- and community-based long-term care program on the basis of countable resources. Pursuant to the qualified state long-term care insurance partnership program:
(a) an individual who otherwise qualifies for medical assistance for institutional care or a medical assistance home- and community-based long-term care program shall qualify on the basis of countable resources when the individual is the beneficiary of a qualified insurance policy, insurance plan, certificate of insurance or rider; and
(b) for purposes of determining eligibility, the individual's total countable resources shall be reduced by an amount equal to the qualified insurance benefits that are made to or on behalf of the individual.
B. The secretary shall consult with the superintendent of insurance in the adoption and promulgation of rules regarding the implementation and operation of the qualified state long-term care partnership insurance program. These rules shall provide for reciprocity with respect to individuals who have purchased qualified insurance in another state participating in a qualified state long-term care insurance partnership program and shall provide that the amount of that individual's countable resources shall be disregarded with respect to that qualified insurance.
C. As used in this section:
(1) "qualified insurance" means an insurance policy, insurance plan, certificate of insurance or rider that the superintendent has certified as qualified long-term care partnership program insurance pursuant to Section 4 [59A-23A-12 NMSA 1978] of this 2013 act; and
(2) "rider" means a long-term care coverage provision added to any type of insurance plan, insurance policy or certificate of insurance.
Laws 2013, ch. 139, § 2.
NMSA 1978, § 27-2-12.18 Medical assistance; prescription drugs; prior authorization request form; prior authorization protocols
27-2-12.18. Medical assistance; prescription drugs; prior authorization request form; prior authorization protocols
A. Beginning January 1, 2014, the department shall require its medicaid contractors to accept the uniform prior authorization form developed pursuant to Sections 2 [59A-2-9.8 NMSA 1978] and 3 [61-11-6.2 NMSA 1978] of this 2013 act. The department shall require its medicaid contractors to accept the uniform prior authorization form as sufficient to request prior authorization for prescription drug benefits on behalf of recipients.
B. The department shall require its medicaid contractors to respond within three business days upon receipt of a uniform prior authorization form. The department shall require each of its medicaid contractors to deem a prior authorization as having been granted if the contractor has failed to respond to the prior authorization request within three business days.
Laws 2013, ch. 170, § 1.
NMSA 1978, § 27-2-12.19 Former foster-care recipients; medical assistance coverage until age twenty-six
27-2-12.19. Former foster-care recipients; medical assistance coverage until age twenty-six
The department shall cover individuals who are residents of New Mexico and who are former recipients of foster care, regardless of the state where the foster care was received, until those individuals reach the age of twenty-six years.
Laws 2015, ch. 31, § 1.
NMSA 1978, § 27-2-12.20 Crisis triage center; medical assistance reimbursement
27-2-12.20. Crisis triage center; medical assistance reimbursement
A. In accordance with federal law, the secretary shall adopt and promulgate rules to establish a reimbursement rate for services provided to recipients of state medical assistance at a crisis triage center.
B. As used in this section, "crisis triage center" means a health facility that:
(1) is licensed by the authority; and
(2) provides stabilization of behavioral health crises and may include residential and nonresidential stabilization.
Laws 2015, ch. 61, § 2; 2018, ch. 34, § 2; 2024, ch. 39, § 71.
NMSA 1978, § 27-2-12.21 Medical assistance; pharmacy benefits; prescription synchronization
27-2-12.21. Medical assistance; pharmacy benefits; prescription synchronization
A. In accordance with federal law, the secretary shall adopt and promulgate rules that allow a recipient to fill or refill a prescription for less than a thirty-day supply of a prescription drug and apply a prorated daily copayment or coinsurance, if applicable, for the fill or refill, if:
(1) the prescribing practitioner or the pharmacist determines the fill or refill to be in the best interest of the patient;
(2) the recipient requests or agrees to receive less than a thirty-day supply of the prescription drug; and
(3) the reduced fill or refill is made for the purpose of synchronizing the recipient's prescription drug fills.
B. Medical assistance coverage shall not:
(1) deny coverage for the filling of a chronic medication when the fill is made in accordance with a plan to synchronize multiple prescriptions for the recipient pursuant to Subsection A of this section established among the department or the recipient's managed care plan, the prescribing practitioner and a pharmacist. The medical assistance coverage shall allow a pharmacy to override any denial indicating that a prescription is being refilled too soon for the purposes of medication synchronization; and
(2) prorate a dispensing fee to a pharmacy that fills a prescription with less than a thirty-day supply of prescription drug pursuant to Subsection A of this section. The medical assistance coverage shall pay in full a dispensing fee for a partially filled or refilled prescription for each prescription dispensed, regardless of any prorated copayment or coinsurance that the recipient may pay for prescription synchronization services.
Laws 2015, ch. 65, § 2.
NMSA 1978, § 27-2-12.22 Incarcerated persons; medicaid eligibility; county jail technical assistance; presumptive eligibility determiner training and certification
27-2-12.22. Incarcerated persons; medicaid eligibility; county jail technical assistance; presumptive eligibility determiner training and certification
A. Incarceration shall not be a basis to deny or terminate eligibility for medicaid.
B. Upon release from incarceration, a formerly incarcerated person shall remain eligible for medicaid until the person is determined to be ineligible for medicaid on grounds other than incarceration.
C. An incarcerated person who was not enrolled in medicaid upon the date that the person became incarcerated shall be permitted to submit an application for medicaid during the incarcerated person's period of incarceration.
D. The provisions of this section shall not be construed to abrogate:
(1) any deadline that governs the processing of applications for medicaid pursuant to existing federal or state law; or
(2) requirements under federal or state law that the authority be notified of changes in income, resources, residency or household composition.
E. The provisions of this section shall not require the authority to pay for services on behalf of any incarcerated person except as permitted by federal law.
F. A correctional facility shall:
(1) inform the authority when an eligible person is incarcerated;
(2) facilitate, with assistance from the authority, eligibility determinations for medicaid during the incarcerated person's incarceration or upon release;
(3) notify the authority upon an eligible person's release; and
(4) facilitate the authority's or any authority contractor's provision of care coordination pursuant to the provisions of Section 33-1-22 NMSA 1978.
G. Upon the written request of a county, the authority shall provide a behavioral health screening tool to facilitate screenings performed in accordance with the provisions of Subsection A of Section 33-1-22 NMSA 1978, technical assistance and training and certification of county jail presumptive eligibility determiners to a county jail.
