Here - National Academy for State Health Policy

June, 2014
New Mexico Human Services Department, Medical Assistance Division
PRESUMPTIVE ELIGIBILITY AND
PRESUMPTIVE ELIGIBILITY PLUS (PE+)
TRAINING MANUAL
TABLE OF CONTENTS
Chapter 1 - Medicaid Overview_______________________________________________ 5
Medicaid __________________________________________________________________
New Mexico Medicaid _______________________________________________________
Medicaid for Children ________________________________________________________
Centennial Care_____________________________________________________________
Fee for Servie Medicaid ______________________________________________________
Medicaid and the Affordable Care Act___________________________________________
Medicaid Expansion _________________________________________________________
Former Foster Care Coverage__________________________________________________
Centennial Care Managed Care Organizations ____________________________________
Choosing a Managed Care Organization _________________________________________
Value-Added Services ________________________________________________________
Centennial Care Managed Care Organization Contact Information ____________________
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Chapter 2 - Medicaid Presumptive Eligibility and Presuptive Eligibility Determiners _ 10
Presumptive Eligibility ______________________________________________________
Presumptive Eligibility Determiners ____________________________________________
Entities Eligible to Participate as Presumptive Eligibility Determiners _________________
Certification and Training ____________________________________________________
Performance Standards _____________________________________________________
Corrective Action Plan ______________________________________________________
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Chapter 3 - Presumptive Eligibility Determiner Specialty Types ___________________ 16
Presumptive Eligibilty Determiner Specialty Types ________________________________ 16
Presumptive Eligibility Determiners - Specialty Type 170 ___________________________ 16
Presumptive Eligibility Determiners - Specialty Type 171 ___________________________ 17
Chapter 4 - New Mexico Medicaid Categories Eligible for Presumptive Eligibililty ___ 18
Category 100 - Medicaid for Other Adults ______________________________________
Category 200 - Medicaid for Parent/Caretakers __________________________________
Category 300 - Pregnancy Medicaid____________________________________________
Category 301 - Pregnancy-Related Services______________________________________
Categories 400, 401, 402 and 403 - Regular Medicaid for Children ___________________
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Categories 420 and 421 - Children's Health Insurance Program (CHIP) ________________ 24
Chapter 5 - Systems to Be Utilized By Presumptive Eligibility Determiners _________ 25
New Mexico Medicaid Portal _________________________________________________
Your Eligibilty System New Mexico for Presumptive Eligibility Determiners (YESNM-PE)__
Enrolling as a Presumptive Eligibility Determiner on the Portal ______________________
Registering as a User on the Portal ____________________________________________
Registering as a User on YESNM-PE ____________________________________________
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Chapter 6 - Electronic Screening for Presumptive Eligibility ______________________ 40
Checking Applicant Eligibility on the Portal ______________________________________ 40
Screening for Presumptive Eligibility on YESNM-PE _______________________________ 44
Entering a Presumptive Eligibility Approval on the Portal ___________________________58
Chapter 7 - Manual Screening for Presumptive Eligibility ________________________ 65
Chapter 8 - Completing Manual Forms _______________________________________ 67
Completing MAD 100 for Presumptive Eligibililty _________________________________ 67
Completing MAD 011 for Presumptive Eligibility _________________________________ 71
Chapter 9 - Manual Calculation of Household Size ______________________________ 73
Chapter 10 - Manually Calculating Medicaid Financial Eligibility __________________ 76
Federal Poverty Level Chart __________________________________________________ 76
Chapter 11 - Submitting Presumptive Eligibilty Approvals by Fax _________________ 79
Completing MAD 070 _______________________________________________________ 79
Chapter 12 - Submitting Paper Applications ___________________________________ 81
Submitting Applications for Ongoing Coverage ___________________________________
Central ASPEN Scanning Area (CASA)___________________________________________
Submitting Presumptive Eligibility Applicant Information Sheet _____________________
Presumptive Eligibilty Program Staff Contact Information __________________________
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Chapter 13 - Documents That May be Needed for Ongoing Medicaid- _____________ 83
Documents to Prove Citizenship, Immigrations Status and Identity __________________ 83
NM Department of Health Vital Records Web Portal ______________________________ 84
Proof of Income ___________________________________________________________ 84
Chapter 14 - Glossary and Acronyms _________________________________________ 85
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Chapter 15 - Quick Reference Information, Forms, Checklists and Worksheets ______ 92
Section 1 - Quick Reference Information
 Presumptive Eligibilty Contact and Resource Sheet
 Flow Process for Pesumptive Eligibility Training and Certification
 New Mexico Medicaid Web Portal and YESNM-PE Registration Workflow
 Electronic Presumptive Eligibility Screening Process Workflow
 Manual Screening for Presumptive Eligibility Workflow
 Federal Poverty Level with ACA Categories of Eligibity (MAD 222)
 Medicaid Categories of Eligibility
 Applicant Rights and Responsibilities - English
 Applicant Rights and Responsibilities - Spanish
 YESNM-PE Electronic Signature Page - English
 YESNM-PE Electronic Signature Page - Spanish
Section 2 - Forms
 Presumptive Eigibility Determiner Agreement and Code of Conduct (MAD 219)
 Medicaid-Only Application - English (MAD 100)
 Medicaid-Only Application - Spanish (MAD 100 SP)
 Presumptive Eligibity Applicant Information form - English (MAD 011)
 Presumptive Eligibity Applicant Information form - Spanish (MAD 011 SP)
 Presumptive Eligibity Authorization Form (MAD 070)
Section 3 - Checklists and Worksheets
 How to Determine Household Size flowchart
 Household Comp and Income Calculation Worksheet (MAD 008)
 Manual Presumptive Eligibility Submission Checklist
o For Applicants Who Wish to Apply for Ongoing Medicaid Coverage
o For Applicants Who DO NOT Wish to Apply for Ongoing Medicaid Coverage
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Chapter 1 - Medicaid Overview
Medicaid
Medicaid is a partnership between each state and the federal government to provide low-cost or no
cost health insurance to low-income individuals, families and some disabled individuals. States
establish their own eligibility standards and determine the type, rate of payment, duration and scope
of services based on parameters set by the United States Health and Human Services Department's
Centers for Medicare and Medicaid Services (CMS).
In New Mexico, the Human Services Department's (HSD) Medical Assistance Division (MAD)
administers the Medicaid program. The HSD's Income Support Division (ISD) determines eligibility for
all HSD programs but in some instances, Medicaid applications may be routed to MAD for processing
Eligibility for all Medicaid programs is based on citizenship/immigration status, residency, income and
other factors. The income guidelines used to determine Medicaid eligibility are based on the Federal
Poverty Levels (FPL) as set by the United States Health and Human Services Department. FPLs are set
based on household size and total income.
Although there is no cost to enroll in Medicaid, some categories of eligibility may require minimal co pays for doctor visits, emergency room care and prescriptions. Benefit packages vary for different
categories of eligibility.
New Mexico Medicaid
Currently, New Mexico has approximately 40 categories of Medicaid eligibility. Some of these
categories include coverage for children, families, pregnant women, adults, long-term care recipients
and individuals who are eligible for both Medicare and Medicaid benefits. All New Mexico Medicaid
Categories of Eligibility (COEs) have a designated numeric COE listing associated with the COE name. A
full listing of these COEs can be found at:
http://www.hsd.state.nm.us/uploads/files/Looking%20For%20Information/General%20Information/R
ules%20and%20Statutes/Medical%20Assistance%20Division/MAD%20NMAC%20Eligibility%20Program
%20Manual/Eligibility%20Pamphlet%20011514.pdf
Medicaid services in New Mexico are provided to most recipients through Centennial Care. Centennial
Care is the name of the New Mexico Medicaid Managed Care program. Native Americans who are
eligible for both Medicare and Medicaid or need nursing facility level of care are required to be
enrolled in Centennial Care. All other Native Americans can choose to enroll in Centennial Care or
access services through Fee for Service Medicaid.
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Coverage for most Medicaid programs must be renewed every 12 months. To renew, recipients should
ensure that all information on file with HSD is up-to-date and accurate. Any changes in address,
income, family size, pregnancy status or other factors that could affect eligibility should be reported to
HSD/ISD. When a recipient's renewal date is approaching, HSD will send the recipient a notice
informing them that it is time to renew. Any individual who does not complete the required renewal
process or respond to HSD's request for more information may lose eligibility and their Medicaid
coverage.
Some applicants may be eligible for up to three months of Retroactive Medicaid coverage. This
coverage may be able to assist with payment of any outstanding medical bills incurred in the threemonth retroactive time frame. To be eligible, the applicant must have met the eligibility standards in
the prior months requested. The category of eligibility must also have been in effect in the prior
months that the retroactive coverage is requested.
Medicaid for Children
Medicaid coverage may be available for children in families with household income up to 300% of the
FPL for children who are five years old and younger; or up to 240% FPL for children between six and 18
years-old. Children's Medicaid coverage is provided through regular Medicaid or through the
Children's Health Insurance Program (CHIP). CHIP coverage is generally available to children in families
with incomes at the higher income threshold of Medicaid eligibility. Unlike regular children's Medicaid
coverage, CHIP may have minimal co-pays for some services. In New Mexico, a recipient's enrollment
in regular Medicaid or CHIP coverage is evident by the enrolled category of eligibility (COE). Regular
Medicaid COEs include categories 400, 401, 402 and 403, while CHIP COEs are categories 420 and 421.
Centennial Care
Most New Mexico Medicaid recipients, including Native Americans who choose to enroll in Managed
Care, will access their care through a Managed Care Organization (MCO). An MCO is an insurance
company that contracts with providers and medical facilities to provide healthcare to its members.
New Mexico's Medicaid Managed Care program is called Centennial Care.
Centennial Care offers a full spectrum of physical health, behavioral health, and long-term care
services, including the Community Benefit. The Community Benefit includes services like adult day
health, respite care and personal care services that help to keep people in their homes and
communities.
Individuals who are enrolled in Centennial Care may have a Care Coordinator assigned to help them
manage and coordinate services. Care Coordinators will be assigned to members based on a Health
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Risk Assessment (HRA) that will be given to each Centennial Care enrollee. The HRAs may be given in
person or by phone and are conducted by the member’s MCO.
In Centennial Care, some categories of eligibility may require minimal co-pays; however, Native
Americans are exempt from these co-pays.
Fee for Service Medicaid
Most Native Americans are not required to be in Centennial Care but can choose to enroll if they wish.
Native Americans who are eligible for both Medicare and Medicaid or require a nursing facility level of
care are required to be in Centennial Care. Native Americans who do not enroll in Centennial Care will
receive their services through Fee-for-Service (FFS) Medicaid. FFS covers the basic Medicaid benefit
package, such as preventive, specialty and behavioral health services, and emergency care. Enhanced
Centennial Care services such as care coordination and an MCO's Value-Added Services are not
available to FFS recipients.
There are no co-pays for Native Americans enrolled in the New Mexico Medicaid program, whether
they are in Centennial Care or FFS Medicaid. Native Americans enrolled in Centennial Care or in FFS
Medicaid can get care from any Indian Health Services (IHS) facility or Tribal Health Clinic. Native
Americans who enroll in Centennial Care can also keep their same doctor(s) at IHS.
If a Native American is enrolled in Centennial Care, their MCO would pay the IHS doctors, lab,
pharmacy, and other services. If the member needs to be referred to a specialist outside of IHS, the
MCO would pay for the visit and, if needed, help arrange the transportation and/or cover the cost of
transportation to the visit.
Medicaid and the Affordable Care Act
The Patient Protection and Affordable Care Act (ACA) is a United States federal statute signed into law
by President Barack Obama on March 23, 2010. The ACA was enacted with the goals of increasing the
quality and affordability of health insurance, lowering the uninsured rate by expanding public and
private insurance coverage, and reducing the costs of healthcare for individuals and the government. It
introduced a number of mechanisms—including mandates, subsidies, and insurance exchanges—
meant to increase coverage and affordability.
Medicaid Expansion
One of the new health coverage options that the ACA has created includes an expanded Medicaid
category for low-income adults. The Medicaid Expansion, as it is commonly called, provides coverage
for a new adult population that was not eligible for Medicaid in the past.
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The Medicaid Expansion has its own set of eligibility requirements. As with most categories of
Medicaid, this means that recipients must meet certain guidelines to be enrolled. These guidelines
include citizenship, residency and income requirements that are based on the Federal Poverty Level
(FPL). To be eligible for the Medicaid Expansion, individuals must have income that is at or below
133% of the FPL. Individuals with income between 134%-138% FPL may be eligible for a 5% of 100% of
FPL income disregard that may make them eligible for coverage. The Medicaid Expansion is for nonpregnant individuals 19-64 years old. The Medicaid Expansion cannot cover individuals who are
eligible for and/or receiving Medicare.
Individuals who receive coverage under the Medicaid Expansion have a different benefit package than
Standard Medicaid, which is called the Alternative Benefit Plan (ABP). A list of benefits covered under
the ABP and a comparison of these benefits to Standard Medicaid can be found online at:
http://www.hsd.state.nm.us/LookingForInformation/client-co-payments.aspx. The ABP includes
nominal co-pays for certain services, depending on the income level of the recipient. Like other
Medicaid categories, Native Americans recipients are exempt from these co-pays.
Former Foster Care Coverage
In addition to the Medicaid Expansion, the ACA requires states to cover individuals who were formerly
recipients of foster care, up to age 26. New Mexico covers these individuals when they were recipients
of foster care in New Mexico, but not when they received foster care in another state. These
individuals are eligible for the full Standard Medicaid benefit package and must enroll in Centennial
Care.
Centennial Care Managed Care Organizations
Most Medicaid recipients, including Native Americans who choose to be in Centennial Care and those
who require a nursing facility level of care, will get their services from one of four Centennial Care
MCOs. An MCO is an insurance company that contracts with providers and medical facilities to provide
healthcare to its members. The four MCOs that provide Centennial Care services are:
• Blue Cross Community Centennial
• Molina Health Care of New Mexico, Inc.
• Presbyterian Health Plan, Inc.
• UnitedHealthcare Community Plan of New Mexico
Choosing a Managed Care Organization
Centennial Care members choose one of the four Centennial Care MCOs to provide their coverage.
Medicaid applicants, including Native Americans who choose to be in Centennial Care, are encouraged
to select an MCO at the time of application submission. This includes individuals who are applying for
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Presumptive Eligibility. Native Americans who do not want to be enrolled in Centennial Care should
identify themselves as Native American on their application and do not need to enter an MCO choice.
Any Medicaid applicant who does not indicate that he/she is Native American and does not choose an
MCO will be automatically assigned to an MCO.
Value-Added Services
All four Centennial Care MCOs offer the same basic benefits for each approved Medicaid category of
eligibility. MCOs also offer Value-Added Services to their members. These are additional benefits that
the MCOs are not contractually obligated to offer. Value-Added Services are submitted to and
approved by HSD/MAD. These benefits vary from one MCO to the next and may also vary depending
on the member's approved category of eligibility. An MCO's Value-Added Services are not available
through Fee For Service Medicaid or during the Presumptive Eligibility approval span.
Before a Medicaid recipient enrolls with any one of the MCOs, he/she should ensure that his/her
providers are contracted with that MCO. Recipients should also evaluate the MCO's Value-Added
Services to see which benefits best meet their needs. Providers Directories and information on ValueAdded Services can be accessed on each MCO’s web site or by calling the MCO's Member Services
phone line.
Centennial Care Managed Care Organization Contact Information
Blue Cross Community Centennial
(866) 689-1523
www.bcbsnm.com/coverage/medicaid
Molina Health Care of New Mexico, Inc.
(877) 373-8986
www.molinahealthcare.com/en-us/Pages/home.aspx
Presbyterian Health Plan, Inc.
(888) 977-2333
www.phs.org/pages/default.aspx
UnitedHealthcare Community Plan of New Mexico
(877) 236-0826
www.uhccommunityplan.com/
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Chapter 2 - Medicaid Presumptive Eligibility and Presumptive Eligibility Determiners
Presumptive Eligibility
Presumptive Eligibility (PE) is short-term Medicaid coverage for eligible individuals. PE is not available
for every Medicaid category of eligibility but is available for children, pregnant women, former foster
care recipients, and some adults.
The goal of presumptive eligibility is to provide access to immediate care for eligible recipients and to
ensure assistance with application submission and possible ongoing Medicaid coverage for those
individuals. Individuals who are initially screened for PE are done so based on some of the same
qualifying factors that help to determine ongoing eligibility. Individuals who are accurately screened
for PE are most likely to be approved for ongoing coverage.
To be eligible for PE, applicants must meet citizenship requirements. These requirements state that
individuals applying for coverage must be a US Citizen, a US National or an eligible immigrant.
Applicants are not required to supply a Social Security Number (SSN) to be screened or approved for PE
but are required to if they wish to apply for ongoing Medicaid coverage.
To be eligible for PE or ongoing Medicaid, applicants or recipients must be living in New Mexico on the
date of application or final determination of eligibility. Applicants must also have demonstrated an
intention to remain in the state. Residence in New Mexico is established by living in the state and
carrying out the types of activities associated with day-to-day living, such as occupying a home,
enrolling child(ren) in school, getting a state driver’s license, or renting a post office box. An applicant
or recipient who is homeless is considered to have met the residence requirements if he or she intends
to remain in the state.
Eligible screenings and enrollments of individuals in PE coverage can only be made by certified
Presumptive Eligibility Determiners (PEDs). PEDs must meet the PED certification requirements as
established by the New Mexico Human Services Department's (HSD) Medical Assistance Division
(MAD). Except in instances where technical difficulties prohibit its use, all PEDs must utilize the section
of the on-line Your Eligibility System New Mexico (YESNM) designed for the exclusive use of PEDs to
screen individuals for PE (YESNM-PE). YESNM-PE is only available for use by those individuals who
have met the certification requirements of a PED.
PEDs are required to submit the information used to determine an individual eligible for PE to HSD for
auditing purposes. After screening an applicant for PE, the PED must also ask each applicant if they
wish to be evaluated for ongoing Medicaid coverage. If the applicant chooses to be evaluated for
ongoing coverage, the PED will indicate the applicant's choice and submit the information to HSD via
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YESNM-PE. This information will be used to populate an on-line application for Medicaid eligibility,
which will be evaluated for ongoing coverage.
PE coverage will terminate for any applicant who has been approved for PE but who does not submit
an application for ongoing Medicaid coverage on the last day of the month following their PE approval
date. Any individual who has been approved for PE and who submits an application for ongoing
Medicaid by the last day of the month following their PE approval will have PE coverage in effect until
the day that the final application determination has been made. Failure of an applicant to submit any
information requested by HSD that is needed to process the application for ongoing coverage in the
timeframe requested will be grounds for a denial and will close the Presumptive Eligibility span.
Presumptive Eligibility Determiners
There are a number of Presumptive Eligibility Determiners (PEDs) throughout the state who are trained
and certified to screen and enroll eligible individuals into PE coverage. Each certified PED is issued a
unique PED number that is used in the submission of a PE determination.
PE determinations can only be made by individuals who have met the PED certification requirements
as established by HSD/MAD. These requirements include attending and participating in a stateauthorized training and the completion and passing of a PED program comprehension test. PEDs who
were certified by HSD/MAD prior to October, 2013 are required to recertify in order to maintain their
status of an active PED. Any PED who has not completed the new certification requirements that have
gone into effect on January 1, 2014 will be disenrolled as a PED until the new certification
requirements have been met.
All PEDs are required to maintain applicant confidentiality and adhere to the Health Insurance
Portability and Accountability Act (HIPAA) Privacy rules. PEDs must also agree to meet PED
performance standards as outlined in the Presumptive Eligibility Determiner Agreement form (MAD
Form219). This agreement form must be completed on the New Mexico Medicaid Portal (Portal)
before a PED will be certified to perform PE determinations.
All PEDs must utilize YESNM-PE to determine an applicant eligible for PE. They must also enter all PE
approvals on the Portal on the day of the approval. Both systems must be utilized at all times unless a
system error or power outage prevents their usage. In these extreme instances, a PED must manually
determine the individual’s eligibility and submit the paperwork used to determine the eligibility to HSD
for auditing purposes. The PED will then fax the PE approval to Xerox, the New Mexico Medicaid Fiscal
Agent, on the day of the approval. PEDs utilizing the paper process must still ask the individual if they
wish to be evaluated for ongoing coverage. If the individual wishes to apply for ongoing Medicaid
eligibility, the PED must supply the applicant with a paper version of the Medicaid-only application
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(MAD100; Rev 1/21/14). The PED must assist the individual with the completion of the application and
submit the application to HSD for processing. This application must be submitted to HSD within two
business days of the PE approval.
Entities Eligible to Participate as Presumptive Eligibility Determiners
Entities who may participate as PEDs must be:
(a) a qualified hospital that participates as a provider under the Medicaid state plan or a
Medicaid 1115 demonstration, notifies the Medicaid agency of its election to make
presumptive eligibility determinations and agrees to make PE determinations consistent with
state policies and procedures; or
(b) a qualified hospital that has as not been disqualified by the Medicaid agency for failure to
make PE determinations in accordance with applicable state policies and procedures or for
(c) a federally qualified health center (FQHC), an Indian Health Service (IHS) facility, a
department of health (DOH) clinic, a school, a children, youth and families department (CYFD)
child care bureau staff member, a primary care provider who is contracted with at least one
HSD contracted MCO, a head start agency, or staff at New Mexico Department of
Corrections facilities, County Detention Centers and Jails; or
(d) other entities that HSD has determined as an eligible presumptive eligibility participant
Some of these entities are able to determine PE for any PE-eligible category; however, other entities
are able to determine PE only for children and pregnant women. These distinctions are outlined
further in Chapter 3 of this manual.
Certification and Training
All PEDs must participate in a state-authorized training. These trainings may be available as webinars,
in-person sessions or self-paced on-line trainings. Pre-registration may be required for some sessions
and class size limitations may apply.
Once a training session has been completed, the trained individual must also take and pass a program
comprehension test. A minimum passing score of 90% is required. Any individual who has scored
below 90% is allowed to retake his/her test.
If the second test also results in a score below 90%, the individual will be required to repeat the
training and will again be given the opportunity to take a test to meet the 90% passing grade
requirement.
Once a passing score of 90% has been achieved, the individual must register as a PED and electronically
“sign” the Presumptive Eligibility Determiner Agreement Form (MAD 219). Once this registration is
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complete and submitted, it will be validated by HSD/MAD staff to ensure that the registrant has
completed the training and passed with the minimum required test score. After validation, the
individual will be registered as an eligible Determiner, and a Presumptive Eligibility Determiner number
will be issued. This number will be unique to the PED and is not transferrable to any other individual
or entity. The PED will be held accountable for any and all PE Determinations submitted under his/her
PED number.
Before screening an individual for PE, the PED should check the individual's eligibility in the Portal. PE
coverage is available to a recipient once every 12 months or once per pregnancy. The Portal will show
if the recipient has had a prior PE approval that may make them ineligible. Most recipients who are
currently enrolled in Medicaid coverage are also ineligible for PE. When a PED has determined that an
individual is eligible for PE, the PED will submit the determination to the New Mexico Fiscal Agent,
Xerox, via the New Mexico Medicaid Portal. All PE submissions should be entered via the Portal unless
there is a system error or power outage that necessitates the submission of the PE notification via fax.
If the PE must be submitted by fax, the information must be completed on the Medicaid Presumptive
Eligibility Authorization form (MAD 070; Rev 3/6/14) and faxed to Xerox within 24 hours of the PE
determination.
Performance Standards
To ensure that applicants have been accurately screened for PE, all PEDs must adhere to the
performance standards and procedures as outlined in the Presumptive Eligibility Determiner
Agreement. These standards include:
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100% of PE screening results submitted to HSD/MAD for auditing purposes
PE Determiners will encourage all PE applicants to seek ongoing Medicaid eligibility
90% of applications received result in an approval of ongoing Medicaid eligibility
Utilize the New Mexico Medicaid Portal to verify current individual eligibility and/or enrollment
status
Utilize the New Mexico Medicaid electronic PE screening tool, YESNM-PE, to screen for and
submit PE screening applications
Utilize the New Mexico Medicaid Portal to submit all PE approvals, unless a system error or
power outage or lack of an applicant social security number necessitates the submission of the
PE via fax.
In instances where a fax approval is submitted, the PED must use the Presumptive Eligibility
Approval form (MAD 070; Rev 3/6/14) for the submission.
PEDs must submit the PE approval on the day of the PE determination
Corrective Action Plan
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PEDs are required to adhere to the performance standards, confidentiality clause and PE Determiner
Code of Conduct as outlined in the Presumptive Eligibility Determiner Agreement and Code of Conduct
Rev 3/19/14). PEDs must also follow the procedures for screening, determining and submission of all
PE approvals. This includes the utilization of the automated systems developed by HSD for the use of
PEDs (see Chapter 5 "Systems to be Utilized By Presumptively Eligibility Determiners"). In instances
where these systems are not available, the PED is responsible for accurate and complete applicant PE
screening and approvals.
To ensure a successful PED program, HSD will rely on consistent, highly effective performance by its
PEDs. In instances where a PED’s work performance falls short of established performance standards,
HSD/MAD may implement corrective action measures for improvement, design a performance
improvement plan for the PED or take further disciplinary action when necessary.
HSD/MAD is in the process of finalizing the PED auditing process. In this process, a designated
HSD/MAD PE Program Staff member will monitor, track and analyze PED performance. PED Program
Staff will conduct an objective, constructive evaluation of a PED’s performance; clearly delineate areas
earmarked for improvement; and make every attempt to support the PED in achieving program
performance standard compliance. PE Program Staff may also conduct a performance “coaching”
session(s) prior to making any corrective action decisions.
A progressive corrective action plan, ranging from verbal coaching to immediate dismissal, will be used
in an effort to improve a PED’s work performance.
Progressive corrective action is not applicable in every situation. Overriding the progressive process
and initiating the immediate suspension or termination of the PED may be at the sole discretion of
HSD/MAD PE Program Staff. Any PED who violates client confidentially or privacy or manipulate
client information in any way that might result in an incorrect PE determination will automatically be
terminated as a PED and are not eligible for the progressive action process to a corrective plan.
The normal steps in the progressive action process are as follows:
Step 1: Verbal Warning: Performance Evaluation/Coaching
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Review PED Performance Standard Requirements
HSD/MAD staff will verbally communicate the performance evaluation to the PED
Identify the PED's performance issues
Outline future work performance expectations
Discuss ways to provide additional support or training
Follow-up with PED with updates to let him/her know if work is improving
Step 2: Written Warning
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HSD/MAD staff will supply the PED with a written performance improvement plan
describing:
o Specific performance expectations/results the PED must meet
o Specific steps the PED must take to improve his/her performance
o The support to be provided by HSD/MAD PE Program staff
o The date(s) by which the improvement must occur
Step 3: Suspension
A suspension is a defined period of time that the PED will not be allowed to determine
presumptive eligibility for applicants.
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HSD/MAD PE Program Staff will:
o Identify the reason for the suspension
o Notify the PED of the action plan for reinstatement
o Indentify time frame in which PED must retake PED training and pass with a
minimum comprehension score of 90%
PED will:
o Complete the PED Certification Training
o Pass the PED Training Test with a minimum score of 90%
o Re-complete the PED Agreement and agree to all terms and conditions of the
agreement
Step 4: Dismissal or Termination
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Any PED who has not satisfactorily met performance standards as outlined in the PED
Agreement and who has failed to meet the requirements of the Correction Action Plan
will be terminated.
Termination of a PED after the three-step correction action plan will make the PED
ineligible to be recertified for a minimum of one year after the date of dismissal or
termination
After a time span of one year (termination or dismissal), the PED may be eligible to
begin the recertification process of becoming an active PED
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Chapter 3 - Presumptive Eligibility Determiner Specialty Types
Presumptive Eligibility Determiner Specialty Types
New Mexico Medicaid currently has over 40 categories of eligibility (COEs). Only some of these COEs
are eligible for Presumptive Eligibility (PE) coverage. Prior to the implementation of the Affordable
Care Act (ACA), many COEs were not accessible through the PE process. Only some categories that
covered children or pregnant women were eligible for potential PE coverage. Beginning January 1,
2014 some adult categories, other than pregnancy, may also be eligible for PE coverage by certain
approved Presumptive Eligibility Determiners (PEDs).
Some PEDs have a specialty type that enables them to determine PE for more COEs than just children
and pregnant women. Each person who is established as a valid PED will be certified with a provider
specialty type. These specialty types, 170 or 171, dictate the COEs that the PED is able to determine
for PE.
PEDs who are certified as Specialty Type 170 are eligible to determine PE exclusively for children and
pregnancy COEs. PEDs who are certified as Specialty Type 171 are able to screen for children and
pregnancy coverage but also for some other adult COEs. Specialty Type 171 PEDs are also known as
Presumptive Eligibility Plus (PE+) Determiners. Specific guidelines exist for each specialty type and the
categories for which PE may be determined. PE determinations submitted by a PED not authorized for
that Specialty Type would be rejected by the Xerox, New Mexico Fiscal Agent.
For the purpose of this manual and training, all PE information will be applicable for all PEDs unless it is
noted that it applies only to the PE+ Determiners.
Presumptive Eligibility Determiner Specialty Type 170
PEDs who have been certified to determine PE with a 170 Specialty Type can determine PE for children
and pregnancy coverage. The Children and Pregnancy COEs of New Mexico Medicaid that can be
determined presumptively eligible by PEDs with Specialty Type 170 are:
COE
300
COE Description
Full Medicaid for Pregnant Women
301
400
401
Pregnancy-Related Services Only
Children Ages 0-5
Children Ages 6-18
Federal Poverty Level (FPL)
0% up to app 47% FPL (fixed dollar
amount)
47% up to 250% FPL
0% up to 200% FPL
0% up to 138% FPL
402
403
420
421
Children Ages 0-5
Children Ages 6-18
CHIP Children Ages 0-5
CHIP Children Ages 6-18
200% up to 240% FPL
138% up to 190% FPL
240% up to 300% FPL
190% up to 240% FPL
A 5% income disregard of 100% of the FPL is applied to COEs in some instances
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Presumptive Eligibility Determiner Specialty Type 171
PEDs who have been certified with Specialty Type 171 are also known as PE+ Determiners. In addition
to the children and pregnancy COEs, PE+ Determiners may also determine PE for the "Other Adult" and
"Parent Caretaker" COEs. The Children, Pregnancy, Adult and Parent/Caretaker COEs of New Mexico
Medicaid that can be determined Presumptively Eligible by PEDs with Specialty Type 171 are:
COE
100
200
COE Description
Adult Group Ages 19-64
Parent/Caretaker Relative
Federal Poverty Level (FPL)
0% up to 133% FPL
0% up to app 47% FPL
(fixed dollar amount)
300
Full Medicaid for Pregnant Women
301
400
401
402
403
420
421
Pregnancy-Related Services Only
Children Ages 0-5
Children Ages 6-18
Children Ages 0-5
Children Ages 6-18
CHIP Children Ages 0-5
CHIP Children Ages 6-18
A 5% income disregard is applied to COEs in some instances
0% up to app 47% FPL
(fixed dollar amount)
47% up to 250% FPL
0% up to 200% FPL
0% up to 138% FPL
200% up to 240% FPL
138% up to 190% FPL
240% up to 300% FPL
190% up to 240% FPL
PE+ Determiners are only eligible to participate as such if they are employed by and physically
stationed at a specific location type. This will include hospitals that have elected to participate as a PE
Provider location but does not extend to a hospital's associated clinics or to any PED who is stationed
off-site from their normal work site. New Mexico has opted to further extend the number of eligible
PE+ locations to include employees of Indian Health Services (IHS) medical facilities and clinics as well
as staff at New Mexico Department of Corrections facilities, County Detention Centers and Jails.
PE+ Determiners are required to adhere to the same training, certification and performance standards
required of all PEDs. Any PED who does not meet these standards may be put on a corrective action
plan and, if standards are still not met, may be required to retake a PED training course and program
comprehension test before they are reinstated as a PED in good standing.
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Chapter 4 - New Mexico Medicaid Categories Eligible for Presumptive Eligibility
Determinations
Not all Medicaid categories of eligibility (COEs) are eligible for Presumptive Eligibility (PE)
determinations. The Affordable Care Act (ACA) makes the PE process available for hospitals to screen
individuals who would fall under the Other Adult and Parent/Caretaker categories (COEs 100 an 200)
for possible PE coverage. Presumptive Eligibility Determiners (PEDs) who are certified to determine PE
for these COES are Presumptive Eligibility Plus (PE+) Determiners. New Mexico has opted to further
extend the number of eligible PE+ locations to include employees of Indian Health Services (IHS)
medical facilities and clinics as well as staff at New Mexico Department of Corrections facilities, County
Detention Centers and Jails.
Other optional COEs that New Mexico has included in its PE program are for children in families with
household income up to 300% of the Federal Poverty Level (FPL) and for pregnant women in families
with household income up to 250% of the FPL. These are children's COES 400, 401, 402, 403, 420 and
421 and Pregnancy Medicaid COEs 300 and 301. New Mexico has had a PE program in place for these
COEs for several years and will continue to do so for these optional categories.
All Medicaid COEs have their own set of eligibility guidelines, benefit packages and program
limitations. In some COEs, minimal co-pays may also exist.* Whether coverage is granted through PE
or through a full Medicaid determination, all existing program standards apply for each COE.
*NOTE: Native Americans are exempt from all Medicaid co-pays.
To be eligible for PE, individuals must meet certain general guidelines that apply to PE but also those
that are specific to each category of eligibility (COE). The general guidelines for PE are:

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Household income must be below the monthly limit for the applicable household size
Individual must be a US Citizen, US National or an eligible immigrant
Individual may not be currently enrolled in Medicaid (unless the individual becomes
pregnant while enrolled in Family Planning Medicaid)
The individual has not had a PE approval in the past twelve months. Or, if pregnant, has
not had a PE approval for the same pregnancy.
PE guidelines for specific COEs are outlined in the following section.
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Other Adults and Parent/Caretakers (Categories 100 and 200)
Category 100 - Medicaid for Other Adults
Adults who may be eligible for Medicaid in the Other Adult (Medicaid Expansion), or Category 100 COE,
must be 19 through 64 years of age, have a countable household income of 133% or below of the FPL
and must meet all other non-financial eligibility requirements. Individuals eligible for PE or on-going
Medicaid eligibility for COE 100 will receive the benefits available in New Mexico's Alternative Benefit
Package (ABP).
Most applicants who have been approved for Other Adult PE will be required to choose a Managed
care Organization (MCO) at the point of the PE approval. Native American applicants are exempt from
this requirement and may choose to receive their services from an MCO or through Fee for Service
(FFS) Medicaid. An MCO's Value-Added Services are not available through FFS Medicaid or during the
PE approval span. Value-Added Services are only available to applicants who are approved for ongoing
coverage and are enrolled with an MCO.
Medicaid for Other Adults - COE 100
Category
Age
Income Guideline
100
19-64
Up to 133%* of the FPL
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*5% of 100% of FPL income disregard may apply to the Other Adult COE
Adults age 19-64
Non-pregnant
No longer eligible once age 65 has been reached
PE may only be granted once every 12 months
May not be enrolled in or be eligible for Medicare coverage
Childless adults are eligible
Countable household income must be 133% or below of the FPL (5% of 100% FPL income
disregard may apply)
Must meet all non-financial eligibility requirements
Benefits available through the Alternative Benefit Package (ABP) and may include minimal copays.* THE ABP includes:
o Ambulatory patient services
o Prescription drugs
o Emergency services
o Rehabilitative and habilitative services and devices
o Hospitalization
o Laboratory services
o Maternity and newborn care
o Preventive services and chronic disease management
o Behavioral health care (including substance abuse)
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o Pediatric services, including oral and vision (19 and 20 year-olds only)
o Medically-necessary services for 19 and 20 year-olds added (EPSDT -includes oral and
vision care)
o Nonemergency transportation
o Dental services (prevention and maintenance)
*NOTE: Native Americans are exempt from all Medicaid co-pays
Category 200 - Medicaid for Parent/Caretakers
Adults who may be eligible for Medicaid as a Parent/Caretaker, or Category 200 COE, must be the
parent, stepparent or adoptive parent of a child who resides with them. When the parent(s) do not
live with the child, specified relative(s) within the fifth degree of relationship by blood, marriage or
adoption as determined by New Mexico statute chapter 45 uniform probate code may be eligible for
COE 200. There are no age limitations for COE 200 but eligible enrollees must meet all financial and
non-financial eligibility requirements. Households with countable income less than the income
standard for the household size are financially eligible.
Most applicants who have been approved for Parent/Caretaker PE will be required to choose an MCO
at the point of the PE approval. Native American applicants are exempt from this requirement and
may choose to receive their services from an MCO or through FFS Medicaid. An MCO's Value-Added
Services are not available through FFS Medicaid or during the PE approval span. Value-Added Services
are only available to applicants who are approved for ongoing coverage and are enrolled with an MCO.
If a full Medicaid application is submitted and on-going eligibility is approved, the coverage will remain
in effect for 12 months unless a change in situation causes the individual to no longer meet eligibility
requirements (such as a child no longer being in the household).
Medicaid for Parent/Caretakers - COE 200
Category
Age
Income Guideline
0% up to app 47% FPL (fixed dollar
200
19 +
amount)
*5% of 100% of FPL income disregard may apply to the Parent/Caretakers COE
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Must be a natural, step or adoptive parent of a child, provided they live with the child
Specified relative(s) within the fifth degree of relationship by blood, marriage or adoption may be
eligible
PE may only be granted once every 12 months
Meet all non-financial eligibility requirements
Household with countable Income less than the income standard for the household size
No age restrictions
5% disregard up to 100% of FPL may apply if applicant is 65 or older or is Medicare recipient
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Pregnancy Medicaid and Pregnancy-Related Services Medicaid (Categories 300 and
301)
Category 300 - Pregnancy Medicaid
Women who are pregnant and who have a household income of up to approximately 47 % of the FPL
(fixed dollar amount) may be eligible for Pregnancy Medicaid coverage. Individuals enrolled in this COE
will receive full Medicaid benefits. Applicants/enrollees in this COE may have other insurance coverage
in effect. There are no income disregards for COE 300. No proof of pregnancy is required beyond the
applicant's self-attestation.
During the PE eligibility span, ONLY ambulatory prenatal care is covered. This includes amniocentesis,
sonograms, lab work, pregnancy-related prescriptions, pre-decision counseling, and miscarriages.
Delivery expenses are not covered unless an application for on-going coverage has been submitted and
the applicant has been determined eligible for on-going coverage.
Most applicants who have been approved for Pregnancy PE will be required to choose an MCO at the
point of the PE approval. Native American applicants are exempt from this requirement and may
choose to receive their pregnancy services from an MCO or through FFS Medicaid. An MCO's ValueAdded Services are not available through FFS Medicaid or during the PE approval span. Value-Added
Services are only available to applicants who are approved for ongoing coverage and who are enrolled
with an MCO.
An applicant who has been approved for on-going coverage and who is in her third trimester may
continue to see her existing OB/GYN provider even if that provider is not contracted with a Centennial
Care MCO. The Medicaid recipient should notify her MCO's Member Services Unit about her current
OB/GYN provider.
An applicant who has been approved for on-going COE 300 will remain covered for two months postpartum after their child is born, regardless of income or household changes.
Category
300

