Section 13. Assignment Of Support

As a condition of MAP eligibility, HCA requires an applicant or a re-determining eligible recipient to assign their medical care support rights to HCA for medical support and any third party payments. The assignment authorizes HCA to pursue and make recoveries from liable third parties (42 CFR 433.146; Subsection G of 27-2-28 NMSA 1978. A. Assigning medical support rights: The assignment to HCA of an eligible recipient’s rights to medical support and payments occurs automatically under New Mexico law when the applicant or the re- determining eligible recipient signs the application. B. Third party liability (TPL): This section describes HCA’s responsibility to identify and collect from primarily responsible third parties and the eligible recipient’s responsibility to cooperate with HCA to uncover such payments. MAD is the payer of last resort. If other third party resources are available, these health care resources must be used before MAD makes a reimbursement. As a condition of MAP eligibility, an applicant assigns their rights to physical and behavioral health support and payments to HCA and promises to cooperate in identifying, pursuing, and collecting payments from these resources. Third party resources include the gross recovery by eligible recipient, including personal injury protection benefits, before any reduction in attorney’s fees or costs, obtained through settlement or verdict, for personal injury negligence or intentional tort claims or actions, up to the full amount of MAD payments for treatment of injuries causally related to the occurrence that is the subject of the claim or action. (1) Required TPL information: During the initial determination or re-determination of eligibility for MAP enrollment, ISD must obtain information about TPL from either the applicant or the re- determining eligible recipient tentional tort claims or actions, up to the full amount of MAD payments for treatment of injuries causally related to the occurrence that is the subject of the claim or action. (1) Required TPL information: During the initial determination or re-determination of eligibility for MAP enrollment, ISD must obtain information about TPL from either the applicant or the re- determining eligible recipient. 8.200.430 NMAC 3 (a) HCA is required to take all reasonable measures to determine the legal liability of third parties, including health insurers in paying for the physical and behavioral health services furnished to an eligible recipient (42 CFR 433.138(a)). (b) HCA uses the information collected at the time of determination in order for MAD to pursue claims against third parties. (2) Availability of health insurance: If an applicant or an eligible recipient has health insurance, the applicant or the eligible recipient shall notify ISD. ISD must collect all relevant information, including name and address of the insurance company; individuals covered by the policy, effective dates, covered services, and appropriate policy numbers. (a) An applicant or an eligible recipient with health insurance coverage or coverage by a health maintenance organization (HMO) or other managed care plan (plan) must be given a copy of the TPL recipient information letter. (b) If there is an absent parent, ISD may request the absent parent's name and social security number (SSN). (c) ISD must determine if an absent parent, relative, applicant or any member of the household is employed and has health insurance coverage. (3) Eligible recipients with health insurance coverage: An applicant or an eligible recipient must inform their MAD providers of their TPL. An applicant or an eligible recipient must report changes to or terminations of insurance coverage to ISD umber (SSN). (c) ISD must determine if an absent parent, relative, applicant or any member of the household is employed and has health insurance coverage. (3) Eligible recipients with health insurance coverage: An applicant or an eligible recipient must inform their MAD providers of their TPL. An applicant or an eligible recipient must report changes to or terminations of insurance coverage to ISD. If an applicant or an eligible recipient has health coverage through an HMO or plan, payment from MAD is limited to applicable copayments required under the HMO or plan and to MAD covered services documented in writing as exclusions by the HMO or plan. (a) If the HMO or plan uses a drug formulary, the medical director of the HMO or plan must sign and attach a written certification for each drug claim to document that a pharmaceutical product is not covered by the HMO or plan. The signature is a certification that the HMO or plan drug formulary does not contain a therapeutic equivalent that adequately treats the physical or behavioral health condition of the HMO or plan subscriber. (b) Physical and behavioral health services not included in the HMO or plan are covered by MAD only after review of the documentation and on approval by MAD. (c) An applicant or an eligible recipient covered by an HMO or plan is responsible for payment of medical services obtained outside the HMO or plan and for medical services obtained without complying with the rules or policies of the HMO or plan. (d) An applicant or an eligible recipient living outside an HMO or plan coverage area may request a waiver of the requirement to use HMO or plan providers and services. The applicant or the eligible recipient for whom a coverage waiver is approved by MAD may receive reimbursement for expenses which allow them to travel to an HMO or plan participating provider, even when the provider is not located near the applicant or the eligible recipient's residence an HMO or plan coverage area may request a waiver of the requirement to use HMO or plan providers