H. The secretary shall adopt and promulgate rules consistent with this section.
I. As used in this section:
(1) "care coordination" means an assessment for health risks and the creation of a plan of care to address a person's comprehensive health needs, including access to physical health care and mental health services; substance use disorder treatment; and transportation services;
(2) "eligibility" means a finding by the authority that a person has met the criteria established in state and federal law and the requirements established by authority rules to enroll in medicaid;
(3) "incarcerated person" means a person, the legal guardian or conservator of a person or, for a person who is an unemancipated minor, the parent or guardian of the person, who is confined in any of the following correctional facilities:
(a) a state correctional facility;
(b) a privately operated correctional facility;
(c) a county jail;
(d) a privately operated jail;
(e) a detention facility that is operated under the authority of the children, youth and families department and that holds the person pending a court hearing; or
(f) a facility that is operated under the authority of the children, youth and families department and that provides for the care and rehabilitation of a person who is under eighteen years of age and who has committed an act that would be designated as a crime under the law if committed by a person who is eighteen years of age or older;
(4) "medicaid" means the joint federal-state health coverage program pursuant to Title 19 or Title 21 of the federal Social Security Act and rules promulgated pursuant to that act; and
(5) "unemancipated minor" means a person who is under eighteen years of age and who:
(a) is not on active duty in the armed forces; and
(b) has not been declared by court order to be emancipated.
Laws 2015, ch. 127, § 2; 2018, ch. 74, § 1; 2024, ch. 39, § 72.
NMSA 1978, § 27-2-12.23 Medical assistance; prescription drug coverage; step therapy protocols; clinical review criteria; exceptions
27-2-12.23. Medical assistance; prescription drug coverage; step therapy protocols; clinical review criteria; exceptions
A. By January 1, 2019, the secretary shall require any medical assistance plan for which any step therapy protocols are required to establish clinical review criteria for those step therapy protocols. The clinical review criteria shall be based on clinical practice guidelines that:
(1) recommend that the prescription drugs subject to step therapy protocols be taken in the specific sequence required by the step therapy protocol;
(2) are developed and endorsed by an interdisciplinary panel of experts that manages conflicts of interest among the members of the panel of experts by:
(a) requiring members to: 1) disclose any potential conflicts of interest with health care plans, medical assistance plans, health maintenance organizations, pharmaceutical manufacturers, pharmacy benefits managers and any other entities; and 2) recuse themselves if there is a conflict of interest; and
(b) using analytical and methodological experts to work to provide objectivity in data analysis and ranking of evidence through the preparation of evidence tables and facilitating consensus;
(3) are based on high-quality studies, research and medical practice;
(4) are created pursuant to an explicit and transparent process that:
(a) minimizes bias and conflicts of interest;
(b) explains the relationship between treatment options and outcomes;
(c) rates the quality of the evidence supporting recommendations; and
(d) considers relevant patient subgroups and preferences; and
(5) take into account the needs of atypical patient populations and diagnoses.
B. In the absence of clinical guidelines that meet the requirements of Subsection A of this section, peer-reviewed publications may be substituted.
C. When a medical assistance plan restricts coverage of a prescription drug for the treatment of any medical condition through the use of a step therapy protocol, a recipient and the practitioner prescribing the prescription drug shall have access to a clear, readily accessible and convenient process to request a step therapy exception determination. A medical assistance plan may use its existing medical exceptions process in accordance with the provisions of Subsections D through I of this section to satisfy this requirement. The process shall be made easily accessible for recipients and practitioners on the medical assistance plan's publicly accessible website.
D. A medical assistance plan shall expeditiously grant an exception to the medical assistance plan's step therapy protocol, based on medical necessity and a clinically valid explanation from the patient's prescribing practitioner as to why a drug on the plan's formulary that is therapeutically equivalent to the prescribed drug should not be substituted for the prescribed drug, if:
(1) the prescription drug that is the subject of the exception request is contraindicated or will likely cause an adverse reaction by or physical or mental harm to the patient;
(2) the prescription drug that is the subject of the exception request is expected to be ineffective based on the known clinical characteristics of the patient and the known characteristics of the prescription drug regimen;
(3) while under the recipient's current medical assistance plan, or under the recipient's previous health coverage, the recipient has tried the prescription drug that is the subject of the exception request or another prescription drug in the same pharmacologic class or with the same mechanism of action as the prescription drug that is the subject of the exception request and that prescription drug was discontinued due to lack of efficacy or effectiveness, diminished effect or an adverse event; or
(4) the prescription drug required pursuant to the step therapy protocol is not in the best interest of the patient, based on clinical appropriateness, because the patient's use of the prescription drug is expected to:
(a) cause a significant barrier to the patient's adherence to or compliance with the patient's plan of care;
(b) worsen a comorbid condition of the patient; or
(c) decrease the patient's ability to achieve or maintain reasonable functional ability in performing daily activities.
E. Upon the granting of an exception to a medical assistance plan's step therapy protocol, a medical assistance plan shall authorize continuing coverage for the prescription drug that is the subject of the exception request for no less than the duration of the therapeutic effect of the drug.
F. A medical assistance plan shall respond with its decision on a recipient's exception request within seventy-two hours of receipt. In cases where exigent circumstances exist, a medical assistance plan shall respond within twenty-four hours of receipt of the exception request. In the event the medical assistance plan does not respond to an exception request within the time frames required pursuant to this subsection, the exception request shall be granted.
G. A medical assistance plan's denial of a request for an exception for step therapy protocols shall be subject to review and appeal pursuant to department rules.
H. After a recipient has made an exception request in accordance with the provisions of this section, a medical assistance plan shall authorize continued coverage of a prescription drug that is the subject of the exception request pending the determination of the exception request.
I. The provisions of this section shall not be construed to prevent:
(1) a medical assistance plan from requiring a patient to try a biosimilar, interchangeable biologic or generic equivalent of a prescription drug before providing coverage for the equivalent brand-name prescription drug; or
(2) a practitioner from prescribing a prescription drug that the practitioner has determined to be medically necessary.
J. As used in this section, "medical necessity" or "medically necessary" means health care services determined by a practitioner, in consultation with the medical assistance plan, to be appropriate or necessary, according to:
(1) any applicable, generally accepted principles and practices of good medical care;
(2) practice guidelines developed by the federal government or national or professional medical societies, boards or associations; or
(3) any applicable clinical protocols or practice guidelines developed by the medical assistance plan consistent with federal, national and professional practice guidelines. These standards shall be applied to decisions related to the diagnosis or direct care and treatment of a physical or behavioral health condition, illness, injury or disease.
Laws 2018, ch. 9, § 2; 2024, ch. 42, § 2.
NMSA 1978, § 27-2-12.24 Medical assistance; plan of care; participation required
27-2-12.24. Medical assistance; plan of care; participation required
A. By January 1, 2020, the secretary shall require medical assistance plans to establish, in consultation with the department, hospitals, birthing centers, the children, youth and families department and the department of health, a process for the creation and implementation of a plan of care for a substance-exposed newborn and the relatives, parents, guardians or caretakers of a substance-exposed newborn as provided for in the Children's Code [Chapter 32A NMSA 1978].