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


Income Guideline
0% up to app 47% FPL (fixed dollar
amount)
Household income must be at or below approximately 47% of FPL (fixed dollar amount)
No income disregards in effect
Individual may have other insurance coverage
Self-attestation of pregnancy acceptable
Eligible for one PE determination for each pregnancy
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Category 301 - Pregnancy-Related Medicaid
Women who are pregnant and who have a household income of 47% to 250% of the FPL may be
eligible for Pregnancy-Related Medicaid coverage. Individuals enrolled in this coverage will only have
access to pregnancy-related services. Applicants/enrollees in this coverage may have other insurance
coverage in effect. A 5% disregard up to 100% of FPL may apply. No proof of pregnancy is required
beyond the applicant's self-attestation.
During the PE eligibility span, ONLY ambulatory prenatal care is covered. This includes amniocentesis,
sonograms, lab work, pregnancy-related prescriptions, pre-decision counseling, and miscarriages.
Delivery expenses are not covered unless an application for on-going coverage has been submitted and
the applicant has been determined eligible for the on-going coverage.
Most applicants who have been approved for Pregnancy-Related PE will be required to choose an MCO
at the point of the PE approval. Native American applicants are exempt from this requirement and
may choose to receive their pregnancy-related services from an MCO or through FFS Medicaid.
Individuals who receive services from an MCO may have Value-Added Benefits available to them that
are comparable to those that are available through a full Medicaid COE. However, an MCO's ValueAdded Services are not available through FFS Medicaid or during the PE approval span. Value-Added
Services are only available to applicants who are approved for ongoing coverage and are enrolled with
an MCO.
An applicant who has been approved for on-going coverage for COE 301 and who is in her third
trimester may continue to see her existing OB/GYN provider even if that provider is not contracted
with a Centennial Care MCO. The Medicaid recipient should notify her MCO's Member Services Unit
about her current OB/GYN provider.
An applicant who has been approved for on-going coverage through COE 301 will remain covered for
two months post partum after their child is born, regardless of income or household changes.
Category
301
Income Guideline
47%-250% FPL*
*5% of 100% of FPL income disregard may apply
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Household income must be between 47% - 250% FPL
5% of 100% FPL income disregard in effect
Individual may have other insurance coverage
Self-attestation of pregnancy acceptable
Eligible for one PE determination for each pregnancy
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Children's Regular Medicaid and CHIP Coverage (Categories 400, 401, 402, 403, 420
and 421)
Categories 400, 401, 402 and 403 - Regular Medicaid for Children
Children 0 through 18 years of age in families with a household income up to 240% of the FPL may be
eligible for regular Medicaid coverage. Regular Medicaid coverage provides children with full coverage
medical services. In instances where the child has other primary health insurance in effect, Medicaid
will act as supplemental coverage to help pay for services not covered by the primary carrier. Some
minimal co-pays may apply for children approved for these categories. Native Americans are always
exempt from co-pays.
Most applicants who have been approved for Children's Medicaid PE will be required to choose an
MCO at the point of the PE approval. Native American applicants are exempt from this requirement
and may choose to receive their services from an MCO or through FFS. An MCO's Value-Added
Services are not available through FFS Medicaid or during the PE approval span. Value-Added Services
are only available to applicants who are approved for ongoing coverage and are enrolled with an MCO.
If a full Medicaid application is submitted for a child, that child will be evaluated for on-going
coverage. If a final eligibility approval for the applicant child is made by the HSD, the approval will
result in 12 months continuous eligibility. Changes in household size or income will not impact the 12month coverage unless a change in situation makes the child otherwise ineligible for the approved
COE (i.e.: move out of state, 19th birthday, etc).
Regular Medicaid for Children - COEs 400, 401, 402 & 403
Category
Age
Income Guideline
400
401
402
403
0 - 5 years
6 - 18 years
0 - 5 years
6 - 18 years
Up to 200% of the FPL
Up to 138% of the FPL
200%- 240% of the FPL
138% - up to 190% FPL
5% of 100% of FPL income disregard may apply to all Children's COEs
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Provides full coverage Medicaid for children 0 through 18 years of age
No longer eligible once age 19 has been reached
PE may only be granted once every 12 months
May have other forms of health insurance and still be eligible
Voluntary drop of other health insurance does not affect on-going eligibility
Co-pays for some services and medications may apply for non-Native American enrollees*
Allowable household FPLs vary by age of child
o Children ages 0-5: 0% - 240%
o Children ages 6-18: 0% -190%
*NOTE: Native Americans are exempt from all Medicaid co-pays
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Categories 420 and 421 - Children’s Health Insurance Program (CHIP)
Children 0 through 5 years of age in families with a household income up to 300% of the FPL and
children 6 - 18 in families with a household income up to 240% may be eligible for Children's Health
Insurance Program (CHIP) coverage. CHIP coverage provides children with full coverage medical
services. Children enrolled in CHIP coverage may not have any other insurance in effect. Children who
have applied for CHIP coverage will not be penalized for a voluntary drop of other coverage. Some
minimal co-pays may apply.
Most applicants who have been approved for CHIP PE will be required to choose an MCO at the point
of the PE approval. Native American applicants are exempt from this requirement and may choose to
receive their services from an MCO or through FFS Medicaid. An MCO's Value-Added Services are not
available through FFS Medicaid or during the PE approval span. Value-Added Services are only
available to applicants who are approved for ongoing coverage and who are enrolled with an MCO.
If a full Medicaid application is submitted for a child, that child will be evaluated for on-going
coverage. If a final eligibility approval for the applicant child is made by the HSD, the approval will
result in 12 months continuous eligibility. Changes in household size or income will not impact the 12month coverage unless a change in situation makes the child otherwise ineligible for the approved
COE (i.e.: move out of state, 19th birthday, etc).
Children's Health Insurance Program (CHIP) COEs 420 & 421
Category
Age
Income Guideline
420
0-5
240%-up to 300% of the FPL*
421
6 - 18
190% up to 240% of the FPL*
5% of 100% of FPL income disregard may apply to CHIP COEs
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Provides full coverage Medicaid for children 0 through 18 years of age
Eligibility ends once age of 19 has been reached
PE may only be granted once every 12 months
Children may not have any other form of health insurance coverage
Voluntary drop of other health insurance does not affect eligibility
Co-pays apply for non-Native American CHIP enrollees*
Co-payment amounts may include:
o $5 per doctor, dentist, outpatient, and urgent care visit
o $2 per prescription
o $5 per brand name prescription
o $15 per emergency room visit
o $25 per inpatient hospital admission
o $50 for non-emergent use of the ER
Allowable household FPLs vary by age of child
o Children ages 0-5: 240% - 300%
o Children ages 6-18: 190% - 240%
*Native Americans are exempt from all Medicaid co-pays
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Chapter 5 - Systems to be Utilized by Presumptive Eligibility Determiners
The New Mexico Human Services Department's (HSD) Medical Assistance Division (MAD) has
developed electronic systems to be used by Presumptive Eligibility Determiners (PEDs) to verify an
individual's current Medicaid enrollment status, screen for Presumptive Eligibility (PE), submit PE
determinations and submit applications for on-going Medicaid coverage. These systems include areas
of the New Mexico Medicaid Portal (Portal) and the Your Eligibility System New Mexico (YESNM) that
has been developed exclusively for use by PEDs (YESNM-PE).
New Mexico Medicaid Portal
The New Mexico Medicaid Portal (Portal) is an on-line public portal that can be used by Medicaid
recipients or by Medicaid providers to access eligibility information. Recipients have the ability to
access information about their coverage such as current enrollment status and information about their
category of eligibility (COE). The Portal also has a section that is for the exclusive use of Medicaid
providers, including PEDs. PEDs can use the provider section of the Portal to electronically "sign" their
PE Determiner agreements, check an individual's eligibility status and submit PE determinations. The
Portal is operated and maintained by the New Mexico Medicaid Fiscal Agent, Xerox, on behalf of
HSD/MAD and can be accessed on line at https://nmmedicaid.acs-inc.com
Your Eligibility System New Mexico for Presumptive Eligibility Determiners
Beginning May, 2014, all screening for New Mexico Medicaid PE should be completed through Your
Eligibility System New Mexico for PEDs (YESNM-PE). YESNM-PE has been developed for the use of
certified PEDs for the express purpose of screening for and enrolling eligible individuals in PE coverage.
Utilizing an internet connection, certified PEDs will enter information verbally supplied by the applicant
directly into YESNM-PE. This will include such information as household size, financial information and
citizenship status. This information will be used to screen the applicant for PE.
If an individual is determined eligible for PE coverage, YESNM-PE will provide access to the Portal so
that the PED may enter the individual's eligibility directly into the Portal. Access to Medicaid-covered
services for that individual will be available immediately for their approved COE.
Access to YESNM-PE screening tool and application submission portal is only available to individuals
who have met the training, testing and certification requirements necessary to be a certified PED.
Once all requirements are met, a PED will be allowed to register as an eligible user on both the Portal
and YESNM -PE.
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All PEDs will be required to utilize both the Portal and YESNM-PE for PE screening and eligibility
determinations unless system errors or power outages necessitate the submission of the PE
notification or screening via fax. Any PED who consistently or repeatedly utilizes the paper process
may be subject to disciplinary actions as outlined in the PED Corrective Action Plan standards (see page
14 of this manual).
Enrolling as a Presumptive Eligibility Determiner on the Portal
An individual applying to become a certified PED who has met the training and testing requirements
must sign and agree to the conditions and regulations on the Presumptive Eligibility Determiner
Agreement (MAD 219). This agreement should be signed electronically on the Portal. There are steps
that must be followed for a PED to electronically sign the agreement form.
All certified PEDs must be registered as users on the Portal. To register, the individual must first start
the on-line enrollment process in the Provider section of the Portal. This process is completed once
per user unless unforeseen circumstances or disenrollment by HSD of the PED for failure to comply
with the PED standards and responsibilities necessitates re-registering.
To begin the PED Provider Application process, the user should navigate to the Provider Section of the
Portal Home page (https://nmmedicaid.acs-inc.com).
The Provider section of the Portal is on the right hand side of the Portal home page.
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To begin the Provider Application process on the Portal, select "Provider Online Enrollment (NEW)" in
the Provider section.
The user will then be directed to the Provider Enrollment Application Section. A valid e-mail address is
required to register as a user. This should be a valid work e-mail address, not an individual's personal
e-mail address.
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Anyone registering on-line can start a new application or recall an application that had previously been
started.
Once an e-mail address has been entered, the user will be directed to an information page and must
click "Accept" to move on in the registration process.
On the next page, the user will be asked to choose a provider type. Choose "Presumptive Eligibility
Determiner (MAD 219)."


Any person who has never been a certified PED in New Mexico should choose "Initial
Enrollment "
Any person who had been a certified PED in New Mexico prior to October 2013 (whether
currently Active or Inactive) , should select "Re-Enrollment."
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Click "continue."
The user will now be directed to choose a Specialty Type.
Most PEDs will be certified as Specialty Type 170. These individuals will be permitted to perform PE
determinations for Children and Pregnant Women. Certain entities will be certified as Specialty Type
171s. PEDs certified as Specialty Type 171s, also known as PE+ providers, will be qualified to perform
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PE determinations for Children and Pregnancy as well as some other adult COEs. For more information
on Specialty Types, please Chapter 3 of this manual.
After the appropriate Specialty Type has been entered and the user has clicked "continue," they will be
given a Provider Enrollment Reference number. This number should be saved in the event questions
arise about the provider's application status.
Click "Continue."
Before the user is allowed to proceed with the PED registration process, they must read the
Presumptive Eligibility Determiner Agreement (MAD 219) . This agreement outlines the terms,
conditions and responsibilities of participation as a PED. This document should be read thoroughly and
completely as applicants will be required to agree to these terms and electronically sign this document
before they will be approved as a PED. For questions regarding this agreement, please contact a
member of the MAD PE Program Staff at HSD.PEDeterminers@state.nm.us
A paper version of this agreement is included in this Chapter 15 of this manual.
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Click "Continue."
The user will now be directed to the Provider Enrollment Applicant Information page. On this page,
enter the name of the PED applicant's employer as well as the primary location where the PED will
screen applicants for PE.
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By entering their name in the "PE Determiner's Signature" field, the PED applicant agrees to abide by
the terms and conditions of the PE Determiner Agreement form. Entry of the PED applicant's name in
this section will serve as the PED's electronic signature.
Click "Continue."
Click "Submit" to submit the provider registration application.
A confirmation page notification will auto-generate after the application has been submitted.
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The PED applicant should print/save this confirmation page for their records. An e-mail confirmation
of the provider enrollment will also be sent to the e-mail address that was previously listed on the
"Provider Enrollment Application Information" page.
Once the Provider Enrollment has been received by Xerox, the enrollment will be verified by MAD PE
Program staff and a PED number will be issued to the PED applicant. The number will be sent to the
PED by Xerox in a Provider Enrollment Welcome Packet. This number will be unique to the PED and is
not transferrable to any other individual or entity. The PED will be held accountable for any and all PE
determinations submitted under their PED number.
Registering as a User on the Portal
After the PED has received their Provider Enrollment Welcome Packet and PED number, they must also
register as a user before they can utilize the Provider section of the Portal.
To register, click on the "Log in" link in the Provider section of the Portal home page.
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Click on the "Web Registration" link on the Provider Enrollment Application Page.
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On the "Web Registration" page. Click on "Register Provider ID"
Enter the PED Number issued by Xerox in the "Provider ID" section
Enter 999999999 in the "EIN or SSN" section (PEDs are not required to provide a social security
number)
Enter the zip code of the employer's location in the "Location Zip Code" section. This should be
the main location where the PED physically works most of the time.
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Create a user ID, then enter name and contact information. Click “Continue.”
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Review the information entered. Be sure to write down or note the User Id. Click “Submit.”
Review the Confirmation page and click “Log In.” A temporary password will be sent to the email
address used during registration.
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After becoming a certified PED and completing the Portal registration process, the PED's access to the
Portal will be used to check an individual's eligibility status and enter an applicant's PE approval. PEDs
can also update their own information on the Portal if they have a change of employers or in contact
information.
When logging in to the Portal, PEDs will be required to have their User ID, Provider ID (PED number)
and their password for each session log in.
All steps necessary in checking an individual's eligibility status and the entry of a applicant's PE will be
outlined in Chapter 6, "Electronic Screening for Presumptive Eligibility, "of this manual.
Registering as a User on YESNM-PE
PEDs who have been issued a PED Number will be required to use YESNM-PE to screen applicants for
potential PE coverage. This screening tool is for the exclusive use of PEDs. It will allow a PED to submit
information required to make an accurate PE determination. PEDs can also submit an application for
ongoing Medicaid coverage on YESNM-PE if the applicant wishes to do so. If an ongoing application is
submitted on YESNM-PE, the PED will have access to check the status of that application. To access
YESNM-PE, go to www.yes.state.nm.us/jsp/access/myAccess/PELogin.jsp
Certified PEDs will have the information that was supplied at the time of their PED registration
automatically transferred to YESNM-PE. All PE screenings will be linked to the PED's assigned PED
number. Each PED is responsible for any and all PE screenings and approvals and applications
submitted for ongoing coverage submitted under their assigned PED number.
To access YESNM-PE, each PED must register as a user. This requires creating a unique User ID name
and password. This ID and password is required to be entered at each session login.
To begin the user registration process on YESNM-PE, you must navigate to the area of YESNM designed
exclusively for the use of PEDs. To access this page go to
https://www.yes.state.nm.us/jsp/access/myAccess/PELogin.jsp
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PEDs must then create a User ID and Password.
To create a YESNM-PE User ID and Password, the PED must have their PED number.
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Chapter 6 - Electronic Screening for Presumptive Eligibility
Most people who are currently enrolled in a Medicaid category of eligibility (COE) are not eligible for
Presumptive Eligibility (PE) coverage. To ensure that the applicant is not a current Medicaid recipient,
a Presumptive Eligibility Determiner (PED) is required to check an applicant's current Medicaid
eligibility status on the New Mexico Medicaid Portal (Portal). Any individual who is currently enrolled
in Medicaid will appear as enrolled in the Portal along with their current COE.
All PEDs must utilize the section of the Your Eligibility System New Mexico (YESNM) system designed
for the exclusive use of PEDs (YESNM-PE) to screen applicants for PE. YESNM-PE is only available for
use by those individuals who have met the certification requirements of a PED. PEDs must submit all
PE approvals on the Portal on the day of the PE approval.
Screening for and enrolling individuals in PE coverage can only be done by certified PEDs. PEDs are
required to submit the information used to determine an individual eligible for PE to the New Mexico
Human Services Department's (HSD) Medical Assistance Division (MAD) for auditing purposes.
After screening an applicant for PE, the PED must also ask the applicant if they wish to be evaluated for
ongoing Medicaid coverage. If the applicant chooses to be evaluated for ongoing coverage, the PED
will indicate the individual's choice and submit the information to HSD via YESNM-PE. This information
will be used to populate an on-line application for Medicaid eligibility, which will be evaluated for
ongoing Medicaid eligibility.
PE coverage will terminate for any individual who has been approved for PE but who does not submit
an application for ongoing Medicaid coverage on the last day of the month following their PE approval.
Any individual approved for PE who submits a Medicaid application by the last day of the month
following the month in which his/her PE was approved will have PE coverage in effect until the day that
the final application determination has been made. Failure of an applicant to submit any needed
information requested by HSD to process the application for ongoing coverage in the timeframe
requested will be grounds for a denial, and the PE span will close.
Checking Applicant Eligibility on the Portal
To check an applicant's enrollment status, log-on to the Portal at https://nmmedicaid.acs-inc.com.
Click "Log-in to" in the Provider Section on the right hand side of the page.
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After log-in, click on "Inquiries"
Then, click on "Eligibility."
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To search an applicant's eligibility, multiple search parameters may be utilized. At least one of the
search parameters is required. A beginning date of service is also a required field. Generally, the PED
should enter a date of 12-months prior to the date that the applicant is being screened for a
presumptive eligibility determination. If retroactive coverage is required, a full Medicaid application
must be submitted. Retroactive coverage is not available through PE.
If an applicant has had a PE determination or is currently enrolled in Medicaid coverage, they will be
listed as "not eligible on the requested date(s) of service." This means that the individual is not eligible
for PE at this time.
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Most individuals who are enrolled in a current Medicaid COE are not eligible for Medicaid PE. One
exception to this is women currently enrolled in Family Planning Medicaid (COE 29).
COE 29 has a very limited benefit package. If a woman becomes pregnant while enrolled in COE 29,
she may be granted PE for Pregnancy coverage (COEs 300 and 301). During the PE eligibility span,
ONLY ambulatory prenatal care is covered. This includes amniocentesis, sonograms, lab work,
pregnancy-related prescriptions, pre-decision counseling, and miscarriages. Delivery services will not
be covered unless an application for on-going coverage has been submitted and the applicant has been
determined eligible for the on-going coverage.
Any applicant who is not a current Medicaid recipient or a pregnant woman who is currently enrolled
in COE 29, may be screened for PE.
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The PED should proceed to YESNM-PE to begin the applicant screening process.
Screening for Presumptive Eligibility on YESNM-PE
YESNM-PE has been developed for the use of PEDs to walk them through each step of the PE screening
process. The PED will ask the applicant each question and will enter it in to the screening tool on the
applicant's behalf. PEDs are required to enter each answer as it is supplied to them by the applicant.
At the end of the screening tool process, the applicant will have to affirm that all information they have
supplied to the PED is accurate and correct. PEDs must affirm that the information listed in the
screening tool is the information that has been supplied by the applicant.
Once the applicant's relevant household information has been gathered, the PE Determination Results
page will be displayed. The PED will then utilize a link on PE Determination Results page to enter the
PE on the Portal for eligible individuals. Once entered, the PED will return to the PE Determination
Results Page where they can print the result page for the applicant.
Applicants will then be given the option to submit the information gathered for the screening to HSD
for an ongoing Medicaid application determination. An applicant's PE approval will not be affected if
they choose not to submit an application for ongoing eligibility. However, applicants should be
notified that their PE coverage would end on the last day of the month following the PE approval
unless an application for ongoing eligibility has been received by HSD by that date.
To begin screening for PE coverage, log-in to YESNM-PE at
https://www.yes.state.nm.us/jsp/access/myAccess/PELogin.jsp
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The PED will then be directed to the PED landing page. From this page, the PED may begin to screen a
new applicant for PE or may recall a screening or application that has been started by the PED for the
applicant.
To begin a new screening, click "Screen for Presumptive Eligibility/submit application" and then click
"Next."
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The PED will then be directed to an informational page. This page explains that YESNM-PE is to screen
for and apply for PE. PE is only available for specific Medicaid COEs. If the individual applying with
wishes to apply for COEs that are not available through PE, they may do so through the application
process on this site but they will not receive a possible eligibility result until the application has been
processed by HSD.
Any individual who wishes to apply for other New Mexico Public Assistance Programs, such as Food
Assistance (Supplemental Nutrition Assistance Program - or SNAP), Energy Assistance (Low-Income
Home Energy Assistance Program - or LIHEAP) or Cash Assistance should do so using the public access
web application at www.Yes.state.nm.us or at their local HSD/ISD office. Application submission for
these programs is not available through YESNM-PE.
To proceed to the screening tool, click "Next."
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The PED will be directed to the applicant data collection screens where information on the applicant
and household members will be entered.
All fields in YESNM-PE that are marked with a red asterisk (*) are required fields and must be
completed before the PED can advance to the next screen.
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Any applicant who has a person that has been designated to make decisions on behalf of the applicant
may indicate that in the "Authorized Representative" section of YESNM-PE. PEDs should never be
listed as an applicant's "Authorized Representative."
Next, the PED will be required to enter information about each household member and their
relationship to the applicant. All household members should be listed in the household member
section so that the household size may be accurately evaluated. Any individual in the household who
does not wish to be screened for or apply for PE coverage should be still be listed as a household
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member. To be screened for or apply for Medical Assistance, the PED must check on the "Medical
Assistance" box in the Program Selection section of each individual's information screen.
Any household member that has medical bills that were incurred within the past three months may be
eligible for retroactive coverage to help pay those bills. This coverage must be requested in the
Program Selection section as well.
Retroactive Medicaid coverage is not available with a PE approval. Any individual who wishes to apply
for retroactive coverage must do so by submitting an application for ongoing coverage.
Any individual applying for PE or ongoing Medicaid coverage must meet U.S. Citizenship requirements.
As a condition of PE, applicants are not required to supply a Social Security Number (SSN) with their PE
application. However, any applicant wishes to apply for ongoing Medicaid eligibility may be required
to supply their SSN before their application for ongoing coverage is processed.
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Race and Ethnicity information are asked of applicants but are not required fields and are not a factor
in determining PE. All applicants are required to be a resident of New Mexico to receive New Mexico
Medicaid benefits.
Any household member(s) who is pregnant should indicate this on the "Other Information" section as
it could affect the household size in determining eligibility. A verified due date of the pregnancy is not
required but should be entered if known.
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After all household members have been added, the PED will be required to note the relationships of
the members.
More information may be asked about children in the home and their relationships to the adults listed
in the household.
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Any parent who does not live with their child(ren) should be listed in the "More About Parents" section
if the information is known. This information is not required as a condition of a PE determination.
Applicants should be asked if household members are receiving benefits from another state or if each
of the household members has other Medical Coverage as this may affect Medicaid eligibility.
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Any household member who has other medical coverage should have it noted as this may have an
effect on the individual's PE and ongoing Medicaid eligibility.
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The PED will then be directed to a Household Summary Page. This should be reviewed by the PED with
the applicant to ensure accuracy.
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The PED will then gather information regarding household income. This information will be used to
help determine financial eligibility.
After income has been entered, the "Job Income Summary" page should be reviewed for accuracy.
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Any additional information that may be relevant to a PE or ongoing Medicaid application
determination may be entered by the PED in the "Additional Information" screen.
All information that has been entered will be used to display the PE results on the "Presumptive
Eligibility Results" page. This page will list any household members who may be granted PE with the
COE for which they are eligible.
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Any individual may be granted PE if he or she:



Has been determined eligible for PE (through the YESNM-PE or through a manual
process)
Has not had a PE granted in the past 12 months or has not had a previous PE granted
for the same pregnancy
Is not currently enrolled in New Mexico Medicaid (unless they become pregnant while
enrolled in Family Planning coverage)
Any individual who has been determined presumptively eligible for Medicaid coverage and who wishes
to accept the PE coverage must have their PE approval submitted to Xerox. Any applicant who has
provided a SSN on their PE application should have their PE approval submitted on the Portal. Any
applicant who has not supplied his or her SSN, must have PE submitted via fax. For information on the
manual determination and paper submission of PE, see Chapters 7 - 12 of this manual.
In most cases, PE approvals entered on the Portal will appear within minutes of the PE entry. Providers
who view applicant eligibility will see these results in real time. PE approvals submitted via fax may
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take up to 2 business days (Monday-Friday) to appear in the Portal after the approval has been
received by Xerox. This means that the applicant may not appear as "eligible" in the Portal for a
Medicaid COE for at least two business days after the PE approval has been received by Xerox.
To enter PE for any applicant who has been determined eligible, the PED should proceed to the Portal.
Access to the Portal is available by clicking the "Click Here" link on the "Presumptive Eligibility Results"
page.
Entering a Presumptive Eligibility Approval in the Portal
After clicking the link on the YESNM-PE Results Page, the PED will be directed to the Provider Log-in
Page on the Portal where they will login with their User Name, Password and their Provider ID (PED
number).
After a successful login, the PED may enter the individual's PE span in the Portal.
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The PED must first select the COE to which the individual is being enrolled. Only Medicaid categories
that are eligible for PE coverage are listed. Select the appropriate COE from the list.
Complete the remainder of the information on the Presumptive Eligibility Submission Form. All fields
on the form are required for the PE submission.
Although the race code entry is a required field on this form, it is not required for PE. Any individual
who does not wish to have a race code indicated should be listed as "Unknown." Native Americans
eligible for PE who wish to be exempt from Managed Care should be identified as Native American so
that they are not automatically enrolled with an MCO.
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Once all fields have been entered, click "Verify."
If the verification step indicates that the applicant may be ineligible for PE coverage, the PE may not be
entered on the Portal. PEDs who believe this message may have been received in error should contact
Xerox by phone at 800-705-4452 or 505-246-0710.
If the verification indicates that the individual is eligible for a PE approval, more information will be
requested so that the new PE span may be entered.
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An MCO choice should be made by the applicant at the time of their PE approval entry. If one is not
made, they will be auto-enrolled with an MCO. Native Americans who have been listed as "Native
American" on the race code field will not be auto-enrolled with an MCO. Native Americans will be
enrolled with an MCO only if an MCO choice has been made for the applicant.
Click "Save" after all required fields have been completed.
The PED will receive a confirmation of the successful PE submission.
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After a successful PE submission, the PED should exit the Portal and return to YESNM-PE. To print the
PE Granted" information page for the applicants, the PED must first indicate which household
members were granted PE through the Portal. This is a required field and "Yes" or "No" must be
selected for each household member listed.
The PED should also ask the applicant if they wish to apply for ongoing Medicaid coverage. This is a
required field for each household application screened for PE on YESNM-PE.
Any applicant who chooses to have their application submitted and evaluated for ongoing Medicaid
coverage must be supplied with the "Applicant's Rights & Responsibilities" in Chapter 15 of this
manual.
All applicants should be asked if they wish to register to vote and asked if they wish to provide an email address where a survey about their enrollment experience may be sent.
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To submit the application, both the applicant and the PED must agree to sign the application
electronically. All applicants must agree to the statements in the electronic signature section of the
application. This information will also be printed for the applicant in the "Print My Applications"
section to follow. A PED's electronic signature in this section affirms that they have supplied the
applicant with all required information in the electronic signature process.
Instant notification will let the PED know where the Medicaid application has been routed for
processing. PEDs will be given a tracking number for the application submission.
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From this page, the PED will also print the Voter registration form (if the applicant has opted to
register), print the application for ongoing coverage and print the PE Screening results page.
Applicants should be given copies of all print outs for their records.
A PED may submit documents that may be needed to determine ongoing eligibility for an applicant by
clicking "View and Submit Types of Proof" in the "Your next Steps" section and clicking "Next." PEDs
will be walked through the document upload process.
Once an application has been submitted, the applicant's PE coverage will remain in effect until a final
Medicaid determination has been made on the application.
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Chapter 7 - Manual Screening for Presumptive Eligibility
In any instance, such as lack of internet connectivity or power or system outages, in which the
Presumptive Eligibility Determiner (PED) is unable to screen an applicant for Presumptive Eligibility (PE)
on the Your Eligibility System New Mexico (YESNM) designed for PEDs (YESNM-PE), the PED will be
required to calculate the PE determination manually.
To complete the manual submission of a PE application, a PED must calculate the applicant's eligibility.
The PED must evaluate household size, income and all other factors involved in an accurate eligibility
determination. All information required for a determination must be asked of the applicant. PEDs will
have determination and approval results submitted manually or through YESNM-PE held to the same
performance standards required as a condition of the individual's participation as PEDs.
To manually screen an individual for PE, the PED should utilize the Streamlined Medicaid Application
(MAD 100) or the Presumptive Eligibility Applicant Information Form (MAD 011) to compile and
determine the applicant's household information and financial eligibility. They should also utilize the
Household Comp and Income Calculation Form (MAD 008) to determine the applicant's financial
eligibility.
After screening and determining the applicant PE eligible, the PED must submit the PE approval to
Xerox, the New Mexico Medicaid Fiscal Agent. If the PED is unable to submit the PE approval on the
Portal, they must do so via fax. All paper PE approvals must be submitted on the Presumptive
Eligibility Authorization Form (MAD 070; Rev 3/6/14). This form is available for download on the
Portal at www.nmmedicaid.acs-inc.com.
In most cases, PE approvals entered on the Portal will appear within minutes of the PE entry. Providers
who view applicant eligibility will see these results in real time. PE approvals submitted via fax may
take up to 2 business days (Monday-Friday) to appear in the Portal after the approval has been
received by Xerox. This means that the applicant may not appear as "eligible" in the Portal for a
Medicaid COE for at least two business days after the PE approval has been received by Xerox.
All documents used to make manual PE determinations must be submitted to HSD/MAD PE Program
Staff via e-mail at HSD.PEDeterminers@state.nm.us or by fax at 505-827-7200.
Any PE applicant who has been determined presumptively eligible must also be asked if they wish to
submit an application for ongoing Medicaid coverage. Any applicant who elects to apply for ongoing
Medicaid coverage must be supplied with the Medicaid-Only Application (MAD 100; Rev 1/21/14). This
application should be signed by the applicant and submitted by the PED to HSD within 48 hours of the
PE submission. All MAD 100 applications submitted by PEDs on behalf of an applicant must be
submitted to the Human Services Department's (HSD) Central ASPEN Scanning Area (CASA). All
accompanying documents that may help with determining the applicant's ongoing Medicaid eligibility
should be submitted along with the application. Applications submitted to CASA will be electronically
routed to an HSD office for processing.
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Applications may be submitted to CASA by mail or fax.
Central ASPEN Scanning Area
PO BOX 830
Bernalillo, NM 87004
Phone: 800-283-4465
E-Fax: 855-804-8960
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Chapter 8 - Completing Manual Forms
Beginning April, 2014, the Presumptive Eligibility (PE) process in New Mexico will be, primarily, an
electronic one. Presumptive Eligibility Determiners (PEDs) will be required to use the electronic
processes at all times possible. In the rare instances where PE determinations, approvals and
submissions must be completed on paper, they may only be submitted using acceptable paper forms
developed by the New Mexico Human Services Department's (HSD) Medical Assistance Division (MAD).
Updates and revisions to forms will be made available - via e-mail, postal delivery or through webaccessed downloads to all active PEDs. Submission of out-dated or obsolete forms may delay or
negate the acceptance, processing or entry of a PE determination.
Before beginning the process of determining presumptive eligibility, the PED is required to check the
current Medicaid enrollment status of all applicants. Applicants who are currently enrolled in most
categories of Medicaid eligibility or those that have had a PE determi nation within the past 12 months
are not eligible for PE coverage. When inquiry ability is not available on the New Mexico Medicaid
Portal (Portal), PEDs must call the Medicaid Call Center's Automatic Voice Response System (AVRS) at
800-820-6901 to check an applicant's current enrollment status. It is the responsibility of PEDs to
verify the eligibility of all PE applicants. Any PE approvals that have been submitted without proper
prior verification of an applicant's eligibility status will be subject to PED audit and performance
standards and may result in the revocation of the PED's PED number.
Before screening for PE, the PED should ask the applicant if they wish to apply for PE and ongoing
Medicaid coverage. If the applicant wishes to do both, the PED should use the New Mexico MedicaidOnly Application (MAD 100) to gather information for the PE screening and for the application for
ongoing coverage.
Completing the MAD 100 for Presumptive Eligibility
When using the information on the MAD 100 to screen for PE, not all fields on the application are
required to be completed to determine PE. However, any fields left blank that may be needed to
determine ongoing Medicaid eligibility may be asked of the applicant at a later date by HSD staff.
Therefore, applicants wishing to be evaluated for ongoing coverage should be encouraged to complete
all fields on the MAD 100.
To properly screen for PE, certain information must be gathered for the applicant and all applicable
household members. This same information is needed whether the determination is made through an
electronic or manual process. To begin the screening process, the PED should first ask the applicant
information that will help determine household size and income. To complete this on the MAD 100,
the information in the sections below is required, at the very least, for an accurate PE-only
determination.
On Page 2 of the MAD 100, the highlighted fields should be completed:
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On page 3, Social Security Numbers (SSN) and Race & Ethnicity are not required fields. However, SSNs
will be required when seeking ongoing coverage. Any Native American who wishes to remain exempt
from Managed Care may be auto-assigned to a Managed Care Organization (MCO) if their Race is not
known. If this occurs, the applicant may contact their local HSD Income Support Division (ISD) office to
have their race code corrected and the enrollment with the MCO deleted.
Page 3 also has required questions that relate to the tax filing status of household members. This will
help to determine the financial eligibility of household members based on tax filer status.
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In section 5, only the pregnancy question is relevant to a PE determination screening.
Section 6 must be completed so household income can be accurately evaluated.
Other types of income may count towards a household's income and should be noted.
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Any household members with existing health coverage, including private insurance, Medicaid or
Medicare, should be listed in the section below. Any applicant who is requesting retroactive coverage
for unpaid medical bills for the past three months should list that information in this section. However,
PE coverage will not be granted retroactively. Only approved ongoing Medicaid applications may be
eligible for retroactive coverage.
An MCO choice should be made at the time of application whether applying for PE or for ongoing
Medicaid coverage. Native Americans may choose to be exempt from Managed Care.
The person applying on behalf of the household members listed should read the information below
and is required to sign the application. All information supplied will be used to evaluate the person(s)
listed on the application who are seeking assistance for PE or for ongoing Medicaid coverage.
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After required fields have been completed and the PED is satisfied Citizenship and residency
requirements have been met, financial eligibility must be determined. See Chapter 10 - "Manually
Calculating Medicaid Financial Eligibility."
Completing the MAD 011 for Presumptive Eligibility
Any person or household who chooses to not apply for ongoing coverage at the time of initial PE
screening may be asked the questions needed to determine PE on a separate form. This form will be
submitted to the MAD PE Program Staff for auditing purposes but will not be evaluated for ongoing
Medicaid eligibility. The household and financial information needed to determine PE should be
gathered on the Presumptive Eligibility (PE) Applicant Information form (MAD 011)
To complete the MAD 011, the PED must ask the applicant the information listed on the form. The
person who is supplying the information, whether applying for him/herself or for some or all family
members, is responsible for the accuracy of the information supplied.
When possible, all information listed for each family member residing in the household should be
completed. SSNs are not required to be supplied as a condition of PE. However, all PE applicants are
required to meet Citizenship requirements.
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After applicant and household information has been gathered and the PED is satisfied that household
members have been identified and Citizenship and residency requirements have been met, financial
eligibility must be determined. See Chapter 10 - "Manually Calculating Medicaid Financial Eligibility."
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Chapter 9 - Manual Calculation of Household Size
Household size is one of the factors used to help determine Medicaid Eligibility. This is true for both
Presumptive Eligibility (PE) and applications ongoing Medicaid coverage.
When calculating household size, Presumptive Eligibility Determiners (PEDs) should ensure that all
household members are listed on the Streamlined Medicaid Application (MAD 100) or on the
Presumptive Eligibility Applicant Information Form (MAD 011). Household members listed will be used
in determining the Household Composition. However, the "Assistance Unit" for that household only
includes the individuals who are applying for benefits. Each individual in the Assistance Unit is
evaluated for a budget group individually. Countable income will be based on which members are
included in the budget group at an individual level.
All individuals listed on the application are evaluated according to their living arrangement to
determine if they can be included in an assistance group or budget group. In some cases, an individual
can be counted as being in the home even if they are physically absent from the home. These
individuals are considered to be "extended living." Extended living in the home includes:
(1) attending college or boarding school;
(2) receiving treatment in a title XIX Medicaid facility (including institutionalized when
meeting a nursing facility (NF) level of care (LOC) and intermediate care facilities for the mentally
retarded (ICF-MRs);
(3) emergency absences: an individual absent from the home due to an emergency, who
is expected to return to the household, continues to be a member of the household;
(4) foster care placements: a child removed from the home by a child protective services
agency (tribal, bureau of Indian affairs, or children, youth and families department) will be considered
to be living in the home until the adjudicatory hearing; if the adjudicatory hearing results in custody
being granted to some other entity, the child will be removed from the assistance unit and budget
group;
(5) a stay in a detention center:
(a) regardless of adjudication status the individual continues to be a member of the
household but will not be Medicaid eligible;
(b) once an adjudicated individual leaves the detention center to receive inpatient
services in a medical institution, the individual may be eligible during treatment if all other criteria are
met; eligibility ceases to exist when the individual returns to the detention center.
Extended living in the home also includes:
(1) residential treatment centers;
(2) group homes; and
(3) free-standing psychiatric hospitals.
To be included in the assistance unit of a Parent/Caretaker, a child must be living, or considered to be
living, in the home of:
(1) a biological or adoptive or step parent (there is a presumption that a child born to a
married woman is the child of the husband); or
(2) a specified relative who:
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(a) is related within the fifth degree of relationship by blood, marriage or adoption,
as determined by New Mexico statute Chapter 45 - Uniform Probate Code; a relationship based upon
marriage, such as "in-law" or "step" relationships, continues to exist following the dissolution of the
marriage by divorce or death; and
(b) assumes responsibility for the day-to-day care and control of the child; the
determination of whether an individual functions as the specified relative shall be made by the
specified relative unless other information known to the worker clearly indicates otherwise;
(3) a child considered to be living in the home: a child is considered to be part of the
assistance unit and budget group as evidenced by the child's customary physical presence in the home;
if a child is living in more than one household, the following applies:
(a) the custodial parent is the parent with whom the child lives the greater number
of nights; or
(b) if the child spends equal amounts of time with each household, the child shall be
considered to be living in the household of the parent with the higher MAGI.
[8.291.430.13 NMAC - Rp, 8.291.430.13 NMAC, 1-1-14]
8.291.430.14 BASIS FOR DEFINING THE ASSISTANCE UNIT AND BUDGET GROUPS: At the time of
application, an applicant or recipient and the department shall identify everyone who is to be
considered for inclusion in an assistance unit and budget group. The composition of the assistance unit
and budget group is based on the following factors:
A.
Assistance group: the assistance unit includes an individual who applies and who is
determined eligible under one of the categories of eligibility outlined in 8.291.400.10 NMAC.
B.
Budget group: the budget group consists of the following types and will be established
on an individual basis:
(1) Tax filer(s): households that submit an application where an individual intends to file
for federal taxes or will be claimed as a dependent on federal income taxes for the current year.
(a) The budget group will consist of individuals who are listed on the application as
the taxpayer and tax dependents.
(b) If there are multiple taxpayers listed on a single application, the budget group(s)
will be established based on who the taxpayer intends to claim as a dependent (including the
taxpayer). Only the taxpayer and dependents listed on the application will be considered as part of the
budget group.
(c) In the case of a married couple living together, each spouse will be included in
the household of the other spouse, regardless of whether they expect to file a joint tax return, a
separate tax return or whether one spouse expects to be claimed as a tax dependent by the other
spouse.
(d) Exceptions to tax filer rules: the following individuals will be treated as nonfilers:
(i) individuals other than a spouse or a biological, adopted, or step child who
expect to be claimed as a tax dependent by another taxpayer outside of the household;
(ii) individuals under 19 who expect to be claimed by one parent as a tax
dependent and are living with both parents but whose parents do not expect to file a joint tax return;
and
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(iii)
individuals under 19 who expect to be claimed as a tax dependent by a
non-custodial parent.
(2) Non-filer(s) are individuals applying for Medicaid who have not filed for taxes, do not
intend to file for federal taxes, have not been claimed as a dependent on taxes in the current year or
who meet an exception to tax filer rules in Paragraph (1) above. The following individuals may be
included in a budget group when evaluating eligibility for an ACA related Medicaid eligibility category,
provided that they live together:
(a) the individual;
(b) the individual’s spouse;
(c) parents/step-parents; or
(d) the individual’s biological, adopted and step children under the age of 19.
(3) Households may submit an application that includes both filer and non-filers as
defined in Subsections A and B above. The budget group(s) will be organized using the filer and nonfiler concepts, and eligibility will be established on an individual basis.
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Chapter 10 - Manually Calculating Medicaid Financial Eligibility
To be eligible for Medicaid coverage, individuals must meet certain eligibility guidelines. Some of
these factors could include citizenship, identity, age and medical factors. All categories of eligibility
(COE) are based on income guidelines. Whether an applicant is being screened for Presumptive
Eligibility (PE) or ongoing Medicaid coverage, income will be used in the eligibility determination.
The income guidelines that help determine eligibility are based on the Federal Poverty Levels (FPL) as
set by the United States Health and Human Services Department. FPLs are based on household size
and total income. Medicaid eligibility FPLs change April 1 of each year. The current FPLs for Medicaid
Eligibility that go into effect April 1, 2014 are below:
In the past, a household's FPL was determined using a formula of family size, type of income received
and deductions that the household might receive for some income. And, while that still holds true, the
base income that is counted is calculated using an individual's Modified Adjusted Gross Income (MAGI).
MAGI is a methodology for how income is counted and how household composition and family size are
determined. MAGI is based on Federal Tax rules for determining adjusted gross income (with some
modification). It is not a number on a tax form. In MAGI, there are no asset tests or income disregards
other than those that may exist for some specific Medicaid COEs).
Certain types of income are categorized as "Countable" in calculating MAGI. Types of income
categorized as Countable include:




Taxable wages/salary (before taxes taken out). Pre-tax contributions to dependent care
accounts, health insurance premiums, flexible spending accounts, retirement accounts and
commuter expenses are NOT included as income
Self-employment (profit once business expenses are paid)
Social Security benefits
Unemployment benefits
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






Alimony received
Most retirement benefits
Interest (including tax-exempt interest)
Net capital gains (profit after subtracting capital losses)
Most investment income (profit after subtracting costs)
Other taxable income such as canceled debts, court awards, jury duty pay not given to an
employer, cash support and gambling, prizes or awards
Foreign earned income
Other types of income are categorized as Non Countable Income. These include:









Supplemental Security Income (SSI)
Child Support Received
Veteran's benefits
Worker's compensation payments
Proceeds from life insurance, accident insurance or health insurance
Federal tax credits and Federal income tax refunds
Gifts and loans
Inheritances
Temporary Assistance to Needy Families (TANF) and other government cash assistance
Although standard deductions do not apply, some exemptions exist for income received by a tax
dependent in a household. These exemptions include the income of most children and tax dependents
of the household who are not required to file a federal tax return.
In most cases, a child's income does not count towards household income of his or her parent unless
the child is required to file taxes. The child's income will not be counted in evaluating the child's
eligibility, the eligibility of other household members or in the case of adult children who are tax
dependents of their parent. However, if the child does not live with his or her parent, the child’s
income will count for his or her own eligibility and the eligibility of the child’s other household
members, such as siblings, regardless of whether the child’s income is high enough to require a tax
return to be filed.
Exception for other Tax Dependents

Include income of a tax dependent in household income only if the tax dependent is expected
to be required to file a tax return.
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