and services. The applicant or the eligible recipient for whom a coverage waiver is approved by MAD may receive reimbursement for expenses which allow them to travel to an HMO or plan participating provider, even when the provider is not located near the applicant or the eligible recipient's residence. (4) Potential health care resources: ISD must evaluate the presence of a TPL source if certain factors are identified during the MAD eligibility interview. (a) When the age of the applicant or the eligible recipient is over 65 years old medicare must be explored. A student, especially a college student, may have health or accident insurance through their school. (b) An application on behalf of deceased individual must be examined for "last illness" coverage through a life insurance policy. (c) Certain specific income sources are indicators of possible TPL which include: (i) railroad retirement benefits and social security retirement or disability benefits indicating eligibility for Title XVIII (medicare) benefits; (ii) workers' compensation (WC) benefits paid to employees who suffer an injury or accident caused by conditions arising from employment; these benefits may compensate employees for physical and behavioral health expenses and lost income; payments for physical and behavioral health expenses may be made as physical and behavioral health bills are incurred or as a lump sum award; (iii) black lung benefits payable under the coal mine workers' compensation program, administered by the federal department of labor (DOL), can produce benefits similar to railroad retirement benefits if the treatment for illness is related to the diagnosis of pneumoconiosis; beneficiaries are reimbursed only if services are rendered by specific providers, authorized by the DOL; black lung payments are made monthly and physical and behavioral health expenses are paid as they are incurred; and (iv) Title IV-D support payments or financi an produce benefits similar to railroad retirement benefits if the treatment for illness is related to the diagnosis of pneumoconiosis; beneficiaries are reimbursed only if services are rendered by specific providers, authorized by the DOL; black lung payments are made monthly and physical and behavioral health expenses are paid as they are incurred; and (iv) Title IV-D support payments or financial support payments from an 8.200.430 NMAC 4 absent parent may indicate the potential for physical and behavioral health support; if a custodial party does not have health insurance that meets a minimum standard, the court in a divorce, separation or custody and support proceeding may order the parent(s) with the obligation of support to purchase insurance for the eligible recipient child (45 CFR 303.31(b)(1); Paragraph (1) of Subsection A of Section 40-4C-4 NMSA 1978; insurance can be obtained through the parent's employer or union (Paragraph (2) of Subsection A of Section 40-4C-4 NMSA 1978; parents may be ordered to pay all or a portion of the physical and behavioral health expenses; for purposes of physical l and behavioral health support, the minimum standards of acceptable coverage, deductibles, coinsurance, lifetime benefits, out-of-pocket expenses, co-payments, and plan requirements are the minimum standards of health insurance policies and managed care plans established for small businesses in New Mexico; see New Mexico insurance code. (d) An applicant or an eligible recipient has earned income: Earned income may indicate physical, behavioral health and health insurance made available by an employer. (e) Work history or military services: Work history may indicate eligibility for other cash and physical and behavioral benefits s and managed care plans established for small businesses in New Mexico; see New Mexico insurance code. (d) An applicant or an eligible recipient has earned income: Earned income may indicate physical, behavioral health and health insurance made available by an employer. (e) Work history or military services: Work history may indicate eligibility for other cash and physical and behavioral benefits. Previous military service suggests the potential for veterans administration (VA) or department of defense (DOD) health care, including the civilian health and the medical program of the United States (CHAMPUS), for individuals who reside within a 40-mile radius of a military health care facility. An applicant or an eligible recipient who is eligible for DOD health care must obtain certification of non-availability of medical services from the base health benefits advisor in order to be eligible for CHAMPUS. (f) An applicant or an eligible recipient's expenses show insurance premium payments: Monthly expense information may show that the applicant or the eligible recipient pays private insurance premiums or is enrolled in an HMO or plan. (g) The applicant or the eligible recipient has a disability: Disability information contained in applications or brought up during interviews may indicate casualties or accidents involving legally responsible third parties. (h) The applicant or the eligible recipient has a chronic disease: Individuals with chronic renal disease are probably entitled to medicare. Applications for social security disability may be indicative of medicare coverage. (5) Communicating TPL information: Information concerning health insurance or health plans is collected and transmitted to MAD by ISD, child support enforcement division (CSED), SSA, and the children, youth and families department (CYFD). [8.200.430.13 NMAC - Rp, 8.200.430.13 NMAC, 1/1/2014; A, 10/15/2014; A, 11/1/2024] 8.200.430.14 ELIGIBLE RECIPIENT RESPONSIBILITY TO COOPERATE WITH ASSIGNMENT OF SUPPORT RIGHTS: A TPL information: Information concerning health insurance or health plans is