B. As used in this section, "plan of care" means a plan created by a health care professional pursuant to the Children's Code that is intended to ensure the safety and well-being of a substance-exposed newly born child by addressing the treatment needs of the child and any of the child's parents, relatives, guardians, family members or caregivers to the extent those treatment needs are relevant to the safety of the child.
1978 Comp., § 27-2-12.24, as enacted by Laws 2019, ch. 190, § 5
NMSA 1978, § 27-2-12.25 Prior authorization for gynecological or obstetrical ultrasounds prohibited
27-2-12.25. Prior authorization for gynecological or obstetrical ultrasounds prohibited
A. The department shall prohibit its medicaid managed care and fee-for-service contractors from requiring prior authorization for gynecological or obstetrical ultrasounds.
B. Nothing in this section shall be construed to require payment for a gynecological or obstetrical ultrasound that is not:
(1) medically necessary; or
(2) a covered benefit.
C. As used in this section, "prior authorization" means advance approval that is required as a condition precedent to payment for medical care or related benefits rendered to a covered person, including prospective or utilization review conducted prior to the provision of covered medical care or related benefits.
Laws 2019, ch. 182, § 2
NMSA 1978, § 27-2-12.26 Qualified medicare beneficiary recipients; medicare part B coverage automatic enrollment
27-2-12.26. Qualified medicare beneficiary recipients; medicare part B coverage automatic enrollment
A. The department shall provide for the automatic enrollment into medicare part B coverage of individuals:
(1) whom it deems eligible for participating in the qualified medicare beneficiary program; and
(2) who are not enrolled in medicare part B coverage.
B. By August 1, 2019, the secretary shall adopt and promulgate rules to provide for informing, in writing, applicants for and recipients of qualified medicare beneficiary coverage that, if they are enrolled in the qualified medicare beneficiary program and, at the time of enrollment they are not enrolled in medicare part B, they are eligible for automatic enrollment in medicare part B coverage, regardless of whether general or "open" enrollment of medicare part B beneficiaries is allowed under federal law at the time a qualified medicare beneficiary program recipient enrolls in the qualified medicare beneficiary program.
C. As used in this section:
(1) "medicare part B" means the supplemental medical insurance program provided under part B of Title 18 of the federal Social Security Act; and
(2) "qualified medicare beneficiary program" means the joint state-federal medical assistance program that provides for payment of recipients' premiums under part A of Title 18 of the federal Social Security Act and recipients' coinsurance and deductible amounts on services covered under medicare part B.
Laws 2019, ch. 136, § 1.
NMSA 1978, § 27-2-12.27 Medical assistance; managed care organization contracts; applicability of Prior Authorization Act
27-2-12.27. Medical assistance; managed care organization contracts; applicability of Prior Authorization Act
The secretary shall ensure that contracts with managed care organizations to provide medical assistance to medicaid recipients are subject to and comply with the Prior Authorization Act.
Laws 2019, ch. 187, § 2.
NMSA 1978, § 27-2-12.28 Medical assistance; autism spectrum disorder
27-2-12.28. Medical assistance; autism spectrum disorder
A. The secretary shall ensure that medical assistance coverage provides coverage, which shall not be subject to age restrictions or dollar limits, for:
(1) well-baby and well-child screening for diagnosing the presence of autism spectrum disorder; and
(2) treatment of autism spectrum disorder through speech therapy, occupational therapy, physical therapy and applied behavioral analysis.
B. Coverage required pursuant to Subsection A of this section:
(1) shall be limited to treatment that is prescribed by the recipient's treating physician in accordance with a treatment plan;
(2) shall not be denied on the basis that the services are habilitative or rehabilitative in nature;
(3) may be subject to other general exclusions and limitations of medical assistance coverage, including coordination of benefits, participating provider requirements, restrictions on services provided by family or household members and utilization review of health care services, including the review of medical necessity, case management and other managed care provisions; and
(4) may be limited to exclude coverage for services received under the federal Individuals with Disabilities Education Improvement Act of 2004 and related state laws that place responsibility on state and local school boards for providing specialized education and related services to children three to twenty-two years of age who have autism spectrum disorder.
C. The coverage required pursuant to Paragraph (1) of Subsection A of this section shall not be subject to any recipient cost-sharing.
D. The coverage required pursuant to Paragraph (2) of Subsection A of this section shall not be subject to cost-sharing provisions that are less favorable to a recipient than the cost-sharing provisions that apply to physical illnesses that are generally covered through medical assistance coverage, except as otherwise provided in Subsection B of this section.
E. The treatment plan required pursuant to Subsection B of this section shall include all elements necessary for the health insurance plan to pay claims appropriately. These elements include the:
(1) diagnosis;
(2) proposed treatment by types;
(3) frequency and duration of treatment;
(4) anticipated outcomes stated as goals;
(5) frequency with which the treatment plan will be updated; and
(6) signature of the treating physician.
F. This section shall not be construed as limiting benefits and coverage otherwise available to a recipient through medical assistance coverage.
G. As used in this section:
(1) "autism spectrum disorder" means:
(a) a condition that meets the diagnostic criteria for autism spectrum disorder published in the current edition of the Diagnostic and Statistical Manual of Mental Disorders published by the American psychiatric association; or
(b) a condition diagnosed as autistic disorder, Asperger's disorder, pervasive development disorder not otherwise specified, Rett's disorder or childhood disintegrative disorder pursuant to diagnostic criteria published in a previous edition of the Diagnostic and Statistical Manual of Mental Disorders published by the American psychiatric association;
(2) "cost-sharing" means any deductible, copayment, coinsurance or other payment that a recipient is required to pay for medical assistance items or services provided through medical assistance coverage; and
(3) "habilitative or rehabilitative services" means treatment programs that are necessary to develop, maintain or restore to the maximum extent practicable the functioning of an individual.
Laws 2019, ch. 119, § 2.
NMSA 1978, § 27-2-12.29 Medical assistance; reimbursement for a one-year supply of covered prescription contraceptive drugs or devices
27-2-12.29. Medical assistance; reimbursement for a one-year supply of covered prescription contraceptive drugs or devices
A. In providing coverage for family planning services and supplies under the medical assistance program, the department shall ensure that a recipient is permitted to fill or refill a prescription for a one-year supply of a covered, self-administered contraceptive at one time, as prescribed.
B. Nothing in this section shall be construed to limit a recipient's freedom to choose or change the method of family planning to be used, regardless of whether the recipient has exhausted a previously dispensed supply of contraceptives.
Laws 2019, ch. 263, § 2.