Income of a tax dependent is included in household income of any household where both that
tax dependent and his/her claiming tax filer are present, only if the tax dependent is expected
to be required to file a tax return.
o Applies to adult children who are tax dependents of their parent.
This exception does not apply to a tax dependent’s income when determining the household
income of any household where the tax dependent’s parent and the tax dependent’s claiming
tax filer are not part of that household.
 In such cases, the tax dependent’s income counts toward household income
regardless of whether or not he/she is expected to be required to file a tax
return.
Deductions may apply to the calculation of income for some individuals at certain income levels. A
disregard of 5% of 100% of the current FPL, according to the individual’s budget group size, will be
given according to some Affordable Care Act (ACA) COEs. Categories that may be eligible for this
income disregard include some children's categories, pregnancy, parent/caretakers and other adults.
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Chapter 11 - Submitting a Presumptive Eligibility Approval by Fax
After screening and determining that an applicant is eligible for Presumptive Eligibility (PE), the
Presumptive Eligibility Determiner (PED) must submit the PE approval to Xerox, the New Mexico
Medicaid Fiscal Agent, through the New Mexico Medicaid Portal (Portal). If the PED is unable to
submit the PE approval on the Portal, they must do so via fax. All paper PE approvals must be
submitted on the Presumptive Eligibility Approval Form (MAD 070; Rev 3/6/14). This form is available
for download on the Portal at www.nmmedicaid.acs-inc.com.
Completing a MAD 070 for Submission of a Presumptive Eligibility Approval
The first step is to complete the PED Name and fax number in the upper right hand corner of the form.
Next, the PED should list the information for each person to whom PE is being granted.
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A Managed Care Organization (MCO) choice should be made for each person being granted PE. If the
applicant has no choice "None" may be entered. However they will be auto-assigned to an MCO unless
they have indicated that they are Native American in the Race field.
The PED should also list the category of eligibility (COE) that is being granted to the person listed as
eligible. Only one choice can be made and should be appropriate to the COE that the individual has
been determined eligible.
The Eligibility Begin Date is the date that the individual has been approved for PE and the End Date will
be the last day of the following month the of the PE unless an application for on-going eligibility has
been received by that date. If an application is submitted by the end date, the PE coverage will remain
in effect until a final determination for the ongoing coverage has been made. Any PE determinations
that do not meet the age and eligibility restrictions for the specific COE granted may be rejected by
Xerox. If a PE approval is rejected, Xerox will e-mail the PED with a notification that the PE submission
has not been accepted.
Each individual being granted PE should be listed on a separate line of the form.
Once completed, the form must be faxed to Xerox. PE approvals submitted via fax may take up to 2
business days (Monday-Friday) after they have been received by Xerox to be entered in the Portal. The
applicant will not appear as "eligible" in the Portal until the manual entry has occurred.
All PEs granted must be submitted to Xerox on the date of approval. And all documentation related to
the approval must be submitted the MAD PE Program Staff within 24 hours of the PE approval.
Manual submissions must include the Presumptive Eligibility Applicant Information Form (MAD 011)
OR the Medicaid-Only Application (MAD 100; Rev Date 1/21/14), the Household Comp and Income
Calculation Worksheet (MAD 008) and the Presumptive Eligibility Authorization From (MAD 070).
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Chapter 12 - Submitting Paper Applications or Information Sheets
All information gathered by a Presumptive Eligibility Determiner (PED) to determine Presumptive
Eligibility (PE) should be submitted to the Human Services Department (HSD). If the applicant has
elected to apply for ongoing coverage, the information will be used to make a final eligibility
determination. If the PE applicant has chosen not to apply for ongoing coverage, the information will
be used to evaluate the accuracy of the PED's PE determination.
Submitting Applications for Ongoing Medicaid Coverage
Applicants who have elected to apply for ongoing Medicaid coverage should have completed the fields
on the Medicaid-Only Application (MAD 100; Rev Date 1/21/14) needed to determine their
Presumptive Eligibility (PE) approval or denial. This application will also be used to determine
eligibility for ongoing coverage. Applicants who have been determined not eligible for PE may still
submit an application for ongoing coverage.
Signed MAD 100 applications should be forwarded to the Human Services Department's (HSD) Central
ASPEN Scanning Area (CASA). Any fields that have been left blank on the application that may be
needed to determine ongoing Medicaid eligibility may be asked of the applicant by HSD staff.
Any documentation that an applicant has supplied at the time of their PE application should be
submitted as well. This can include any proofs of income, citizenship, identity, etc. PEDs should also
include the Household Comp and Income Calculation Worksheet (MAD 008) used to make the PE
determination.
Applications and documentation may be mailed or faxed to CASA within two days of the PE
determination. CASA will index the application and documentation and electronically route all items to
be processed by HSD staff. If more information is needed from the applicant to make a final eligibility
determination, HSD will request it. Failure of an applicant to submit any information requested by HSD
that is needed to make a final eligibility determination will be grounds for a denial. Once processed,
the applicant will receive a final eligibility determination notice by mail.
CASA Contact Information
Central ASPEN Scanning Area
PO BOX 830
Bernalillo, NM 87004
Phone: 800-283-4465
E-Fax: 855-804-8960
Submitting Presumptive Eligibility Applicant Information Sheets
Applicants who do not wish to apply for ongoing coverage will not have their information evaluated for
ongoing Medicaid eligibility. However, the PED must submit the information used to determine the PE
applicant's PE approval or denial to HSD for auditing purposes. Information must be submitted by mail
or faxed to the HSD/MAD PE Program Staff. Information should include the Presumptive Eligibility
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Applicant Information Form (Mad 011) and the Household Comp and Income Calculation Worksheet
(MAD 008) used to make the PE determination. HSD/MAD PE Program Staff will evaluate the accuracy
of the PE determination. PEDs are held to the same Performance Standards for PE determinations,
whether the determination is made electronically or manually and are responsible for the accuracy of
all determinations.
PE Program Staff Contact Information
HSD/Medical Assistance Division
Communication and Education Bureau
PE Program Staff
PO BOX 2348
Santa Fe, NM 87504-2348
Phone: 505-827-7717
FAX: 505-827-7200
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Chapter 13 - Documents that May Be Needed for Ongoing Medicaid
Eligibility for all Medicaid categories of eligibility (COE) is based on citizenship/immigration status,
residency, income and other factors. The income guidelines that are used to determine Medicaid
eligibility are based on the Federal Poverty Levels (FPL) as set by the United States Health and Human
Services Department. FPLs are set based on household size and total income.
To be determined eligible for Medicaid coverage, verifications may be needed to prove an applicant's
citizenship or immigration status and income eligibility. The New Mexico Human Services Department
(HSD) will make every effort to use data sources to obtain all necessary verifications. If HSD is unable
to obtain these verifications, proof of the information will be requested from the applicant. Applicants
will be notified by mail of any verification required. They will also be given a timeframe in which the
information must be supplied. Failure to provide the information in the timeframe requested may
result in a denial of the Medicaid application.
Documents Used to Prove Citizenship, Immigration Status and Identity
Medicaid applicants must meet citizenship and identity requirements to be determined eligible for
coverage. U.S. citizens are Medicaid eligible, as are legal permanent residents and legal immigrants. A
legal immigrant is a non-U.S. citizen who has permission to live and/or work in the U.S. as
demonstrated by providing documents issued by the U.S. Citizenship and Immigration Services.
Lawfully residing children and pregnant women, including those who are in nonimmigrant status, can
be Medicaid eligible. In New Mexico, individuals may also be required to show proof of identity to
receive Medicaid services.
Certain documents are acceptable to provide these necessary verifications. Some documents are
acceptable proof of both citizenship and identity while others are only acceptable as citizenship OR
identity. For documents that prove only citizenship or identity, one of each type is required. Some of
the most common proofs of citizenship and identity are listed below.
Type of Proof
Certificate of Indian Blood (CIB) or Certificate of Degree of Indian
Blood (CDIB)
Certificate of Naturalization (DHS Form N-550 or N570)
Certificate of U.S. Citizenship (DHS Form N-56- 0r N561)
Federal, State or Local Government-Issued Identification Card
(w/ photo)
Military Dependent's Identification Card
NM Department of Health Birth Record Web Portal Verification
School-Issued Identity Card (w/Photo)
State-Issued Driver's License (Current & Valid w/Photo)
State-Issued Identity Card (Current & Valid w/Photo)
U.S. Birth Certificate
U.S. Passport (Expired or Unexpired)
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Identity
Citizenship
& Identity
X
X
X
X
X
X
X
X
X
X
X
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For a complete listing of documents deemed acceptable as proof of citizenship and identity, go to
http://www.hsd.state.nm.us/uploads/files/Looking%20For%20Information/08_100_0130.pdf
For the lawfully residing policy and nonimmigrant status descriptions, go to
http://www.hsd.state.nm.us/uploads/FileLinks/1279f87fd1af45bfabc9f4bf1706d624/12_01_Lawfully_
Residing_Children_and_Pregnant_Women_1.pdf
The New Mexico Department of Health's (DOH) Vital Records Bureau Birth Record Web Portal
Verification site can be searched to obtain verification of most individuals born in New Mexico after
1919. This proof may be used to verify an individual's citizenship status. This site is for the use of
employees of state agencies or for individuals who have been certified as New Mexico HSD
Presumptive Eligibility Determiners (PEDs). The site may be accessed at
https://www.health.state.nm.us/partners/bc_confirm.php.
After navigating to the site, the following security message will appear. Click on “continue to the
website (not recommended).”
To search for a New Mexico birth record on this site, the applicant's information must be entered into
the portal exactly as it appears on the individual's birth certificate. The following information must be
entered:
First Name; Last Name
Date of Birth (mm/dd/yyyy)
County of Birth
Gender
Mother’s First Name
Mother’s Maiden Name
If a birth record is found, it should be submitted with the application for ongoing Medicaid eligibility.
Proof of Income
To meet Medicaid financial eligibility requirements, proof of income may be required of the applicant.
HSD will utilize data matches to obtain income verifications. Any applicant who has financial
information such as proof of wages from employment (past 4 weeks of income), social security
statements or tax information for countable income should supply proofs of this income with their
Medicaid application. For more information on countable and non-countable income types, please
see Chapter 10 of this manual.
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Chapter 14 - Glossary of Terms and Acronyms
ABP - Alternative Benefit Plan
ACA - Affordable Care Act
Alternative Benefit Plan (ABP) - Most adults who qualify for the Medicaid category known as the
“Other Adult Group” receive services under the New Mexico Alternative Benefit Plan (ABP). The ABP
covers doctor visits, preventive care, hospital care, emergency and urgent care, specialist visits,
behavioral health care, substance abuse treatment, prescriptions, certain dental services, and more.
Some recipients will have to pay small co-pays for certain services, depending on their income.
AVRS - Automatic Voice Response System
Categories of Eligibility (COEs) - Medicaid Categories of Eligibility. Medicaid COEs include coverage for
children, families, pregnant women, adults, long-term care recipients and individuals who are eligible
for both Medicare and Medicaid benefits. All New Mexico Medicaid COEs have a designated numeric
COE listing associated with the COE name.
Centers for Medicare and Medicaid Services (CMS) - A federal agency within the United States
Department of Health and Human Services (DHHS) that administers the Medicare program and works
in partnership with state governments to administer Medicaid, the Children's Health Insurance
Program (CHIP), and health insurance portability standards.
Children, Youth and Families Department (CYFD) - New Mexico Children, Youth and Families
Department
Children's Health Insurance Program (CHIP) - CHIP coverage is generally available to children in
families with incomes at the higher income threshold of Medicaid eligibility. Unlike regular children's
Medicaid coverage, CHIP may have minimal co-pays for some services. In New Mexico, the categories
of eligibility for CHIP are categories 420 and 421.
CHIP - Children's Health Insurance Program
CMS - Centers for Medicare and Medicaid Services
COE - Category of Eligibility
Countable Income - The amount of income remaining after all applicable deductions and disregards
have been deducted from the GROSS income.
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CYFD - New Mexico Children, Youth and Families Department
DOH - New Mexico Department of Health
Early and Periodic Screening, Diagnostic and Treatment (EPSDT) - Provides comprehensive and
preventive health care services for children under age 21 who are enrolled in Medicaid. EPSDT is key to
ensuring that children and adolescents receive appropriate preventive, dental, mental health, and
developmental and specialty services.
EPSDT - Early and Periodic Screening, Diagnostic and Treatment
Federal Poverty Levels (FPL) - The income guidelines that are used to determine Medicaid eligibility.
FPLs are set by the United States Health and Human Services Department and are based on household
size and total income.
Federally Qualified Health Center (FQHC) - FQHCs include all organizations receiving grants under
Section 330 of the Public Health Service Act. FQHCs qualify for enhanced reimbursement from
Medicare and Medicaid, as well as other benefits. FQHCs must serve an underserved area or
population, offer a sliding fee scale, provide comprehensive services, have an ongoing quality
assurance program, and have a governing board of directors.
Fee For Service (FFS) - A Medicaid delivery system where health care providers are paid for each
service (like an office visit, test, or procedure). FFS covers the basic Medicaid benefit package, such as
preventive, specialty and behavioral health services, and emergency care. Most Native Americans can
choose to receive Medicaid services through FFS or Managed Care. Native Americans who are eligible
for both Medicare and Medicaid or require a nursing facility level of care are required to be in
Managed Care and do not have the option of receiving Medicaid services through FFS.
FFS - Fee for Service
FPL - Federal Poverty Level
FQHC - Federally Qualified Health Center
Health Insurance Portability and Accountability Act (HIPAA) - Provides national standards to protect
the privacy of personal health information (PHI?). To improve the efficiency and effectiveness of the
health care system, HIPAA included "Administrative Simplification" provisions that required the United
States Department of Health and Human Services to adopt national standards for electronic health
care transactions. Congress incorporated into HIPAA provisions that mandated the adoption of Federal
privacy protections for individually identifiable health information.
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Health Risk Assessment (HRA) - A systematic approach to collecting information from individuals that
identifies risk factors, provides individualized feedback, and links the person with at least one
intervention to promote health, sustain function and/or prevent disease. Centennial Care members
will receive an HRA by phone or in person by their Managed Care Organization.
HIPAA - Health Insurance Portability and Accountability Act
HRA - Health Risk Assessment
HSD - New Mexico Human Services Department
IHS - Indian Health Service
Income Support Division (ISD) - The Division within the New Mexico Human Services Department that
determines eligibility for the State's Public Assistance Programs. ISD field offices are located statewide.
Indian Health Service (IHS) - An Agency within the Department of Health and Human Services responsible
for providing federal health services to American Indians and Alaska Natives. The IHS is the principal federal
health care provider and health advocate for Indian people, and its goal is to raise their health status to
the highest possible level. The IHS provides a comprehensive health service delivery system for
approximately 1.9 million American Indians and Alaska Natives who belong to 566 federally recognized
tribes in 35 states.
ISD - Income Support Division
LIHEAP - Low Income Energy Assistance Program
Legal Immigrant - A non-U.S. citizen who has permission to live and/or work in the U.S. as
demonstrated by providing documents issued by the U.S. Citizenship and Immigration Services.
Low Income Home Energy Assistance Program (LIHEAP) - Assists eligible New Mexico residents and
families with their heating and cooling costs. LIHEAP is federally funded through the Department of
Health and Human Services. The federal government establishes funding levels annually.
MAD - Medical Assistance Division
MAD 008 - Household Comp and Income Calculation Worksheet
MAD 011 - Presumptive Eligibility (PE) Applicant Information Form
MAD 070 - Presumptive Eligibility Authorization Form
MAD 100 - New Mexico Medicaid-only application
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MAD 219 - Presumptive Eligibility Determiner Agreement and Code of Conduct
MAD 222 - Federal Poverty Level Guidelines (Revised each April 1 for Medicaid Categories of Eligibility)
MAGI - Modified Adjusted Gross Income
Managed Care Organization (MCO) - An insurance company that contracts with providers and medical
facilities to provide healthcare to its members. New Mexico's Medicaid Managed Care program is
called Centennial Care and there are four MCOs contracted to provide Centennial care services. The
four MCOs are Blue Cross Community Centennial, Molina Healthcare of New Mexico, Presbyterian
Health Plan and UnitedHealth care Community Plan of New Mexico.
MCO - Managed Care Organization
Medicaid – A state, federally funded, health coverage program for people who meet certain
requirements. There are numerous categories of Medicaid, each with specific eligibility requirements
and benefit packages. States establish their own eligibility standards; determine the type, amount, rate
of payment; and duration and scope of services based on broad national parameters set by CMS
(Centers for Medicare and Medicaid Services, a federal agency).
Medicaid Call Center's Automatic Voice Response System (AVRS) - Unmanned telephone system
where providers can check Medicaid client eligibility.
Medical Assistance Division (MAD) - The Division with the New Mexico Human Services Department
that administers the State's Medicaid program and, in some cases, may also process Medicaid eligibility
applications.
Medicare -- is a national social insurance program administered by the U.S. Federal Government since
1965 that guarantees access to health insurance for Americans ages 65 and older and younger people
with disabilities.
Modified Adjusted Gross Income (MAGI) - The figure used to determine eligibility for lower costs in
the Marketplace and for Medicaid and CHIP. Generally, modified adjusted gross income is an
individual's adjusted gross income plus any tax-exempt Social Security, interest, or foreign income they
may have.
New Mexico Human Services Departments (HSD) - Administrator of all New Mexico Public Assistance
Programs including the Medicaid, Cash Assistance, the Supplemental Nutrition Assistance Program
(SNAP) and the Low-Income Home Energy Assistance Program (LIHEAP).
New Mexico Medicaid Portal (Portal) - An on-line public portal operated and maintained by the New
Mexico Medicaid Fiscal Agent, Xerox, on behalf of the New Mexico Human Services Department's
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Medical Assistance Division. The Portal can be used by Medicaid recipients or by Medicaid providers to
access eligibility information.
Patient Protection and Affordable Care Act (ACA) - A United States federal statute signed into law by
President Barack Obama on March 23, 2010. The ACA was enacted with the goals of increasing the
quality and affordability of health insurance, lowering the uninsured rate by expanding public and
private insurance coverage, and reducing the costs of healthcare for individuals and the government. It
introduced a number of mechanisms—including mandates, subsidies, and insurance exchanges—
meant to increase coverage and affordability.
PE - Presumptive Eligibility
PE+ - Presumptive Eligibility Plus
PED - Presumptive Eligibility Determiner
PED Number - Presumptive Eligibility Determiner Number
PHI - Personal Health information
Portal - New Mexico Medicaid Portal
Presumptive Eligibility (PE) - Short-term Medicaid coverage for eligible individuals. PE is not available
for every Medicaid category of eligibility but is available for children, pregnant women, former foster
care recipients, and some adults.
Presumptive Eligibility Determiners (PEDs) - Individuals who are trained and certified to screen and
enroll eligible individuals into Presumptive Eligibility coverage. PEDs who can determine PE for
Children and Pregnancy only categories of eligibility are Specialty Type 170.
Presumptive Eligibility Determiner Number -- The number a Presumptive Eligibility Determiner (PED)
is assigned after completing a Presumptive Eligibility training and fulfilling all other certification
requirements. This number is required in order to determine PE eligibility by accessing the New Mexico
Medicaid Portal.
Presumptive Eligibility Plus (PE+) Determiners - PEDs who have been certified with Specialty Type 171
are also known as PE+ Determiners. PE+ Determiners can determine eligibility for children, pregnancy,
Other Adult and Parent Caretaker categories of eligibility. PE+ Determiners are only eligible to
participate as such if they are employed by and physically stationed at a specific location type. This
includes hospitals that have elected to participate as a PE Provider location but does not extend to a
hospital's associated clinics or to any PED who is stationed off-site from their normal work site. PE+
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locations also include employees of Indian Health Services (IHS) medical facilities and clinics as well as
staff at New Mexico Department of Corrections facilities, County Detention Centers and Jails.
SNAP - Supplemental Nutrition Assistance Program (re-alphabetized)
SSI - Supplemental Security Income
SSN - Social Security Number
Social Security Number (SSN) - A nine-digit number assigned to citizens, some temporary residents and
permanent residents in order to track their income and determine benefit entitlements. The Social
Security Number was created in 1936 and while the original intention was just to track earnings and
benefits, it is now also used to identify individuals and sometimes track their credit record.
Supplemental Nutrition Assistance Program (SNAP) - Serves as the first line of defense against hunger
for New Mexico residents. It enables low-income families to buy nutritious food with coupons and
Electronic Benefits Transfer (EBT) cards. SNAP recipients spend their benefits to buy eligible food in
authorized retail food stores.
Supplemental Security Income (SSI) - The monetary benefits received by retired workers who have
paid in to the Social Security system during their working years. Social Security benefits are paid out on
a monthly basis to retired workers and their surviving spouses. They are also paid to those who are
permanently and totally disabled according to the strict criteria set forth by the Social Security
Administration.
TANF - Temporary Assistance to Needy Families
Temporary Assistance to Needy Families (TANF) - The New Mexico Temporary Assistance for Needy
Families (TANF) program, known as NMWorks, provides cash assistance and job training to eligible
New Mexico families. This monthly cash assistance benefit should be used to meet family needs such
as housing, utilities, and clothing costs.
Value-Added Services - Services or benefits provided by a Managed Care Organization that are above
and beyond what is contractually required to be provided to the MCO's members.
Xerox -- The contracted Fiscal Agent for New Mexico Medicaid who processes claims for payment to
Medicaid providers. Xerox operates and maintains New Mexico Medicaid Portal, Omnicaid system
and AVRS systems on behalf of the New Mexico Human Services Department's Medical Assistance
Division.
YESNM - Your Eligibility System New Mexico
YESNM-PE - Your Eligibility System New Mexico for Presumptive Eligibility Determiners
June, 2014
NM HSD/MAD - PE & PE+ Training Manual
Page 90
Your Eligibility System New Mexico (YESNM) - On-line application system used by the public to apply
for New Mexico's Public Assistance Programs.
Your Eligibility System New Mexico for Presumptive Eligibility Determiners (YESNM-PE) - The area of
the YES-NM system designed for the exclusive use of Presumptive Eligibility Determiners to screen
applicants for Presumptive Eligibility.
June, 2014
NM HSD/MAD - PE & PE+ Training Manual
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Chapter 15 - Quick Reference Information, Forms, Checklists and Worksheets
The following quick reference materials, forms, checklists and worksheets can be found in this section.
Section 1 - Quick Reference Information
 Presumptive Eligibilty Contact and Resource Sheet
 Flow Process for Pesumptive Eligibility Training and Certification
 New Mexico Medicaid Web Portal and YESNM-PE Registration Workflow
 Electronic Presumptive Eligibility Screening Process Workflow
 Manual Screening for Presumptive Eligibility Workflow
 Federal Poverty Level with ACA Categories of Eligibity (MAD 222)
 Medicaid Categories of Eligibility
 Applicant Rights and Responsibilities - English
 Applicant Rights and Responsibilities - Spanish
 YESNM-PE Electronic Signature Page - English
 YESNM-PE Electronic Signature Page - Spanish
Section 2 - Forms
 Presumptive Eigibility Determiner Agreement and Code of Conduct (MAD 219)
 Medicaid-Only Application - English (MAD 100)
 Medicaid-Only Application - Spanish (MAD 100 SP)
 Presumptive Eligibity Applicant Information form - English (MAD 011)
 Presumptive Eligibity Applicant Information form - Spanish (MAD 011 SP)
 Presumptive Eligibity Authorization Form (MAD 070)
Section 3 - Checklists and Worksheets
 How to Determine Household Size flowchart
 Household Comp and Income Calculation Worksheet (MAD 008)
 Manual Presumptive Eligibility Submission Checklist
o For Applicants Who Wish to Apply for Ongoing Medicaid Coverage
o For Applicants Who DO NOT Wish to Apply for Ongoing Medicaid Coverage
June, 2014
NM HSD/MAD - PE & PE+ Training Manual
Page 92
Presumptive Eligibility Contact & Resource Sheet
Contact:
Assistance For:
E-Mail/URL:
Claim & Eligibility
Information
FAQs
NMPRSupport@xerox.com
NM Medicaid Web Portal
Provider Relations Help Desk
User administration/web
registration inquiry
Xerox Help Desk
(AVRS) Automated Voice Response
System
Eligibility information
Client Eligibility Questions
Medicaid Call Center
General Client Questions
YESNM-PE
Screen for PE
YESNM Customer Service
YES Information
Central ASPEN Scanning Area
(CASA)
Assistance with
Mailing address:
applications or documents - PO BOX 830
submitted through Aspen
Bernalillo, NM 87004
800-283-4465
NM Medicaid Web Portal
Customer Service for: Central ASPEN
Scanning Area (CASA)
nmmedicaid.acs-inc.com
Phone/Fax #:
800-705-4452
505-246-0710
Fax#: 877-285-6790
800-705-4452
505-246-0710
800-820-6901
Xerox Medicaid Call Center:
888-997-2583
www.yes.state.nm.us/jsp/access/myAcc
ess/PELogin.jsp
www.yes.nm.state.us
800-283-4465
505-841-6700
CASA E-fax#: 855-804-8960
HSDCASA@state.nm.us
Managed Care Organizations
Blue Cross Community
Centennial
Molina Health Care of New
Mexico, Inc.
www.bcbsnm.com/coverage/medicaid
(866) 689-1523
www.molinahealthcare.com/enus/Pages/home.aspx
(877) 373-8986

Presbyterian Health Plan, Inc.
www.phs.org/pages/default.aspx
(888) 977-2333

UnitedHealthcare Community
Plan of New Mexico
www.uhccommunityplan.com
(877) 236-0826
HSD.PEDeterminers@hsd.state.nm.us
505-827-7717


PE Determiner Training Program
HSD/MAD 3/2014
PED training, scheduling,
questions & issues
Fax #: 505-827-7200
Flow process for Presumptive Eligibility
Training and Certification
• Individuals from Providers contact
MAD for upcomming trainings.
• MAD will create a contact list and
email individuals requesting
training with dates and times.
Pre
Registration
Registration
and Training
•Individual will access the link located
in email from MAD and complete the
registration process.
•Individual will attend training on
registered date and time.
•Once training is complete the
individual must complete a
comprehension test with a minimum
score of 90%
•After passing score is achieved, the indivifual
must register on the New Mexico Medicaid
Web Portal (Portal).
•Individual completes the online PE Determiner
Agreement by submitting an electronic
signature acknowledgement.
•The individual is issued a Determiner number
which they will use to complete the Portal
registration.
•individual registers as a USER on YESNM-PE to
begin screening appicants for PE.
PE
Certification
New Mexico Medicaid Web Portal & YESNM-PE Registration Workflow
Individual achieves passing score
on comprehension test.
Individual accesses the New
Mexico Medicaid Web Portal
(Portal) to begin Provider
enrollment registration process.
(https://nmmedicaid.acs-inc.com)
Individual completes the online
electronic acknowledgement for
the PE Determiner Agreement
(MAD 219).
Once the Welcome Packet and PED
number are received, the PED
must register as a USER on the
Portal.
After verification, a Welcome
Packet and the individual`s unique
PED number will be sent.
Once the Provider enrollment has
been completed, HSD/MAD PE
Program Staff will verify for
accuracy.
To access the YESNM-PE screening
tool, each PED must register as a
user on YESNM-PE
(https://www.yes.state.nm.us/jsp/
access/myAccess/PELogin.jsp)
Registration Complete
Electronic Presumptive Eligibility Screening Process Workflow
Log-in to the Portal and verify client
eligibility.
Log into YESNM-PE and complete
applicant information screens.
At the YESNM-PE PE Determination
Results page, access to a link will be
given for the Portal. The PED will
enter the PE approval into the
portal.
PE Screening Complete
Applicants will be given the option
to submit the information gathered
for the screening to HSD for an
ongoing Medicaid application
determination.
Once PE is entered in the Portal, the
PED will return to the PE
Determination Results page where
they will print the results for the
applicant.
Manual Screening for
Presumptive Eligibility
Access the Medicaid Web Portal
or call the Medicaid Call Centers
Automatic Voice Response
System (AVRS) at
(800) 820-6901 to verify
applicant eligibility.
Ask Client if they want to
apply for ongoing
Medicaid coverage:
YES
NO
*PED assists applicant with
completion of MAD 100
*PED assistis applicant with
completion of MAD 011
*PED calculates Household size
*PED calculates Household size
*PED calculates Financial
Eligibility
*PED calculates Financial
Eligibility
Is the client
eligible for
PE?
Is the client
eligible for
PE?
YES
*PED faxes completed
MAD 070 to Xerox
NO
*Submit forms - MAD
100, MAD 070, calculation
worksheets and any
additional applicant
documents to Central
ASPEN Scanning Area
(CASA)
*PED submits MAD 100
calculation worksheets
and any additional
applicant documents to
Central ASPEN Scanning
Area (CASA)
CASA Fax:
855-804-8960
YES
Xerox Fax:
877-285-6790
*PED Faxes completed
MAD 070 to Xerox
*PED submits forms MAD 011, MAD 070 & all
calculation worksheets to MAD PE Program Staff
NO
*PED submits forms MAD 011, MAD 070 & all
calculation worksheets to MAD PE Program Staff
MAD PE Program Staff Fax:
505-827-7200
AFFORDA
A
BLE CARE
E MEDICA
AID PROGRAMS
ral Pover
rty Guide
elines (FP
PL)
Feder
Efffective 7/
/1/14 – 3
3/31/15
CATEGORY 100
0 – Covera
age
dults
for Ad




A
Alternative Be
enefit Coverage
In
ncome must be under 133
3% FPL
N
No resource standard
N
No Medicare
HOUSE
EHOLD
SIZE
MONT
THLY
INCO
OME
1
2
3
4
5
6
7
8
$ 1,2
294
$ 1,7
744
$ 2,1
194
$ 2,6
644
$ 3,0
094
$ 3,5
544
$ 3,9
994
$ 4,4
444
$ 45
50
----------------------------------------------------------------------------------------+1- - - - - - - - - - - -
CATEGORY 200
0 – Parent
aker
Careta




Full Medica
aid
Income mu
ust be under fixed
standard
Household must have a
relative child in household
ce standard
No resourc
CA
ATEGORY 301 – Pre gnancy
Se
ervices Only
y
5% DISR
REGARD - Amount
Disregard
ded when A
Applicable










Pregnancy Services
S
Income must be under 2
250% FPL
2 months post partum
No resource
e standard
HO
OUSEHOLD
SIZ
ZE
M ONTHLY
I
INCOME
2
3
4
5
6
7
8
$ 3,278
$ 4,123
$ 4,969
$ 5,815
$ 6,661
$ 7,507
$ 8,353
$ 846
-----------------------------------------------------------------------------+1
1- - - - - - - - - - - -
HOUSEHOL
H
D SIZE
MONTHLY
M
INCOME
I
1-------------2-------------3-------------4-------------5-------------6-------------7-------------8-------------+1+ ------------
Category 400 - Medicaid
M
forr Children
 Fu
ull Medicaid
 Ch
hildren unde
er 19 years of age
 Income underr the following FPL:
 Children ag
ges 0-5 ------0%-240%
%
 Children ag
ges 6-18-------0%-190%
%
 No
o resource Standard
S
 Eliigible even if children have
h
health insurance or
o
ha
ave voluntarrily dropped insurance
Category 420 - Children's
C
Health Insura
ance Progra
am
(CHIP))
 Fu
ull Medicaid
 Income underr the following FPL:
 Children ag
ges 0-5 --------240%-3
300%
 Children ag
ges 6-18--------190%-240%
 Do
o NOT have existing ins
surance
 Co
o-payments on doctor visits,
v
prescriptions, etc
c.
 Na
ative Americ
can children
n do not mak
ke co-payments
MAD
D 222 Revised 07/01/20
014
$
$
$
$
$
$
$
$
$
451
608
765
923
1,080
1,238
1,395
1,553
158
Category
Category
Category
Category
Category
Category
100
200
300
301
400
420
HOUSEHOLD
SIZE
1
2
3
4
5
6
7
8
(only iff Medicare eligible)
M
MONTHLY
DI
ISREGARD
----------------------------------------------------------------------------------------+1- - - - - - - - - - - -
$
$
$
$
$
$
$
$
$
49
66
83
99
116
133
150
167
17
CATEGO
ORY 300 – Full
Coverage
e for Pregn
nant Women




