Section 21. Alternative Benefits Plan (Abp) Benefits For Abp Mco Members

The MAD category of eligibility “other adults” has an alternative benefit plan (ABP). The MCO shall cover the ABP specific services for an ABP member. Services are made available through a MCO under a benefit plan similar to services provided by commercial insurance plans. ABP benefits include preventive services and treatment services. An ABP member: A. has limitations on specific benefits; B. does not have all standard medicaid state plan benefits available; and C. has some benefits, primarily preventive services that are available only to an ABP member. The ABP benefits and services are detailed in Sections 12 through 18 of 8.309.4 NMAC. All EPSDT services are 8.308.9 NMAC 14 available to an ABP member under 21 years. Services for an ABP member under the age of 21 years not subject to the duration, frequency, and annual or lifetime benefit limitations that are applied to an ABP eligible recipient 21 years of age and older. The MCO shall comply with all HSD contractual provisions and with all NMAC rules that pertain to the MCO’s responsibilities to its members as listed below: (1) provider networks found in 8.308.2 NMAC; (2) managed care eligibility found in 8.308.6 NMAC; (3) enrollment and disenrollment from managed care found in 8.308.7 NMAC; (4) managed care member education - rights and responsibilities found in 8.308.8 NMAC; (5) care coordination found in 8.308.10 NMAC; (6) transition of care found in 8.308.11 NMAC; (7) managed care cost sharing found in 8.308.14 NMAC; (8) managed care grievance and appeals found in 8.308.15 NMAC; (9) managed care reimbursement found in 8.308.20 NMAC; (10) quality management found in 8.308.21 NMAC; and (11) managed care fraud, waste and abuse found in 8.308.22 NMAC. [8.308.9.21 NMAC - Rp, 8.308.9.21 NMAC, 5/1/2018] 8.308.9.22 MAD ALTERNATIVE BENEFITS PLAN GENERAL BENEFITS FOR ABP EXEMPT MEMBERS (ABP exempt): An ABP member who self-declares they have a qualifying condition is evaluated by their MCO for determination if they meet an ABP qualifying condition y management found in 8.308.21 NMAC; and (11) managed care fraud, waste and abuse found in 8.308.22 NMAC. [8.308.9.21 NMAC - Rp, 8.308.9.21 NMAC, 5/1/2018] 8.308.9.22 MAD ALTERNATIVE BENEFITS PLAN GENERAL BENEFITS FOR ABP EXEMPT MEMBERS (ABP exempt): An ABP member who self-declares they have a qualifying condition is evaluated by their MCO for determination if they meet an ABP qualifying condition. An ABP exempt member may select to no longer utilize their ABP benefits package. Instead, the ABP exempt member will utilize their MCO’s medicaid benefits package. See 8.308.9.11-20 NMAC for detailed description of the MCO medicaid benefit services. All services, services limitations and co-payments that apply to full benefit medicaid recipients apply to APB-exempt recipients. An ABP-exempt recipient does not have access to the benefits that only apply to ABP recipients. The ABP co-payments do not apply to an ABP-exempt recipient. The limitations on services that apply only to ABP- recipients do not apply to ABP-exempt recipients. The MCO shall comply with all HSD contractual provisions and with all NMAC rules that pertain to the MCO’s responsibilities to its members as listed below: A. provider networks found in 8.308.2 NMAC; B. managed care eligibility found in 8.308.6 NMAC; C. enrollment and disenrollment from managed care found in 8.308.7 NMAC; D. managed care member education - rights and responsibilities found in 8.308.8 NMAC; E. care coordination found in 8.308.10 NMAC; F. transition of care found in 8.308.11 NMAC; G. community benefits found in 8.308.12 NMAC; H. managed care member rewards found in 8.308.13 NMAC I. managed care cost sharing found in 8.308.14 NMAC; J. managed care grievance and appeals found in 8.308.15 NMAC; K. managed care reimbursement found in 8.308.20 NMAC; L. quality management found in 8.308.21 NMAC; and M. managed care fraud, waste and abuse found in 8.308.22 NMAC.