NMSA 1978, § 27-2-12.30 Pharmacist prescriptive authority services; reimbursement parity
27-2-12.30. Pharmacist prescriptive authority services; reimbursement parity
A medical assistance program or its contractor shall reimburse a participating provider that is a certified pharmacist clinician or pharmacist certified to provide a prescriptive authority service who provides a service at the standard contracted rate that the medical assistance program reimburses, for the same service under that program, any licensed physician or physician assistant licensed pursuant to the Medical Practice Act [Chapter 61, Article 6 NMSA 1978] or any advanced practice certified nurse practitioner licensed pursuant to the Nursing Practice Act [Chapter 61, Article 3 NMSA 1978].
Laws 2020, ch. 58, § 2; 2021, ch. 54, § 10.
NMSA 1978, § 27-2-12.31 Heart artery calcium scan coverage
27-2-12.31. Heart artery calcium scan coverage
A. In accordance with federal law, the secretary shall adopt and promulgate rules that provide medical assistance coverage for eligible enrollees to receive a heart artery calcium scan.
B. Medical assistance coverage provided pursuant to this section shall:
(1) be limited to the provision of a heart artery calcium scan to an eligible enrollee to be used as a clinical management tool;
(2) be provided every five years if an eligible enrollee has previously received a heart artery calcium score of zero; and
(3) not be required for future heart artery calcium scans if an eligible enrollee receives a heart artery calcium score greater than zero.
C. At its discretion or as required by law, a managed care organization providing medical assistance may offer or refuse coverage for further cardiac testing or procedures for eligible enrollees based upon the results of a heart artery calcium scan.
D. The provisions of this section shall not apply to short-term travel, accident-only or limited or specified-disease policies, plans or certificates of health insurance.
E. As used in this section:
(1) "eligible enrollee" means an enrollee who:
(a) is a person between the ages of forty-five and sixty-five; and
(b) has an intermediate risk of developing coronary heart disease as determined by a health care provider based upon a score calculated from an evidence-based algorithm widely used in the medical community to assess a person's ten-year cardiovascular disease risk, including a score calculated using a pooled cohort equation;
(2) "health care provider" means a physician, physician assistant, nurse practitioner or other health care professional authorized to furnish health care services within the scope of the professional's license; and
(3) "heart artery calcium scan" means a computed tomography scan measuring coronary artery calcium for atherosclerosis and abnormal artery structure and function.
Laws 2020, ch. 79, § 2.
NMSA 1978, § 27-2-12.32 Biomarker testing coverage
27-2-12.32. Biomarker testing coverage
A. In accordance with federal law, the secretary shall adopt and promulgate rules that provide medical assistance coverage for enrollees to receive biomarker testing.
B. A medical assistance plan providing coverage pursuant to this section shall be for the purposes of diagnosis, treatment, appropriate management or ongoing monitoring of an enrollee's disease or condition when the test is supported by medical and scientific evidence, including:
(1) labeled indications for a United States food and drug administration-approved or -cleared test;
(2) indicated tests for a United States food and drug administration-approved drug;
(3) warnings and precautions on United States food and drug administration labels;
(4) federal centers for medicare and medicaid services national coverage determinations or medicare administrative contractor local coverage determinations; or
(5) nationally recognized clinical practice guidelines.
C. Medicaid contractors delivering services to enrollees shall provide biomarker testing at the same scope, duration and frequency as the medical assistance plan otherwise provides to enrollees.
D. A medical assistance plan providing coverage for biomarker testing pursuant to this section shall ensure that:
(1) coverage is provided in a manner that limits disruptions in care, including coverage for multiple biopsies or biospecimen samples; and
(2) a patient and a practitioner who prescribes biomarker testing have clear, readily accessible and convenient processes to request an appeal of a benefit denial by the insurer and that those processes are accessible on the medical assistance division of the department's website.
E. As used in this section:
(1) "biomarker" means a characteristic that is objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes or pharmacologic responses to a specific therapeutic intervention, including known gene-drug interactions for medications being considered for use or already being administered. "Biomarker" includes gene mutations, characteristics of genes or protein expression;
(2) "biomarker testing" means analysis of a patient's tissue, blood or other biospecimen for the presence of a biomarker and includes single-analyte tests, multi-plex panel tests, protein expression and whole exome, whole genome and whole transcriptome sequencing; and
(3) "nationally recognized clinical practice guidelines" means evidence-based clinical practice guidelines that are:
(a) developed by independent organizations or medical professional societies using a transparent methodology and reporting structure and with a conflict-of-interest policy; and
(b) used to establish standards of care informed by a systematic review of evidence and an assessment of the benefits and risks of alternative care options and include recommendations intended to optimize patient care.
Laws 2023, ch. 138, § 2.
NMSA 1978, § 27-2-12.33 Study of the medicaid forward plan
27-2-12.33. Study of the medicaid forward plan
A. The secretary, in coordination with the superintendent of insurance and in consultation with the medicaid advisory committee, other stakeholders identified by the secretary and representatives of Indian nations, tribes and pueblos that are located wholly or partially in New Mexico, shall study the following operational needs for and effects of implementing the medicaid forward plan and amending the New Mexico medicaid state plan, pursuant to the federal act to provide medical assistance to residents who are under age sixty-five, are not otherwise eligible for and enrolled in mandatory coverage under the New Mexico medicaid state plan and have a household income that exceeds one hundred thirty-three percent of the federal poverty level:
(1) the effects on the individual, group and self-insured health insurance markets, including the New Mexico health insurance exchange and the health benefits programs provided to state or local public employees or public school employees, of providing mandatory or optional medicaid coverage to individuals who would otherwise be eligible for health insurance through those markets;
(2) the effects on health care providers and health care facilities, including reimbursement rates needed to maximize access to health care services;
(3) the operational needs for administering the medicaid forward plan, including staffing and technical needs for enrollment and collection of premiums or cost-sharing;
(4) the funding plan, including necessary expenditures and total revenue generated;
(5) the fiscal effects on recurring and nonrecurring spending in the state budget; and
(6) the financial sustainability, including steps necessary for the department and the superintendent of insurance to apply for federal waivers to maximize federal funding and leverage those waivers to ensure affordability for enrollees in the medicaid forward plan.
B. The secretary's proposed program design for the medicaid forward plan shall be contingent on the results of the study and shall include:
(1) a financing plan, which shall include recommended appropriation of state funds, projected federal funds, savings directly or indirectly attributable to the program design, a sliding scale for premiums and cost-sharing based on household income for individuals eligible to enroll in the medicaid forward plan and other potential cost offsets;
(2) information about recommended reimbursement rates to maximize access to health care services under the medicaid forward plan;
(3) details about the department's operational needs for administering the medicaid forward plan; and
(4) information about federal waivers needed to maximize federal funding and ensure affordability and choice for enrollees.
C. By October 1, 2024, the secretary shall submit a report to the legislative finance committee and the legislative health and human services committee detailing the secretary's study of, and proposed program design for, the medicaid forward plan.
Laws 2023, ch. 198, § 2.
