Section 14. Retroactive Medicaid

A. HCA must make eligibility for medicaid effective no later than the first or up to the third month before the month of application if the individual: (1) Requested coverage for months prior to the application month; (2) received medicaid services, at any time during that period, of a type covered under the plan and; (3) would have been eligible for medicaid at the time they received the services, if they had applied (or an authorized representative has applied for them) regardless of whether the individual is alive when application for medicaid is made. B. Eligibility for medicaid is effective on the first day of the month if an individual was eligible at any time during that month. C. Eligibility for each retroactive month is determined separately. Retroactive medicaid must be requested within 180 days of the date of the medicaid application. D. Retroactive medicaid is allowed for up to three months prior to the application month for the following medicaid categories: (1) other adults (COE 100); (2) parent caretaker (COE 200); (3) pregnant women (COE 300); (4) pregnancy-related services (COE 301); (5) children under age 19 (COEs 400, 401, 402, 403, 420, and 421); (6) family planning (COE 029); (7) children, youth and families department (CYFD COEs 017, 037, 046, 047, 066, and 086); (8) supplemental security income (SSI COEs 001, 003, and 004); (9) SSI (COEs 001, 003, and 004, e.g. 503s, disabled adult children, ping pongs, and early widowers); (10) working disabled individuals (COE 074); (11) breast and cervical cancer (BCC COE 052); (12) specified low income beneficiaries (SLIMB COE 045); (13) qualified individuals (QI1 COE 042); (14) qualified disabled working individuals (COE 050); (15) refugees (COE 049); and 8.200.400 NMAC 6 (16) institutional care medicaid (COEs 081, 083, and 084) excluding the program for all- inclusive care for the elderly (PACE). E. The following categories do not have retroactive medicaid: (1) emergency medical services for non-citizens EMSNC (COE 085) 5); (13) qualified individuals (QI1 COE 042); (14) qualified disabled working individuals (COE 050); (15) refugees (COE 049); and 8.200.400 NMAC 6 (16) institutional care medicaid (COEs 081, 083, and 084) excluding the program for all- inclusive care for the elderly (PACE). E. The following categories do not have retroactive medicaid: (1) emergency medical services for non-citizens EMSNC (COE 085). EMSNC provides coverage for emergency services, which may be provided prior to the application month, but is not considered retroactive medicaid. Eligibility is determined in accordance with 8.285.400, 8.285.500, and 8.285.600 NMAC; (2) home and community based-services waivers (COEs 091, 093, 094, 095, and 096); (3) PACE (COEs 081, 083, and 084); (4) qualified medicare beneficiaries (COEs 041 and 044); and (5) transitional medicaid (COEs 027 and 028). F. Newborns (COE 031) are deemed to have applied and been found eligible for the newborn category of eligibility from birth through the month of the child’s first birthday. This applies in instances where the labor and delivery services were furnished prior to the date of the application and covered by medicaid based on the mother applying for up to three months of retroactive eligibility. [8.200.400.14 NMAC - Rp, 8.200.400.14 NMAC, 1/1/2019; A, 2/1/2020; A, 1/1/2022; A/E, 10/1/2024; A, 2/1/2025] 8.200.400.15 NMAC AUTOMATIC ENROLLMENT OF SSI RECIPIENTS IN THE QMB GROUP: A. SSI recipients entitled to premium-free part A: Effective October 1, 2024, the HCA shall automatically deem SSI recipients into QMB the first month they are eligible for SSI Medicaid and entitled to premium-free part A. The start of the part B buy-in coverage is the first month of entitlement to premium-free part A and the QMB eligibility group coverage is the first day of the following month. B . SSI recipients entitled to premium-free part A: Effective October 1, 2024, the HCA shall automatically deem SSI recipients into QMB the first month they are eligible for SSI Medicaid and entitled to premium-free part A. The start of the part B buy-in coverage is the first month of entitlement to premium-free part A and the QMB eligibility group coverage is the first day of the following month. B. SSI recipients enrolled in part B only: Effective upon the centers for medicare and medicaid services (CMS) and HCA systems’ capacity, the HCA shall automatically deem individuals enrolled in SSI medicaid eligible for the QMB eligibility group the first month they are both enrolled in part B and eligible for a medicare enrollment period, bypassing the need for actual or conditional part A enrolment at the social security administration. C. Effective January 1, 2024, the HCA’s liability for retroactive part B premiums for full-benefit medicaid beneficiaries, including individuals receiving SSI medicaid, is limited to a period of no greater than 36 months prior to the date of the medicare enrollment determination. D. For SSI medicaid recipients deemed eligible for the QMB group, renewal for QMB is required only to the extent to verify that an individual continues to receive SSI medicaid and has continued medicare part A coverage. The regular renewal process for QMB applies when an individual loses their SSI medicaid.