collected and transmitted to MAD by ISD, child support enforcement division (CSED), SSA, and the children, youth and families department (CYFD). [8.200.430.13 NMAC - Rp, 8.200.430.13 NMAC, 1/1/2014; A, 10/15/2014; A, 11/1/2024] 8.200.430.14 ELIGIBLE RECIPIENT RESPONSIBILITY TO COOPERATE WITH ASSIGNMENT OF SUPPORT RIGHTS: A. Cooperation: As a condition of MAP eligibility, an applicant or an eligible recipient must cooperate with HCA to: (1) obtain physical and behavioral health support and payments for them and other individuals for whom they can legally assign rights; (2) pursue liable third parties by identifying individuals and providing information to HCA; (3) cooperate with CSED to establish paternity and medical support as appropriate, see 8.50.105.12 NMAC; (4) appear at a state or local office designated by HCA to give information or evidence relevant to the case, appear as a witness at a court or other proceeding or give information or attest to lack of information, under penalty of perjury; (5) refund HCA any money received for physical or behavioral health care that has already been paid; this includes payments received from insurance companies, personal injury settlements, and any other liable third party; and (6) respond to the trauma inquiry letter that is mailed to an eligible recipient (42 CFR 433.138(4); the letter asks an eligible recipient to provide more information about possible accidents, causes of accidents, and whether legal counsel has been obtained (42 CFR 433.147; 45 CFR 232.42, 232.43; Paragraph (3) of Subsection G of Section 27-2-28 NMSA 1978. B. Good cause waiver of cooperation: The requirements for cooperation may be waived by HCA if it decides that the applicant or the eligible recipient has good cause for refusing to cooperate. Waivers can be obtained for cooperating with CSED. The applicant or the eligible recipient should request a good cause waiver from CSED per 8.50.105.14 NMAC. C 3) of Subsection G of Section 27-2-28 NMSA 1978. B. Good cause waiver of cooperation: The requirements for cooperation may be waived by HCA if it decides that the applicant or the eligible recipient has good cause for refusing to cooperate. Waivers can be obtained for cooperating with CSED. The applicant or the eligible recipient should request a good cause waiver from CSED per 8.50.105.14 NMAC. C. Penalties for failure to cooperate: 8.200.430 NMAC 5 (1) When the parent, the specified relative or legal guardian fails or refuses to cooperate, the parent or specified relative will not be eligible for MAD services. The eligible recipient child maintains MAP eligibility provided all other eligibility criteria are met. (2) When the parent or the specified relative fails or refuses to refund payments received from insurance or other settlement sources, such as personal injury case awards, they are not eligible for MAD services for one year and until full restitution has been made to HCA. The eligible recipient child maintains MAP eligibility provided all other eligibility criteria are met. [8.200.430.14 NMAC - Rp, 8.200.430.14 NMAC, 1/1/2014; A, 10/15/2014; A, 11/1/2024] 8.200.430.15 ELIGIBLE RECIPIENT RESPONSIBILITY TO GIVE PROVIDER PROPER IDENTIFICATION AND NOTICE OF ELIGIBILITY CHANGES: A. An eligible recipient is responsible for presenting a current MAP eligibility card and evidence of any other health insurance to a MAD provider each time service is requested. (1) An eligible recipient is responsible for any financial liability incurred if they fail to furnish current MAP eligibility identification before the receipt of a service and as a result the provider fails to adhere to MAD rules, such as a failure to request prior approval. If this omission occurs, the settlement of claims for services is between the eligible recipient and the provider. An individual is financially responsible for services received if they were not eligible for MAD services on the date services are furnished fication before the receipt of a service and as a result the provider fails to adhere to MAD rules, such as a failure to request prior approval. If this omission occurs, the settlement of claims for services is between the eligible recipient and the provider. An individual is financially responsible for services received if they were not eligible for MAD services on the date services are furnished. (2) When a provider bills MAD and the claim is denied, the provider cannot bill the eligible recipient. Exceptions exist for denials caused by MAP ineligibility or by an eligible recipient's failure to furnish MAP identification in a timely manner. (3) If an eligible recipient fails to notify the provider that they have received services that are limited by time or amount, the eligible recipient is responsible for payment of the service prior to rendering the service if the provider made reasonable efforts to verify whether the eligible recipient has already received services. B. Notification of providers following retroactive eligibility determinations: If an eligibility determination is made, the eligible recipient is responsible for notifying MAD providers of this eligibility determination. When an individual receives retro MAP eligibility, the now-eligible recipient must notify all of their MAD providers of their change of eligibility. If the eligible recipient fails to notify the provider and the provider can no longer file a claim for reimbursement, the eligible recipient becomes the responsible payer for those services. C. Notification if an eligible recipient has private insurance: If an eligible recipient is covered under a private health insurance policy or health plan, they are required to inform their MAD providers of the private health coverage, including applicable policy numbers and special claim forms.