NMSA 1978, § 27-2-12.34 Community-based pharmacy reimbursement
27-2-12.34. Community-based pharmacy reimbursement
A. Each managed care organization that contracts with the department shall ensure that community-based pharmacy providers that provide services to medicaid recipients are reimbursed as follows:
(1) for the ingredient cost of a drug at a value that is at least equal to the national average drug acquisition cost for the prescription drug at the time that the drug is administered or dispensed, or if data for the national average drug acquisition is unavailable, the wholesale acquisition cost of the drug; and
(2) a professional dispensing fee.
B. The professional dispensing fee reimbursed to community-based pharmacy providers shall be no less than the professional dispensing fee reimbursed to community-based pharmacy providers for covered outpatient drugs in the medicaid fee-for-service program.
C. By January 1, 2025, and annually thereafter, the department shall compile a list of all community-based pharmacy providers in the state and publish the list on the department's website.
D. For the purposes of this section:
(1) "community-based pharmacy provider" means a pharmacy that is:
(a) open to the public for prescriptions to be filled, regardless of the facility or practice where the prescription was written;
(b) located in the state or near the state border, if the border town is a primary source of prescription drugs for medicaid recipients residing in the border area; and
(c) not: 1) government-owned; 2) hospital-owned; 3) owned by a corporation that owns hospitals; 4) an extension of a medical practice or special facility; 5) owned by a corporate chain of pharmacies with stores outside of the state; or 6) a mail-order pharmacy;
(2) "ingredient cost" means the actual amount paid to a community-based pharmacy provider for a prescription drug, not including the professional dispensing fee or cost sharing;
(3) "managed care organization" means a person or entity eligible to enter into risk-based prepaid capitation agreements with the department to provide health care and related services;
(4) "medicaid" means the medical assistance program established pursuant to Title 19 of the federal Social Security Act and regulations issued pursuant to that act;
(5) "medicaid recipient" means a person whom the department has determined to be eligible to receive medicaid-related services;
(6) "national average drug acquisition cost" means the national average of prices at which pharmacies purchase a prescription drug from manufacturers or wholesalers; and
(7) "wholesale acquisition cost" means a manufacturer's list price for a prescription drug sold to wholesalers in the United States, not including discounts, rebates or reductions in price.
1978 Comp., § 27-2-12.34, enacted by Laws 2024, ch. 35, § 1.
NMSA 1978, § 27-2-12.35 Mi via waiver program; gross receipts taxes
27-2-12.35. Mi via waiver program; gross receipts taxes
A. The health care authority shall promulgate rules to ensure that gross receipts taxes are not used to calculate the individual budgetary allotments for individuals participating in the mi via waiver program. A health care provider's costs for gross receipts taxes shall be billed and reimbursed as a separate line item that is in addition to a participant's individual budgetary allotment.
B. For the purposes of this section:
(1) "individual budgetary allotment" means the total approved annual budget assigned to a mi via waiver program participant for services, supports and goods; and
(2) "mi via waiver program" means the state's self-directed medicaid home- and community-based services waiver program.
Laws 2025, ch. 43, § 1.
NMSA 1978, § 27-2-12.36 Equitable reimbursement for services provided at birth centers
27-2-12.36. Equitable reimbursement for services provided at birth centers
A. For the purposes of this section:
(1) "birth center" means a freestanding birth center licensed by the state for the primary purpose of performing low-risk deliveries that is not a hospital, attached to a hospital or in a hospital and where births are planned to occur away from the pregnant person's residence following a low-risk pregnancy;
(2) "medicaid" means the medical assistance program established pursuant to Title 19 of the federal Social Security Act and regulations issued pursuant to that act; and
(3) "medicaid recipient" means a person whom the department has determined to be eligible to receive medicaid-related services.
B. The secretary shall adopt rules that:
(1) create a methodology to determine medicaid facility fee reimbursement rates for birth centers that are comparable to rates for similar services provided at a hospital; and
(2) require annual increases to birth center facility fee reimbursement rates that are equivalent to hospital reimbursement rate increases.
Laws 2025, ch. 88, § 1.
NMSA 1978, § 27-2-12.37 Reimbursement for gross receipts taxes
27-2-12.37. Reimbursement for gross receipts taxes
A. When a health care provider contracts with a managed care organization for medicaid reimbursement for providing health care services to a recipient, the managed care organization shall:
(1) reimburse the health care provider for all applicable gross receipts taxes that the health care provider is required to pay for the contracted health care services; and
(2) provide documentation that differentiates the medicaid reimbursement for health care services from the amount of gross receipts taxes paid to the health care provider.
B. For the purposes of this section:
(1) "managed care organization" means a person eligible to enter into risk-based prepaid capitation agreements with the authority to provide health care and related services; and
(2) "medicaid" means the federal-state program administered by the authority pursuant to Title 19 or Title 21 of the federal Social Security Act.
Laws 2025, ch. 121, § 1.
NMSA 1978, § 27-2-13 Conflict in federal and state laws
27-2-13. Conflict in federal and state laws
Any section of the NMSA 1978 relating to public assistance which is in conflict with the provisions of the federal act or the federal Food Stamp Act, as may be amended from time to time, and federal regulations issued pursuant thereto, shall be suspended in its operation if the attorney general certifies that such conflict exists.
1953 Comp., § 13-17-16, enacted by Laws 1973, ch. 376, § 17.
NMSA 1978, § 27-2-14 Continuing effect of regulations and standards
27-2-14. Continuing effect of regulations and standards
Regulations and standards of the board and department adopted prior to the effective date of the Public Assistance Act are continued in full force and effect, unless modified or revoked.
1953 Comp., § 13-17-17, enacted by Laws 1973, ch. 376, § 18.
NMSA 1978, § 27-2-15 Cooperation with the United States
27-2-15. Cooperation with the United States
A. The authority is designated as the state agency to cooperate with the federal government in the administration of the provisions of Title 1, Title 4, Parts 2 and 3 of Title 5 and Title 10 of the federal Social Security Act. The authority shall cooperate with the proper departments of the federal government and with all other departments of the state and local governments in the enforcement and administration of those provisions of the federal Social Security Act and rules adopted in accordance with that act in the manner prescribed in Chapter 27 NMSA 1978 or as otherwise provided by law.
B. The authority shall make reports in such form and containing such information as any agency or instrumentality of the United States with which it is cooperating may require and shall comply with such provisions as that agency or instrumentality may find necessary to assure the correctness and verification of the reports.
Laws 1937, ch. 18, § 9; 1941 Comp., § 73-109; 1953 Comp., § 13-1-9; 1978 Comp., § 27-2-15; 2024, ch. 39, § 73.
NMSA 1978, § 27-2-16 Compliance with federal law
27-2-16. Compliance with federal law
A. Subject to the availability of state funds, the authority may provide assistance to aged, blind or disabled persons in the amounts consistent with federal law to enable the state to be eligible for medicaid funding. Persons shall be determined to be aged, blind or disabled according to rules of the authority.
