N.M. Code R. § 8.308.9.21 - 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 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.

Notes

N.M. Code R. § 8.308.9.21

8.308.9.21 NMAC - N, 1-1-14, Adopted by New Mexico Register, Volume XXIX, Issue 08, April 24, 2018, eff. 5/1/2018