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Acute Care Services
Long-Term Care Services


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Benefits by State: New Mexico (October 2008) Notes
 
 
 
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Acute Care Services

Is the Benefit Covered? Copayment Requirement Prior Approval Requirement Coverage Limitations Reimbursement Methodology Populations Covered


Institutional and Clinic Services
Clinic Services, by an organized facility or clinic not part of a hospital: Freestanding Ambulatory Surgery Center
Yes Fee for service using Medicare methodology for grouping surgical procedures CN
Clinic Services, by an organized facility or clinic not part of a hospital: Public Health and Mental Health Clinics
Yes A - $5/visit, B - $7/visit non-preventive services - see state-specific FN Fee for service CN
Federally Qualified Health Center Services
Yes A - $5/visit, B - $7/visit non-preventive services - see state-specific FN Prospective cost based rate/encounter CN
Inpatient Hospital Services, other than in an Institution for Mental Diseases
Yes A - $25/admission, B - $30/admission - see state-specific FN Prospective payment/discharge using DRG for general acute care hospitals, cost based payment with limits for rehab and specialty hospitals CN
Outpatient Hospital Services
Yes A - $15/non-emergency visit to ER and $5/visit for other services, B - $20/non-emergency visit to ER and $5/visit for other services - see state-specific FN Allergy testing and treatment, therapies Cost based payment with limits CN
Rehabilitation Services: Mental Health and Substance Abuse
Yes A - $5/visit, B - $7/visit - see state-specific FN Fee for service CN
Rural Health Clinic Services
Yes A - $5/visit, B - $7/visit non-preventive services - see state-specific FN Prospective cost based rate/encounter CN
Practitioner Services
Certified Registered Nurse Anesthetist Services
Yes Fee for service CN
Chiropractor Services
No
Dental Services
Yes A - $5/visit, B - $7/visit non-preventive services - see state-specific FN Specified services Exam and cleaning 1/year, frequency of x-rays limited by type, specified limits on endodontic, periodontic and restorative services Fee for service CN
Medical and Remedial Care - Other Practitioners
Medical/Surgical Services of a Dentist
Yes A - $5/visit, B - $7/visit - see state-specific FN Services provided on an inpatient hospital basis Fee for service CN
Nurse Midwife Services
Yes A - $5/visit, B - $7/visit non-preventive services - see state-specific FN Fee for service CN
Nurse Practitioner Services
Yes A - $5/visit, B - $7/visit non-preventive services - see state-specific FN Fee for service at 90% of physician fee for independent practitioners CN
Optometrist Services
Yes A - $5/visit, B - $7/visit - see state-specific FN 1 refractive exam/2 years Fee for service CN
Physician Services
Yes A - $5/visit, B - $7/visit non-preventive services - see state-specific FN Specified surgical procedures, allergy testing and treatment 2 inpatient hospital or NF visits/day, 3 physical medicine or manipulative therapy visits/month Fee for service, some services performed in hospital setting paid 60% of fee CN
Podiatrist Services
Yes A - $5/visit, B - $7/visit - see state-specific FN Specified services including routine foot care Coverage parameters follow Medicare criteria Fee for service, some services performed in hospital setting paid 60% of fee CN
Psychologist Services
Yes A - $5/visit, B - $7/visit - see state-specific FN Specified services Fee for service CN
Prescription Drugs
Prescription Drugs
Yes A - $3/Rx up to $12/month, B - $5/Rx - see state-specific FN Rx must be generic unless DAW, mail order dispensing permitted AWP-14%, plus $3.65 dispensing fee CN
Physical Therapy and Other Services
Occupational Therapy Services
Yes A - $5/visit, B - $7/visit - see state-specific FN Yes Fee for service CN
Physical Therapy Services
Yes A - $5/visit, B - $7/visit - see state-specific FN Yes Fee for service CN
Services for Speech, Hearing and Language Disorders
Yes A - $5/visit, B - $7/visit - see state-specific FN Yes Audiological testing and evaluation require physician order Fee for service CN
Products and Devices
Dentures
Yes Yes Fee for service CN
Eyeglasses
Yes 1 pair/2 years, replacement of lost or broken pairs only covered for developmentally disabled adults Acquisition cost with ceilings CN
Hearing Aids
Yes New or replacement hearing aid 1 hearing aid/4 years Cost up to $1400/hearing aid plus dispensing fee CN
Medical Equipment and Supplies
Yes Specified med equipment items Most med equipment items covered only once/3 years, specified monthly quantity limits for medical supplies, custom wheelchair requires prior PT and/or OT evaluation Fee for service using Medicare payment ceilings CN
Prosthetic and Orthotic Devices
Yes Specified services or items Most items covered only once/3 years, orthopedic shoes must be attached to brace Fee for service using Medicare payment ceilings, some items paid invoice cost plus percentage CN
Transportation Services
Ambulance Services
Yes Fee for service CN
Non-Emergency Medical Transportation Services
Yes Transportation to pharmacy for prescription pick-up not covered See service-specific FN CN
Other Services
Diagnostic, Screening and Preventive Services
No
Early and Periodic Screening, Diagnosis and Treatment
See service-specific FN.
Extended Services for Pregnant Women
Family Planning Services
See service-specific FN.
Laboratory and X-Ray Services, outside Hospital or Clinic
Yes Specified services Fee for service using Medicare payment ceilings CN
Targeted Case Management
Yes Fee for service CN


Long-Term Care Services

Community Based Care
Home and Community Based Services Waiver
Yes Services for the following populations: 2, 4, 5 & 8 - See service-specific FN Dependent upon the services provided CN
Home Health Services, includes nursing services, home health aides, and medical supplies/equipment
Yes A - $5/visit, B - $7/visit - see state-specific FN Yes Cost based payment with limits CN
Hospice Care
Yes Yes Prospective rates based on Medicare methodology CN
Personal Care Services
Yes Yes Fee for service CN
Private Duty Nursing Services
No
Program of All-Inclusive Care for the Elderly
Yes Yes Contracted rate CN
Institutional Care
Inpatient Hospital, Nursing Facility and Intermediate Care Facility Services In Institutions for Mental Diseases, age 65 and older
Yes Admission Cost based payment with limits CN
Inpatient Psychiatric Services, under age 21
Yes Cost based payment with limits CN
Intermediate Care Facility Services for the Mentally Retarded
Yes 65 leave days/year of any type with additional 6 days allowed if approved plus 6 leave days for discharge planning Prospective cost based per diem with limits CN
Nursing Facility Services, other than in an Institution for Mental Diseases
Yes Admission 6 leave days/year of any type with additional 6 days allowed if approved Prospective per diem based on cost, with limits, leave days paid at 50% of per diem rate CN
Religious Non-Medical Health Care Institution and Practitioner Services
No


Notes: This State has added the optional Medicaid buy-in group of disabled adults permissible through the Balanced Budget Act of 1997 in its Working Disabled Individuals program. These beneficiaries are allowed to continue Medicaid coverage, and receive full benefits, if their income is at or below 250 percent of the federal poverty level (FPL). Beneficiaries in this group, as well as women with income between 133 percent and 250 percent of the FPL who qualify for Medicaid through the State’s Breast and Cervical Cancer Program (BCCP) are required to make copayments for some services. Traditional Medicaid beneficiaries have no copayment requirements. Copayment amounts for the BCCP beneficiaries are identified on the tables as “A” and copayment amounts for the buy-in beneficiaries are identified as “B.” There are annual income-based cost sharing limits for each group.
 
 
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