B. If drug product selection is permitted by Section 26-3-3 NMSA 1978, reimbursement by the medicaid program shall be limited to the wholesale cost of the lesser expensive therapeutic equivalent drug generally available in New Mexico plus a reasonable dispensing fee of at least three dollars sixty-five cents ($3.65).
1953 Comp., § 13-17-18, enacted by Laws 1974, ch. 31, § 1; 1982, ch. 26, § 2; 1984, ch. 27, § 1; 2024, ch. 39, § 74.
NMSA 1978, § 27-2-17 Custodian of funds
27-2-17. Custodian of funds
The authority is designated as the custodian of all money received by the state, which the authority is authorized to administer, from any appropriations made by the congress of the United States for the purpose of cooperating with the several states in the enforcement and administration of the provisions of the federal Social Security Act and all money received from any other source for the purposes set forth in Chapter 27 NMSA 1978. The authority is authorized to receive such money, provide for its proper custody and make disbursements of it under such rules as the authority may prescribe.
Laws 1937, ch. 18, § 10; 1941 Comp., § 73-110; 1953 Comp., § 13-1-10; 1978 Comp., 27-2-17; 2024, ch. 39, § 75.
NMSA 1978, § 27-2-21 Assistance not assignable
27-2-21. Assistance not assignable
Assistance granted under this act shall not be transferable or assignable, at law or in equity, and none of the money paid or payable under this act shall be subject to execution, levy, attachment, garnishment or other legal process, or to the operation of any bankruptcy or insolvency law.
Laws 1937, ch. 18, § 11g; 1941 Comp., § 73-118; 1953 Comp., § 13-1-19.
NMSA 1978, § 27-2-23 Third party liability
27-2-23. Third party liability
A. The income support division of the department shall make reasonable efforts to ascertain any legal liability of third parties who are or may be liable to pay all or part of the medical cost of injury, disease or disability of an applicant for or recipient of medical assistance pursuant to the provisions of Chapter 27 NMSA 1978.
B. When the department makes medical assistance payments on behalf of a recipient, the department is subrogated to any right of the recipient against a third party for recovery of medical expenses to the extent that the department has made payment.
C. Health insurers, including self-insured plans, group health plans, service benefit plans, managed care organizations, pharmacy benefit managers or other parties, that are, by statute, contract or agreement, legally responsible for payment of a claim for a health care item or service, as a condition of doing business with New Mexico, shall:
(1) provide, with respect to individuals who are eligible for or are provided medical assistance under the medicaid program, upon the request of the state, information to determine during what period the individual, the individual's spouse or the individual's dependents may be, or may have been, covered by a health insurer and the nature of the coverage provided by the health insurer, including the name, address and identifying number of the plan;
(2) accept New Mexico's right of recovery and the assignment to New Mexico of any right of an individual or other entity to payment from the party for an item or service for which payment has been made under the medicaid program;
(3) respond to any inquiry by New Mexico regarding a claim for payment for any health care item or service that is submitted no later than three years after the date of the provision of such health care item or service; and
(4) agree not to deny a claim submitted by New Mexico solely on the basis of the date of submission of the claim by the provider, the type of the claim form or a failure to present proper documentation at the point-of-sale that is the basis of the claim, if:
(a) the claim is submitted by New Mexico within the three-year period beginning on the date on which the item or service was furnished; and
(b) any action by New Mexico to enforce its rights with respect to such claim is commenced within six years of New Mexico's submission of such claim.
D. Nothing in this section shall be construed to preclude the application of common law principles in determining equitable reimbursement from any third-party source for New Mexico or a health insurer, including self-insured plans, group health plans, service benefit plans, managed care organizations, pharmacy benefit managers or other parties.
1953 Comp., § 13-1-20.1, enacted by Laws 1969, ch. 232, § 1; 2007, ch. 246, § 1.
NMSA 1978, § 27-2-23.1 Employee Retirement Income Security Act employee health benefit plans; clauses to exclude medicaid coverage prohibited
27-2-23.1. Employee Retirement Income Security Act employee health benefit plans; clauses to exclude medicaid coverage prohibited
No employee health benefit plan established under the Employee Retirement Income Security Act of 1974, 29 U.S.C. 1144, that provides payments for health care on behalf of individuals residing in the state shall contain any provisions excluding or limiting coverage or payment for any health care for an individual who would otherwise be covered or entitled to benefits or services under the terms of the employee health benefit plan, because that individual is provided, or is eligible for, benefits under the medicaid program of this state pursuant to Title XIX of the federal Social Security Act, 42 U.S.C. 1396, et seq.
1978 Comp., § 27-2-23.1, enacted by Laws 1989, ch. 184, § 1.
NMSA 1978, § 27-2-24 [Federal government entitled to share recovery.]
27-2-24. [Federal government entitled to share recovery.]
The federal government shall be entitled to a share of any amounts recovered under the preceding two sections [27-2-22, 27-2-23 NMSA 1978] if required as a condition to federal financial participation. The federal government's share shall be limited to a percentage of the net recovery equal to the percentage of federal participation claimed by the state for the payments when originally made. The amount due the United States shall be paid promptly from the funds so collected to the United States government.
Laws 1937, ch. 18, § 11i; 1941, ch. 116, § 6; 1941 Comp., § 73-120; 1953 Comp., § 13-1-21; Laws 1969, ch. 232, § 2.
NMSA 1978, § 27-2-25 Funeral expenses
27-2-25. Funeral expenses
A. On the death of:
(1) a recipient of financial assistance under Section 27-2-6 [repealed] or 27-2-7 NMSA 1978 or under the federal supplemental security income program; or
(2) a person living in a nursing home or an intermediate care facility, the payment for whose care is made in whole or in part pursuant to Title 19 of the federal Social Security Act; funeral expenses up to two hundred dollars ($200) shall be paid by the income support division of the authority if the deceased's available resources, as defined by rule of the division, are insufficient to pay the funeral expenses, the persons legally responsible for the support of the deceased are unable to pay the funeral expenses and no other person will undertake to pay those expenses.
B. No payment shall be made by the income support division when resources available from all sources to pay the funeral expenses total six hundred dollars ($600) or more. When the resources are less than six hundred dollars ($600), the division shall pay the difference between six hundred dollars ($600) and the resources, or two hundred dollars ($200), whichever is less.
Laws 1937, ch. 18, § 11j; 1941 Comp., § 73-121; 1953 Comp., § 13-1-22; Laws 1959, ch. 49, § 1; 1969, ch. 234, § 1; 1975, ch. 220, § 1; 1978 Comp., § 27-2-5; 2024, ch. 39, § 76.
NMSA 1978, § 27-2-26 Money received from other sources; duty and liability of funeral director
27-2-26. Money received from other sources; duty and liability of funeral director
Should any funeral director accept payment from sources other than the income support division of the authority for burial of a deceased person for whom a claim for burial expenses has been made to the division, the funeral director shall immediately notify the division of the payment. The division shall consider the payment in determining the amount of any funeral expense payment it makes. If the division has already made payment, the funeral director shall refund to the division any excess over the amount that the division would have paid had it known of the payment from other sources. If any funeral director fails to notify the division of any such payment from other sources, the funeral director shall be liable to the division in an amount double the amount paid or to be paid by the division.
1953 Comp., § 13-1-22.1, enacted by Laws 1975, ch. 220, § 2; 1978 Comp., § 27-2-26; 2024, ch. 39, § 77.
NMSA 1978, § 27-2-27 Single state agency; powers and duties
27-2-27. Single state agency; powers and duties
A. The authority is designated as the single state agency for the enforcement of child and spousal support obligations pursuant to Title 4-D of the federal Social Security Act with the following duties and powers to:
(1) establish the paternity of a child in the case of the child born out of wedlock with respect to whom an assignment of support rights has been executed in favor of the authority;
(2) establish an order of support for children receiving aid from temporary assistance for needy families and, at the option of the authority, for the spouse or former spouse with whom such children are living, but only if a support obligation has been established with respect to such spouse or former spouse, for whom no order of support currently exists and seek modification, based upon the noncustodial parent's ability to pay, of existing orders in which the support order is inadequate to properly care for the child and the spouse or former spouse with whom the child is living;
(3) enforce as the real party in interest any existing order for the support of children who are receiving temporary assistance for needy families or of the spouse or former spouse with whom such children are living;
(4) provide services to non-aid families with dependent children in the establishment and enforcement of paternity and child support obligations, including locating the absent parent. For these services, the authority is authorized to establish and collect fees, costs and charges permitted or required by federal law or by regulations adopted pursuant to that federal law; and
(5) adopt rules for the disposition of unclaimed child, spousal or medical support payments.
B. In all cases handled by the authority pursuant to the provisions of this section, the child support enforcement division or an attorney employed by the division represent the authority, to the exclusion of any other party, in establishing, modifying and enforcing support obligations.
C. An attorney employed to provide the Title 4-D services represents only the authority's interests, and no attorney-client relationship shall exist between the attorney and another party.
D. The authority shall, at the time an application for child support services is made, inform the applicant that neither the Title 4-D agency nor the attorney who provides services under this section is the applicant's attorney and that the attorney who provides services under this section shall not provide legal representation to the applicant.
E. The authority may initiate an action or may intervene in an action involving child support.
F. The attorney employed by the authority pursuant to this section shall not act as a guardian ad litem for the applicant.
G. A court shall not disqualify the authority in a legal action filed pursuant to the Support Enforcement Act of the federal Social Security Act because the authority has previously provided services to a party whose interests are now adverse to the relief requested.
1978 Comp., § 27-2-27, enacted by Laws 1981, ch. 90, § 1; 1982, ch. 12, § 1; 1984, ch. 98, § 1; 1995, ch. 46, § 1; 2003, ch. 283, § 2; 2004, ch. 41, § 1; 2024, ch. 39, § 78.
NMSA 1978, § 27-2-28 Liability for repayment of public assistance
27-2-28. Liability for repayment of public assistance
A. In cases where the authority has provided cash assistance to children in a household, the court shall award judgment in favor of the authority and against the noncustodial parents of the children for child support, calculated pursuant to Section 40-4-11.1 NMSA 1978, for all months in which the children received cash assistance benefits.
B. Equitable defenses available to the noncustodial parent in claims by the custodian for retroactive support or past due support shall not operate to deprive the authority of its right to request retroactive support or past due support for months during which the noncustodial parent's children received cash assistance benefits.
C. Amounts of support collected that are in excess of the amounts specified in Subsections A and B of this section shall be paid by the authority to the custodian of the child.
D. No agreement between any custodian of a child and a parent of that child, either relieving the parent of any duty of child or spousal support or responsibility or purporting to settle past, present or future support obligations, either as a settlement or prepayment, shall act to reduce or terminate any rights of the authority to recover from that parent for support provided, unless the authority has consented to the agreement in writing.
E. The noncustodial parent shall be given credit for any support actually provided, including housing, clothing, food or funds paid prior to the entry of any order for support. The noncustodial parent has the burden to prove that the noncustodial parent has provided any support.
F. An application for public assistance by any person constitutes an assignment by operation of law of any support rights the person is entitled to during the time the person's household receives public assistance, whether the support rights are owed to the applicant or to any family member for whom the applicant is applying for or receiving assistance. The assignment includes all support rights that accrue as long as the applicant receives public assistance.
G. By operation of law, an assignment to the authority of any and all rights of an applicant for or recipient of medical assistance under the medicaid program in New Mexico or supplemental security income through the social security administration:
(1) is deemed to be made of:
(a) any payment for medical care from any natural person, firm or corporation, including an insurance carrier; and
(b) any recovery for personal injury, whether by judgment or contract for compromise or settlement;
(2) shall be effective to the extent of the amount of medical assistance actually paid by the authority under the medicaid program; and
(3) shall be effective as to the rights of any other persons who are eligible for medical assistance and whose rights can legally be assigned by the applicant or recipient.
H. An applicant or recipient is required to cooperate fully with the authority in its efforts to secure the assignment and to execute and deliver any instruments and papers deemed necessary to complete the assignment by the authority.
1978 Comp., § 27-2-28, enacted by Laws 1981, ch. 90, § 2; 1982, ch. 12, § 2; 1991, ch. 223, § 1; 1995, ch. 202, § 1; 2009, ch. 32, § 1; 2024, ch. 39, § 79.
NMSA 1978, § 27-2-29.1 Compensation under contingent fee contracts; suspense fund created
27-2-29.1. Compensation under contingent fee contracts; suspense fund created
A. To make disbursements and distributions pursuant to this section, the "health care authority reimbursement suspense fund" is created in the state treasury.
B. When pursuing a claim arising under Section 27-2-23 or 27-2-28 NMSA 1978, in addition to other available alternatives, the authority may contract with a person to represent the authority on a contingent fee basis if the contract:
(1) is approved by the attorney general;
(2) provides that all amounts received by the contractor as satisfaction of the claim shall be transferred to the authority and deposited into the health care authority reimbursement suspense fund to the credit of the authority; and
(3) provides that, upon the direction of the secretary, the compensation due to the contractor shall be disbursed from the suspense fund to the contractor.
C. After a disbursement to a contractor pursuant to Paragraph (3) of Subsection B of this section, the balance of each deposit into the health care authority reimbursement suspense fund shall be distributed to the general fund and shall be appropriated to the authority to reimburse the authority for the public assistance from which the claim arose and, if required, for reimbursing the federal government.
Laws 2010, ch. 80, § 1; 2024, ch. 39, § 80.
NMSA 1978, § 27-2-30 [Enforcement of support;] orders
27-2-30. [Enforcement of support;] orders
The court in term time or judge in vacation may make and enforce by attachment or otherwise such order to restrain the use or disposition of the property of the defendant to provide for the support of the dependents during the pendency of the suit as in his discretion may seem just and proper.
1953 Comp., § 13-1-27.3, enacted by Laws 1965, ch. 66, § 3.
NMSA 1978, § 27-2-31 Judgments and proceeds
27-2-31. Judgments and proceeds
Upon final hearing, judgment for the authority shall include all sums expended during the pendency of the action. When the authority recovers judgments under Chapter 27, Article 2 NMSA 1978, it may enforce, compromise or settle the judgments in any way considered by the authority to be in the public interest. Any proceeds of judgments or settlements shall be retained by the authority for its authorized activities and required reimbursements to the federal government.
1953 Comp., § 13-1-27.4, enacted by Laws 1965, ch. 66, § 4; 1978 Comp., § 27-2-31; 2024, ch. 39, § 81.
NMSA 1978, § 27-2-32 Duty of agencies to cooperate
27-2-32. Duty of agencies to cooperate
All state, county and municipal agencies, departments, bureaus and divisions shall cooperate in the location of absent parents who are not fulfilling their obligation to support their children and shall on request supply the authority with all information on hand relative to the location, social security number, income and property of such absent parents, notwithstanding any other provision of law making the information confidential. The authority shall use such information only for the purpose of enforcing the support liability of such absent parents and shall not use the information or disclose it for any other purpose.
1953 Comp., § 13-1-28, enacted by Laws 1969, ch. 182, § 3; 1981, ch. 90, § 3; 1985, ch. 105, § 14; 2024, ch. 39, § 82.
NMSA 1978, § 27-2-34 Limitations of act
27-2-34. Limitations of act
All assistance granted under this act shall be deemed to be granted and to be held subject to the provisions of any amending or repealing act that may hereafter be passed, and no recipient shall have any claim for compensation, or otherwise, by reason of his assistance being affected in any way by any amending or repealing act.
Laws 1937, ch. 18, § 22; 1941, ch. 116, § 7; 1941 Comp., § 73-132; 1953 Comp., § 13-1-35.
NMSA 1978, § 27-2-41 Short title
27-2-41. Short title
Sections 27-2-41 through 27-2-47 NMSA 1978 may be cited as the "Indigent Catastrophic Illness Hospital Funding Act".
Laws 1990, ch. 93, § 1; 2024, ch. 39, § 83.
NMSA 1978, § 27-2-42 Legislative findings; purpose
27-2-42. Legislative findings; purpose
A. The legislature finds that twenty-five percent of New Mexicans have no health insurance. When such individuals suffer a catastrophic illness, the large hospital bills that are incurred can often result in indigency for that sick person and his family.
B. The purpose of the Indigent Catastrophic Illness Hospital Funding Act [27-2-41 to 27-2-47 NMSA 1978] is to reduce the impact of medical indigency on the cost of health care in New Mexico by providing for payment of some portion of large hospital bills incurred by medically indigent patients.
Laws 1990, ch. 93, § 2.
NMSA 1978, § 27-2-43 Definitions
27-2-43. Definitions
As used in the Indigent Catastrophic Illness Hospital Funding Act [27-2-41 to 27-2-47 NMSA 1978]:
A. "authority" or "department" means the health care authority;
B. "fund" means the indigent catastrophic illness hospital fund;
C. "hospital" means any general or special hospital that is licensed by the authority and that has annual gross charges for medicare, medicaid and indigent patients greater than ten percent of the hospital's total annual gross charges; and
D. "medically indigent patient" means a person who is a New Mexico resident who incurs hospital charges, who is not eligible for medicaid or medicare and whose family or household income does not exceed two hundred fifty percent of the federal poverty level.
Laws 1990, ch. 93, § 3; 2024, ch. 39, § 84.
NMSA 1978, § 27-2-44 Indigent catastrophic illness hospital fund created
27-2-44. Indigent catastrophic illness hospital fund created
The "indigent catastrophic illness hospital fund" is created as a nonreverting fund in the state treasury. Money in the fund is appropriated to the authority to reimburse hospitals for eligible claims for hospital charges incurred by medically indigent patients and for paying administrative costs of the authority not to exceed three percent of the annual appropriation or other distribution or transfer to the fund. Money in the fund shall be invested as provided for other state funds and income earned on the fund shall be credited to the fund.
Laws 1990, ch. 93, § 4; 2024, ch. 39, § 85.
NMSA 1978, § 27-2-45 Hospitals; claims for payment
27-2-45. Hospitals; claims for payment
A. A hospital may submit eligible claims to the department on or before April 1 of each year for payment from the fund by June 30 of each year in an amount determined pursuant to this section.
B. A claim submitted by a hospital for payment from the fund shall be deemed an eligible claim if it is for:
(1) uncovered hospital charges of five thousand dollars ($5,000) or more for an illness of a medically indigent patient;
(2) hospital charges incurred within the twelve months immediately prior to the applicable April 1 closing deadline; and
(3) an amount determined by subtracting from the base claim the medically indigent patient's deductible and then reducing the resulting balance, based on the hospital's medicare cost-to-charge ratio, to an amount equal to medicare allowable costs.
C. The department shall pay from the fund to each hospital the amount of each eligible claim if there is sufficient money in the fund. If there is not sufficient money in the fund to pay all eligible claims of hospitals for that year, the amount of each claim that shall be paid shall be an amount derived from multiplying the full amount of the eligible claim by the percentage derived from dividing the balance in the fund, after administrative costs have been subtracted, by the sum of the eligible claims.
Laws 1990, ch. 93, § 5.
NMSA 1978, § 27-2-46 Medically indigent patient deductible
27-2-46. Medically indigent patient deductible
A medically indigent patient's deductible shall be an amount determined by the hospital that the medically indigent patient is able to pay the hospital in monthly installments over an eighteen-month period. That determination shall be made pursuant to department rules and regulations and shall include, but not be limited to, consideration of the medically indigent patient's family size, household income and obligations.
Laws 1990, ch. 93, § 6.
NMSA 1978, § 27-2-47 Department; regulations
27-2-47. Department; regulations
The department shall adopt and promulgate by September 30, 1990 rules and regulations necessary to implement and administer the Indigent Catastrophic Illness Hospital Funding Act [27-2-41 to 27-2-47 NMSA 1978].
Laws 1990, ch. 93, § 7.
Source: New Mexico Compilation Commission (nmonesource.com)URL: https://nmonesource.com/nmos/nmsa-unanno/en/item/18527/index.doFetched: 10/20/2026