Full Medicaid
Income
e must be und
der Standard of
Need
2 months post partu
um
No reso
ource standarrd
Hou sehold
e
Size
1--- --------------------2--- --------------------3--- --------------------4--- --------------------5--- --------------------6--- --------------------7--- --------------------8--- --------------------+1-----------------------
Mo
onthly Gross
s Income
2
240%
300
0%
$2
2,334
$2,,918
$3
3,146
$3,,933
$3
3,959
$4,,948
$4
4,770
$5,,963
$5
5,582
$6,,978
$6
6,395
$7
7,206
$8
8,018
$8
812
$7,,993
$9,,008
$10
0,023
$1,,015
COE Descriptions
ACA
January 1, 2014
New
COE
COE Description & FPL
Former Medicaid
COEs
Prior to January 1,
2014
Old
COE
COE
Description
027
Four Months transitional Medicaid
027
Four Months
transitional
Medicaid
028
12 month transitional Medicaid
028
12 month
transitional
Medicaid
029
Family Planning
0%-185%
029
031
Newborns
031
Newborns
085
Emergency
Medical
Services for
Aliens
Family Planning
085
Emergency Medical Services for Aliens
100
Other Adults * (age 19-64)
0%-133%
200
Parent Caretaker*
0-47%
072
Family
Medicaid
300
Full Medicaid for Pregnant Women
0%-138%
030
Full Medicaid
Pregnant
Women
301
Pregnancy-Related Medicaid *
138%-250%
035
400
Children’s Medicaid (ages 0-5)
0%-138%
032
401
Children’s Medicaid (ages 6-18)
0%-138%
032
402
Children’s Medicaid (ages 0-5)
138%-240%
403
Children’s Medicaid (ages 6-18)
138%-240%
036
036
Pregnancy
Related Only
Children’s
Medicaid
(ages 0-5)
Children’s
Medicaid
(ages 6-19)
Children’s
Medicaid
(ages 0-5)
Children’s
Medicaid
(ages 6-19)
1
Changes
COE 027 was provided to individuals due to loss of COE 072
from increased earnings of child or spousal support. COE
027 is now provided due to loss of COE 200 from increased
earnings of spousal support only. Child support is no longer
countable under ACA rules.
COE 028 was provided to individuals due to loss of COE 072
from increased earnings. COE 028 is now provided due to
loss of COE 200 from increased earnings.
Family planning individuals were transitioned to an ACA
category if eligible. Those not eligible for an ACA category
remain on family planning and are referred to the Exchange
for minimum essential coverage.
No changes. To be eligible, the newborn must be born to a
woman who is eligible for and receiving Medicaid on the
date the newborn is born.
No changes. EMSA is available for all individuals eligible for
any of the new ACA categories.
COE 100 is a new category for adults (19-64). Other
insurance can coexist with COE 100, except for Medicare.
COE 072 will be replaced by COE 200 at recertification over
the next year, if client remains eligible. Eligibility for an ACA
category will be evaluated per individual. COE 200 is for
adults only. A 5% disregard can be applied if the adult is
receiving Medicare or is age 65 or over. Children on COE 072
will transition to one of the children’s Medicaid categories if
eligible at recertification.
COE 030 is replaced by the new COE 300. COE 030 was
around 25% FPL. The new COE 300 provides full Medicaid
up to 138% FPL. More women will qualify for full Medicaid
for pregnant women due to the increase in FPL.
COE 035 is replaced by COE 301.
COE 032 will be replaced by the new COE 400 at
recertification over the next year, if client remains eligible.
COE 032 will be replaced by the new COE 401 at
recertification over the next year, if client remains eligible.
COE 036 will be replaced by the new COE 402 at
recertification over the next year, if client remains eligible.
COE 036 will be replaced by the new COE 403 at
recertification over the next year, if client remains eligible.
COE Descriptions
420
CHIP Medicaid (ages 0-5)
240%-300%
071
Children’s
Medicaid
(ages 0-5)
421
CHIP Medicaid (ages 6-18)
190%-240%
071
Children’s
Medicaid
(ages 6-19)
Program ended 12/31/2013
062
063
064
State Coverage
Insurance
COE 071 will be replaced by the new COE 420 at
recertification over the next year, if client remains eligible.
COE 071 will be replaced by the new COE 421 at
recertification over the next year, if client remains eligible.
SCI ended 12/31/2013. Individuals were evaluated for an
ACA category:
1. If eligible, they were placed on the ACA category.
2. If ineligible, evaluated for family planning and referred
to the Exchange for minimum essential coverage.
3. If ineligible for family planning, eligibility was ended
12/31/2013 and client was referred to the Exchange for
minimum essential coverage.
*5% income disregard can be applied if needed.
Non Modified Adjusted Gross Income (MAGI) Categories/No Changes
COE
COE Description
001, 003, 004
Supplemental Security Income (SSI)-The Social Security Administration determines eligibility for these categories. SSI
provides cash benefits and Medicaid provides health care coverage for eligible individuals under aged (Category 001),
blind (Category 003), or disabled (Category 004).
041, 044
Qualified Medicare Beneficiaries (QMB) - Medicaid covers payment of Medicare premium amounts for Parts A and B
and the coinsurance and deductibles on Medicare-covered services. Medicaid does not pay for services which are not
Medicare benefits, services denied by Medicare, or services furnished by providers who have not accepted Medicare
assignment. Reimbursement is made to providers of covered services and not directly to recipients.
042
Qualified Individuals (QI1s) - Medicaid pays the Medicare part B premium. Applicants/recipients eligible for QI1
coverage under another Medicaid category may not be eligible for QI1. QI1 eligibility is funded by limited block grant
funding beginning in 1998 and ending when the congressional extension period expires. Since payment of the Medicare
part B premium is the only benefit, no Medicaid card is issued.
045
Specified Low-Income Medicare Beneficiaries (SLIMB) - Medicaid pays the Medicare part B premium.
Applicants/recipients eligible for Medicaid coverage under another Medicaid category may also be eligible for SLIMB.
SLIMB eligibility allows the state to receive federal matching funding for the purchase of Medicare part B. Since
payment of the Medicare part B premium is the only benefit, no Medicaid card is issued and there is no interaction with
the Medicaid claims processing contractor.
049/059
Refugee Medicaid Assistance (RMA)-RMA offers health coverage for refugees within the first eight months from their
date of entry to the United States, when they do not qualify for Medicaid. RMA eligible refugees have access to a
benefit package that parallels the full coverage Medicaid benefit package. This program is not funded by Medicaid.
RMA is funded through a grant under Title IV of the Immigration and Nationality Act. The purpose of this grant is to
provide for the effective resettlement of refugees and to assist them to achieve economic self-sufficiency as quickly as
possible.
2
COE Descriptions
052
Breast and Cervical Cancer (BCC)- a program for uninsured women under the age of 65 years, who meet the screening
criteria , an income test of 250% of the Federal Poverty Guidelines and diagnostic testing by a contracted Centers for
Disease Control and Prevention’s provider resulting in a diagnosis of breast or cervical cancer including pre-cancerous
conditions. Women who have met CDC screening criteria and identified as needing treatment for a diagnosis of breast
or cervical cancer, including pre-cancerous conditions will be referred for treatment that includes the completion of a
Medicaid application for the BCC program. The Breast and Cervical Cancer Prevention and Treatment Act allows states
to extend presumptive eligibility to applicants in order to ensure that needed treatment begins as early as possible.
074
Working Disabled Individuals (WDI) - The working disabled individuals program covers disabled individuals who are
employed or disabled individuals who have lost eligibility for supplemental security income (SSI) and Medicaid due to
initial receipt of social security disability insurance ( SSDI) and who are not yet qualified for Medicare; this group is
referred to as “medigap”; once the medigap individual begins receiving Medicare, they must become employed to
retain eligibility for WDI.
081, 083, 084
Institutional Care Medicaid-Provides Medicaid to individuals requiring institutional care in nursing facilities (NFs)
designated as High NFs or Low NFs, Intermediate Care Facilities for the Mentally Retarded (ICF-MRs) or acute care
hospitals. These individuals must meet all SSI eligibility criteria except income. As of January 1, 2014 the maximum
allowable countable income limit is $2,163 per month.
090, 091,
092, 093,
094, 095, 096
Home and Community-Based Waivers-Recipients in these programs are persons who qualify both financially and
medically for institutional care but who remain in the community. The Department of Health or Aging and Long Term
Services Department must determine that adequate care can be provided to the individual in the community at a lesser
cost than in an institutional setting.
CYFD Categories
Medicaid is provided for children in state substitute care programs and in adoption subsidy situations. The Children, Youth and Families
Department make eligibility determinations for these categories. To be eligible on the basis of income, a child in a substitute care
placement must have an income below the maximum AFDC standard of need 5 for one person.
COE
COE Description
017
Adoption Subsidy established by other states
037
Adoption Subsidy in state
047
Adoption Subsidy placed out of NM
066
Foster Care
086
Foster Care with state other than NM
3
Applicant's Rights and Responsibilities
If you are a person with a disability and you require this information in an alternative format, or require a special accommodation to participate in
any public hearing, program or services, please contact the NM Human Services Department toll-free at 1-800-432-6217 or through the New
Mexico Relay System TDD at 1-800-659-8331 or by dialing 711. The Department requests at least 10 days advance notice to provide requested
alternative formats and special accommodations.
Your Civil Rights
All programs administered by the Human Services Department (HSD) are equal opportunity programs. If you believe you have been treated
unfairly because of race, color, national origin, age, disability, and where applicable, sex, marital status, familial status, parental status, religion,
sexual orientation, genetic information, political beliefs, reprisal, or because all or part of an individual's income is derived from any public
assistance program, you may file a complaint. Complaints of discrimination may be filed with the New Mexico Human Services Department
central office or the local Human Services county office. Complaints of discrimination about the SNAP/Food program may be filed with the
USDA, Director, Office of Civil Rights, Room 326, W. Whitten Bldg., 1400 Independence Ave, S.W. Washington, DC 20250-9410 or call (202)
720-5964 (voice and TDD). Complaints of discrimination about Cash Assistance and Medical Assistance programs may be filed with the Office
of Civil Rights, Department of Health & Human Services, 1301 Young Street, Suite 1169, Dallas, TX 75202 or call (800) 368-1019 (voice) and
(214) 767-8940 (TDD).
Your Privacy
The information you give HSD will be used to determine whether your household is eligible or continues to be eligible to take part in HSD
programs. We will check this information through computer matching programs or other means. This information will also be used to make sure
that you meet program rules and help us to manage the program.
This information may be given to other Federal and State agencies for official examination, and to law enforcement officials for the purpose of
picking up persons fleeing to avoid the law.
If you get benefits that you were not eligible for and have to pay them back, this is called a claim. If your household gets a claim against it, the
information on this application including all Social Security Numbers, may be given to Federal and State agencies, as well as private claims
collection agencies for claims collection action. Providing the requested information, including Social Security Numbers of each household
member is voluntary. However, each person applying for assistance must give a Social Security Number or it will result in the denial of program
benefits to each individual applicant failing to give a Social Security Number. Non-Citizen Immigrants not requesting assistance for themselves
do not need to give immigration status information or Social Security Numbers. Any Social Security Numbers given will be used & disclosed in
the same manner as Social Security Numbers of eligible household members. We also check with other agencies, the federal Income and
Eligibility Verification Service (IEVS) and The Public Assistance Reporting Information System (PARIS) about the information that you give us.
This information may affect your household eligibility and benefit amount.
Child Support Enforcement Division
By accepting Cash or Medical Assistance, you assign (give) HSD rights to collect child support from the child's absent parent(s). You must help
HSD find the absent parent(s) unless there is a good reason not to do so such as domestic violence; ask ISD. If it is decided that you have to work
with the Child Support Office to establish or enforce child support and you do not, cash benefits may be reduced and eventually lost, and adults
may lose their medical assistance.
Non-Citizen Immigrant Eligibility What types of Non-Citizen Immigrants are eligible for HSD assistance programs?
For most programs, non-citizens must have a "qualified" immigrant status and meet certain other conditions to qualify. Most non-citizens in the
following categories can get benefits if they meet all other program eligibility requirements:
Lawful Perm. Res. (LPRs)
 Refugees
 Asylees
 Cuban Haitian Entrants
 Amerasians
 Paroled to U.S. - 1 year
 Withholding of Deportation
Certain:
 Battered women and children
 Veterans, active duty military
 Hmong or Laotian Tribe
 Canada/Mexico born Native American
 Human Trafficking Victims
Certain non-citizens, including undocumented non-citizens may be eligible for emergency medical services including pregnant
women's labor and delivery.
Is there a waiting period (bar) before non-citizen immigrants can get benefits? The general rule now is that most qualified immigrant
children are eligible to receive SNAP/Food, Medical, Cash and Energy Assistance. However some "qualified" immigrant adults can get
benefits after they have been in the United States in "qualified" immigrant status for five years and some immigrants can get them right
away. In general, adults in certain humanitarian immigration categories (such as Refugees and Asylees), people with military
connections, credit for 10 years of work history in the US, and persons receiving disability benefits may be eligible right away.
Derechos y Responsabilidades
Si usted es una persona con una discapacidad y Ud. requiere esta información en un formato alternativo o requiere un acomodamiento
especial para poder participar en cualquier audiencia pública, programa o servicio, comuníquese con el Departamento de Servicios
Humanos de NM gratis al 1-800-432-6217 o a través del sistema de relais de Nuevo México TDD en 1-800-659-8331 o llamando al
711. Las peticiones del Departamento de por lo menos 10 días por anticipado para poder proporcionar los formatos alternativos y
acomodamientos especiales.
Sus Derechos Civiles
Todos los programas administrados por el Departamento de Servicios Humanos (HSD) son programas de oportunidades iguales. Si
usted cree que ha sido tratado injustamente debido a la raza, el color, origen nacional, la edad, la incapacidad, y donde aplicable, el
sexo, el estado civil, estatus familiar, estatus paternal, la religión, orientación sexual, información genética, las creencias políticas, la
represalia, o porque todo o la parte de los ingresos de un individuo son derivados de cualquier programa de ayuda estatal, puede
presentar una queja. Las quejas de discriminación se pueden presentar en la oficina central del Departamento de Servicios Humanos
de Nuevo México, ATTN: Quality Improvement Section, Pollon Plaza, P. O. Box 2348, Santa Fe, Nuevo Mexico 87504-2348 o en la
oficina local de su condado.Las quejas de discriminación sobre el Programa de Ayuda de Nutrición Suplemental se pueden presentar
con el USDA, Director, Office of Adjudication, 1400 Independence Ave. SW, Washington, DC 20250-9410 o llame 1-866-632-9992 o
202-401-0216 (TDD).
Su Privacidad
La información que Ud. da a HSD será utilizada para determinar si su casa tiene elegibilidad o continúa a tener
elegibilidad para participar en los programas de HSD. Verificaremos esta información por programas de computadora. Esta
información también será utilizada para asegurar de que Ud. sigue las reglas del programa y para ayudarnos a manejar el programa.
Esta información puede ser dada a otras agencias federales y estatales para un examen oficial, y los agentes del orden con el
propósito de recoger a personas que huyen de la ley.
Si usted recibe beneficios de que usted no era elegible y tiene que pagarlos, esto se llama un reclamo. Si su familia recibe una
demanda en contra de ella, la información en esta solicitud incluyendo todos los números de Seguro Social, puede ser dada a las
agencias federales y estatales, así como agencias privadas de colección de reclamos por la acción de cobro. Proporcionar la
información solicitada, incluyendo números de seguro social de cada miembro de la familia es voluntario. Sin embargo, cada persona
que solicita asistencia debe dar un número de Seguro Social o resultará en la negación de los beneficios del programa a cada
solicitante individual que no da un número de Seguro Social. Ciudadanos no inmigrantes no solicitando asistencia por sí mismos no
necesitan dar información de estatus migratorio o números de Seguro Social. Los números de seguro social dados serán usados y
revelados de la misma manera como números de seguro social de los miembros elegibles del hogar. También comprobamos con otras
agencias el ingreso federal y el Servicio de Verificación de Elegibilidad (IEVS) y en el Sistema de Información Reportada de Asistencia
Pública (PARIS)
acerca de la información que usted nos da. Esta información puede afectar su elegibilidad del hogar y la cantidad de beneficios.
División de Sostenimiento de Niños
Al aceptar asistencia en efectivo o médica, usted asigna (otorga) a HSD derechos para cobrar el sostenimiento de niños del padre
ausente del niño (s). Usted debe ayudar a HSD a encontrar al padre ausente (s) a menos que haya una Buena razón para no hacerlo,
como la violencia doméstica, pregúntele a ISD. Si se decide que usted tiene que trabajar con la Oficina de Sostenimiento de Niño para
establecer o hacer cumplir el sostenimiento y usted no lo hace, los beneficios en efectivo pueden ser reducidos y eventualmente
perdidos, y los adultos pueden perder su asistencia médica.
Elegibilidad de Inmigrantes No Ciudadanos
(a)¿Qué tipos de Inmigrantes no ciudadanos son elegibles para programas de asistencia de HSD?
Para la mayoría de los programas, los no ciudadanos deben tener un estado de inmigrante "calificado" y cumplir otras condiciones
para calificar. La mayoría de los no ciudadanos en las categorías siguientes pueden obtener beneficios si cumplen con todos los
requisitos de elegibilidad del programa:

Residente Permanente Legal (LPR)

Refugiados

Asilados

Entrados cubanos haitianos

Amerasiáticos

Libertad condicional a EE.UU. - 1 año

Retención de la deportación
Ciertos:

Mujeres y niños maltratados

Veteranos, militares en servicio activo

Hmong de Laos o Tribu

Nativo Americano nacido en Canadá / México

Las víctimas de tráfico de personas
Algunos no ciudadanos, incluidos los no ciudadanos indocumentados pueden ser elegibles para los servicios médicos de emergencia,
incluyendo el parto y alivio de las mujeres embarazadas.
(b) ¿Existe un período de espera (bar) antes de que los inmigrantes no ciudadanos pueden obtener beneficios?
La regla general es que ahora la mayoría de los niños inmigrantes calificados son elegibles para recibir SNAP / Comida, Medicaid,
Efectivo y Asistencia de Energía. Sin embargo, algunos adultos inmigrantes "calificados" pueden recibir beneficios después de haber
estado en los Estados Unidos en condición de inmigrante "calificado" durante cinco años y algunos inmigrantes pueden obtener de
inmediato. En general, los adultos en ciertas categorías de inmigración humanitarias (como refugiados y asilados), las personas con
conexiones militares, el crédito por 10 años de historia de trabajo en los EE.UU., y las personas que reciben beneficios por
incapacidad pueden ser elegibles de inmediato.
Electronic Signature
An applicant's signature makes this application valid. The application for ongoing eligibility cannot be
processed without a signature. A signature is also an indication that:
•
I understand that making false statement or hiding information could mean State & Federal penalties
& I have given HSD true, correct and complete information.
•
•
I am declaring the identity of the children under age of 16 for whom I am applying.
I will give proof of things I report to HSD. If I cannot get proof, I know that I can ask HSD to help
me & I will let HSD to contact other people & companies to get proof.
I will let HSD give limited information to approved agencies which give other related help for which
I may be eligible.
I understand that if I receive benefits for which I am not eligible, that I may have to pay HSD back
for those benefits.
I know that HSD will check the information that I give. HSD may use computers or other means to
check the information on this form.
I know that HSD will check the immigration status of people who apply for or get benefits. I
understand that immigration for any household member that I am applying for may be subject to
verification by USCIS (INS), and that it may affect the household's eligibility and level of benefits.
I understand that I must cooperate with Quality Control (QC). QC is a part of HSD. QC reviews cases
to make sure we determine who can get help correctly.
I understand that I must give HSD any money I receive for medical services which have already been
paid for by Medicaid. If I fail to do so, I, or the person(s) for whom I am applying, may lose
Medicaid coverage for at least one year AND until the amount owed to Medicaid has been paid back
in full.
•
•
•
•
•
•
I affirm under penalty of perjury that the verbal statements I have given to the Presumptive Eligibility
Determiner who has assisted me with the completion of this application are true and correct. This includes
statements about the persons in my home, income and all other information used to determine ongoing
Medicaid eligibility.
Firma Electrónica
Su firma hace que esta aplicación sea válida y no puede ser procesada sin la firma. Su firma también es una indicación
de lo siguiente:














Entiendo que si hago declaraciones falsas u oculto información podría significar penalizaciones Estatales y
Federales y he dado a HSD información verdadera, correcta y completa.
Estoy declarando la identidad de los niños menores de 16 años de edad para quien estoy solicitando.
Voy a dar prueba de lo que reporte a HSD. Si no puedo conseguir la prueba, sé que puedo pedir que HSD me
ayude y dejaré que HSD se ponga en contacto con otras personas y las empresas para obtener.
Dejaré que HSD dé información limitada a las agencias acreditadas que dan otro tipo de ayuda relacionada para
que yo pueda ser elegible.
Entiendo que si recibo beneficios para los cuales no soy elegible, que tendré que pagar a HSD por esos
beneficios.
Yo sé que HSD revisará la información que dé. HSD puede usar computadoras u otras maneras para revisar la
información en este formulario.
Yo sé que HSD verificará el estatus migratorio de las personas que solicitan o reciben beneficios. Entiendo que la
inmigración de cualquier miembro de la casa que estoy solicitando puede ser objeto de verificación por parte
de USCIS (INS), y que puede afectar la elegibilidad del hogar y el nivel de los beneficios.
Yo entiendo que tengo que cooperar con el control de calidad (QC). QC es una parte de HSD. QC revisa caso
para asegurar que determinamos correctamente quién puede obtener ayuda.
Entiendo que debo dar a HSD cualquier dinero que recibo por los servicios médicos que ya han sido pagados
por Medicaid. Si yo no lo hago, yo o la persona(s) para quien estoy solicitando, podría perder la cobertura de
Medicaid por lo menos un año y hasta que el monto adeudado a Medicaid se ha pagado en su totalidad.
Yo afirmo bajo pena de perjurio que las declaraciones verbales que he dado al determinante de Elegibilidad Presunta que
me ha asistido con la finalización de esta solicitud son verdaderas y correctas. Esto incluye declaraciones acerca de las
personas en mi hogar, el ingreso y el esto de la información utilizada para determinar la elegibilidad para Medicaid en
curso.
PRESUMPTIVE ELIGIBILITY DETERMINER AGREEMENT
AND CODE OF CONDUCT
HSD and
(Presumptive Eligibility Determiner Name)
enter into this Agreement to allow the person named above to be certified as a Medicaid Presumptive Eligibility Determiner (PED). PEDs are
authorized to make Presumptive Eligibility (PE), or short-term, Medicaid determinations for eligible individuals. The goal of presumptive eligibility
is to provide access to immediate care for eligible recipients and to ensure assistance with application submission and possible ongoing Medicaid
coverage for those individuals. PE is not available for all Medicaid categories of eligibility and is limited to those as outlined by the New Mexico
Human Services Department's (HSD’s) Medical Assistance Division (MAD).
Individuals who are initially screened for PE are done so based on some of the same qualifying factors that help to determine ongoing eligibility.
Individuals who are accurately screened for PE are most likely to be approved for ongoing coverage. Eligible screenings and enrollments of
individuals in PE coverage can only be made by certified PEDs. PEDs must meet the PED certification requirements as established by HSD/MAD.
Eligible entities approved to participate as PEDs include:
(a) a qualified hospital that participates as a provider under the Medicaid state plan or a Medicaid 1115 demonstration, notifies the
Medicaid agency of its election to make presumptive eligibility determinations and agrees to make PE determinations consistent with State policies
and procedures; or for
(b) a qualified hospital that has as not been disqualified by the Medicaid agency for failure to make PE determinations in accordance
with applicable state policies and procedures; or for
(c) a Federally Qualified Health Center (FQHC), an Indian Health Service (IHS) facility, a Department of Health (DOH) clinic, a school,
a Children, Youth and Families Department (CYFD) Child Care Bureau staff member, a primary care provider who is contracted with at least one
HSD contracted MCO, a Head Start Agency; or
(d) other entities that HSD has determined as an eligible Presumptive Eligibility participant including eligible employees of the New
Mexico Department of Corrections, County Jails or Detention Centers
DETERMINER CODE OF CONDUCT
DISCLOSURE OR MISUSE OF CONFIDENTIAL OR OFFICIAL INFORMATION AND PERFORMANCE STANDARDS
HSD serves the citizens of New Mexico. PEDs are considered agents of the State and must conduct the State’s business with the highest standards
of integrity. HSD provides services to eligible New Mexicans with public funds and is accountable for those funds.
PEDs must conduct themselves in a professional manner in all dealings with the public. It is never acceptable to convey an indifferent, hostile or
careless attitude toward clients, even if clients are abusive. If a client continues to be abusive or threatening, please courteously refer them to an ISD
office.
PEDs shall disqualify themselves from participating in any official action affecting a client or any other person related to them by blood or marriage,
(e.g. a first cousin or closer relative); clients or other persons with whom they enjoy a personal relationship that could compromise or be reasonably
perceived by Department management or the public as compromising the integrity of their official actions; or any client or any other person with
whom that PE Determiner is engaged in a sexual relationship and/or is sharing living quarters.
PEDs may not receive any financial benefits, as a result of his/her provision of services to a client, other than what may be provided for, by the
Department.
PEDs may not disclose confidential or official information, if the disclosure of such information is prohibited by law or regulation or would be
contrary to the best interest of the Department or its clients. This includes confidential information from other governmental agencies that PE
Determiners may access via electronic data connections. PEDs may not disclose or misuse confidential or official information not generally available
to the public or acquired by virtue of his/her affiliation with the Human Services Department, for his/her own or another’s private gain.
PEDs may have access to an applicant's of Personally Identifiable Information (PII) and Protected Health Information (PHI). Any unauthorized or
unofficial use of the PII or PHI, including any misuse, may be prosecuted under New Mexico State statutes and The United States regulations and
laws regarding the use of this information, particularly the Standards for Privacy of Individually Health Information 45 CFR Parts 160 and 164.
PEDs shall conduct themselves in a law abiding manner at all times. The possession and/or use of illicit drugs and/or misuse of prescription drugs
during work hours or reporting for work and/or being on department premises, under the influence of any of the above, is strictly prohibited and
will subject the Determiner to immediate termination of their Determiner status.
PEDs under investigations or charged with criminal activities and/or unethical practices will subject the Determiner to immediate termination of
their Determiner status.
PEDs shall remain objective and may not recommend an MCO to a client. This decision is to be made solely by the client, independent of a PED’s
influence.
PEDs agree to:

Participate in trainings sponsored by HSD;

Complete the PED certification process;

Maintain client confidentiality;

Assist PE clients who wish to apply for ongoing coverage with the completion of a Medicaid application. PEDs must submit the
completed applications to HSD within 2 business days of the PE approval;

Keep complete records on all PE clients; these records are subject to review by State and/or Federal agencies
MAD 219 5/1/14
HSD agrees to:

Make PED certification training sessions available for qualified individuals;

Allow access to YESNM-PE and the Portal to PEDs in good standing;

Supply initial forms needed for PE determinations
PED PERFORMANCE STANDARDS
To ensure applicants have been accurately screened for PE. All PEDs must adhere to the performance standards and procedures as outlined below:

100% of PE screening results are submitted to HSD/MAD for auditing purposes

90% of applications received result in an approval of ongoing Medicaid eligibility

Utilize the New Mexico Medicaid Portal (Portal) to verify current individual eligibility and/or enrollment status

Utilize the New Mexico Medicaid electronic PE screening tool, YESNM-PE, to screen for and submit PE screening applications

Utilize the Portal to submit all PE approvals, unless a system error or power outage or a lack of an applicant’s Social Security Number
necessitates the submission of the PE via fax.

In instances where a fax approval is submitted, the PED must use the Presumptive Eligibility Approval form (MAD 070; Rev 3/6/14) for the
submission.

PEDs must submit the PE approval on the day of the PE determination

HSD may terminate PED status immediately if the Code of Conduct is breached or if the PED fails to comply with HSD guidelines.
PROVIDER STATUS AND AGREEMENT
I affirm that I am eligible to participate as PED as I am employed by and physically doing business at an entity that meets the qualifications of a PE
Provider location.
I understand that as a PED, I will use HSD’s systems, forms and methodology to screen applicants for Medicaid PE. I will also encourage and assist
all individuals that I screen for PE to submit an application for ongoing Medicaid coverage.
As a PED, I understand that I am required to maintain client confidentiality and adhere to the Health Insurance Portability and Accountability Act
(HIPAA) Privacy rules. Any HIPAA violations, misuse of client information or unethical practices will be grounds for immediate revocation of my
status as a qualified PED.
I understand that when I provide application assistance, I am acting solely on behalf of the applicant and not HSD, and I agree to assume all
responsibility and liability for protecting case record information, PII and PHI that the applicant provides to me.
I agree to notify HSD within 24 hours of the receipt of any unofficial or unauthorized verbal or written requests for any PII or PHI of applicants.
I agree to communicate to HSD any questions or concerns about the security of PII and PHI of applicants, and I agree to notify HSD no later than 24
hours after I become aware of or suspect an actual or possible incident of unauthorized access of PII and PHI, computer security incident, weakness,
misuse or violation of any policy related to the security and protection of client and applicant PII and PHI.
I understand that I will not be paid for determining PE and that I cannot bill any additional time included in the office visit for determining PE for
applicants. I understand that I must keep complete and thorough records on all PE clients and that these records are subject to review by state
and/or federal agencies.
I understand I must sign and abide by the Presumptive Eligibility Determiner Agreement and Code of Conduct. Failure to sign this Agreement or to
comply with HSD guidelines for establishing PE status may result in denial of application for Determiner status or immediate termination of
determiner status by HSD/MAD.
PED Name
PED Title
PED’s Employer (No Abbreviations)
PED’s Direct Telephone Number/Extension
Physical Address
City
State
Zip Code
State
Zip Code
Billing Address
City
PED’s Work E-MAIL Address:
By signing this document, I agree to abide by the PE Determiner Code of Conduct and comply with HSD's guidelines for establishing PE status and
submission. Either party may terminate this Agreement without cause, with fourteen (14) days written notice. HSD may exercise its right to
terminate a PE Determiner’s status immediately for cause if the PED breaches the Code of Conduct or fails to comply with HSD guidelines.
Certified PE Determiner Name (Please Print)
PE Determiner’s Signature
Date
Official Use Only
Provider Type
HSD/MAD PE Program Staff:
170
MAD 219 5/1/14 – Page 2
171
PED # Assigned
Test Date
Test Score
Information Sheet for Medicaid Application for Assistance
Human Services Department benefits:
Medicaid: Provides health care for certain people and
families with low incomes and resources. Depending on your
income and resources you may qualify for full or partial
benefits. (If you do not qualify for Medicaid, your application
will be automatically forwarded to the Health Insurance
Marketplace where you may be eligible for other health
insurance affordability programs.)
Depending on your income you may qualify for full or partial
benefits. The following are types of Medicaid that you may
qualify for:
•
•
•
•
•
Newborns
Children up to age 18
Parent(s)/Caretaker(s)
Pregnant women
Low-income adults
• Emergency Services for Aliens
Apply for the benefits above online at:
www.yes.state.nm.us/selfservice.
Or
Send your complete, signed application to your
local Income Support Division office or mail it to:
Health Insurance Marketplace
• The marketplace is a way to shop
for and compare health insurance
plans for individuals and families
who are not eligible for Medicaid.
• You may qualify for a program that
can help you pay for a health
insurance even if you earn as much
as $94,000 a year (for a family of
4).
• New tax subsidies that can
immediately help pay your
premiums for health coverage may
be available.
To apply for health insurance
online through the Health
Insurance Marketplace, you can go
to:
www.bewellnm.com
Or
Central ASPEN Scanning Area (CASA)
PO BOX 830
Bernalillo, NM 87004
Call 1-855-99NMHIX (996-6449)
TTY: 1-855-889-4325
MAD100 01/21/2014 Page 1 of 13
MEDICAID APPLICATION FOR ASSISTANCE
Si Ud. necesita este formulario en español, comuníquese con su trabajador(a).
Intérpretes están disponibles gratuitamente.
Check the assistance program(s)
you are applying for: (adults not
Assistance Programs
seeking assistance for themselves may
apply on behalf of other household
members)
Depending on your income an individual may qualify for full or partial benefits.
The following are types of Medicaid that you may qualify for:
•
•
•
•
•
•
MEDICAID
(If you or your household does not qualify for
Medicaid, your application will be automatically
forwarded to the Health Insurance Marketplace
where you or your household may be eligible
for other health insurance affordability
programs.)
Newborns
Children up to age 18
Parent(s)/Caretaker(s)
Pregnant women
Low-income adults
Emergency Services for Aliens
HEALTH INSURANCE MARKETPLACE
The marketplace is a way to shop for and compare health insurance plans.
Individuals and families who are not eligible for Medicaid may be eligible to
receive a new tax subsidy that can immediately help pay for health insurance
premiums.
1. Tell Us About You:
If you need help filling in this application or in getting the needed information, contact your local ISD office. If you are applying for someone else,
complete this section for that person.
First Name, Middle Initial, Last Name
E-Mail Address
Best Time to Contact You
Morning
Street Address
City
County
State
Zip Code
Telephone Number
(
)
If your mailing address is different, please fill it in below. If not, please leave blank.
Street or PO Box Address
Are you a resident of New Mexico?
 YES  NO
City
State
Do you intend to remain in New Mexico?
 YES  NO
Zip Code
Are you homeless?
 YES  NO
Do you want to receive information electronically? If YES, please fill out your most current e-mail address above.
 Yes  No
2. Person to Represent You (Authorized Representative or Guardian)
The authorized representative may or may not be the same individual designated as an authorized representative for the application processing or for
meeting reporting requirements. The authorized representative designation must be made in writing.
Do you want this person to:
Name of Authorized Person(s)
 Apply for benefits on your behalf?
Mailing Address
Preferred Telephone # / TDD
(
)
(
)
MAD100 01/21/2014 Page 2 of 13
3. Tell us About the People who live with You:
Please list everyone that lives in your household even if you do not want to apply for them. You only have to give U.S. Citizenship and Social Security
Numbers for those household members that you are applying for. Remember that you do not need to be a U.S. Citizen to apply. Receiving
SNAP/food, energy or medical assistance will not prevent you from becoming a lawful permanent resident or U.S. Citizen. Non-citizen immigrants not
requesting assistance for themselves do not need to give immigration status information, Social Security Numbers, or other similar proofs; however,
they must give proof of income and things they own because part of their income and things they own may count towards the household’s eligibility for
assistance. Certain benefits may be available for people without a Social Security Number; ask ISD. If needed, please use an additional sheet of
paper for additional household members who do not fit on this page.
List the names and information for yourself and all the
people who live with you:
Name
(First and Last)
1.
Relationship
(Self)
Sex
M/F
Date of
Birth
Race &
Ethnicity
(Optional)
SSN #
(Optional for
non-applicants)
Fill out this section only for each person applying for
benefits.
U.S.
Citizen
Y/N
Legal
immigrant
status?
Y/N
Will you file
federal income
taxes for the
current year?
Y/N
Will you
claim this
person on
your current
year’s tax
return?
Y/N
M
Y
Y
Y
Y
2.
M
Y
Y
Y
Y
3.
M
Y
Y
Y
Y
4.
M
Y
Y
Y
Y
5.
M
Y
Y
Y
Y
6.
M
Y
Y
Y
Y
7.
M
Y
Y
Y
Y
8.
M
Y
Y
Y
Y
Racial and ethnic data on participating households is voluntary, it will not affect the eligibility or the amount of benefits your household will receive.
Native Americans are urged to identify themselves as such because Native Americans are entitled to certain special protections under the law. The
reason we ask everyone for racial and ethnic information is to assure that benefits are distributed without regard to race, color, or national origin.
4. Please answer these Federal Income Tax Questions only about the people listed in
Section 3 who will NOT be claimed as the applicant’s tax dependents if they appear on a
different tax return. *Applicant can still get Medicaid if they don’t file Federal taxes.
Please list each individual tax filer and their dependent that are listed on the application, below.
Tax filer 1.___________________ Dependent Name:_________________; Relationship:___________________
Dependent Name:_________________; Relationship:___________________
Tax filer 2.___________________ Dependent Name:_________________; Relationship:___________________
Dependent Name:_________________; Relationship:___________________
Tax filer 3.___________________ Dependent Name:_________________; Relationship:___________________
Dependent Name:_________________; Relationship:___________________
MAD100 01/21/2014 Page 3 of 13
5. Please Answer the Following Questions About the People You Listed in Section 3 who
are seeking health coverage.
List all individuals applying for coverage who have legal immigration status and add information below.
Who?____________________; Document Type_________________; ID Number:___________________
Who?____________________; Document Type_________________; ID Number:___________________
Who?____________________; Document Type_________________; ID Number:___________________
Has any non-citizen applicant lived in the U.S. since 1996? Who ________________________
Is any non-citizen applicant or spouse or parent a veteran or on active duty with the U.S military? Who: ______________
Is any applicant getting benefits in another state?
If, YES, Who? ________________________
 Yes  No
Is any applicant already in or going into a nursing home, hospital or treatment facility? Who? _________________
If, YES, what type of facility:


Nursing Home/ Nursing Facility
Intermediate Care facility for the Mentally Retarded (ICFMR)

 Other:
Hospital

 Yes  No
PACE
If other, where? _________________________
 Yes  No
Is anyone disabled? Who? _______________________________
Is any applicant in the household receiving Supplemental Security Income (SSI)?
 Yes  No
Who? ______________________________Which State? _____________________________
Is anyone in the household pregnant? Who? _____________________________
How many babies are expected from this pregnancy? ______ Estimated Due Date ______________
 Yes  No
Name of the Father of the unborn? (optional)_____________________
Has any applicant received a Primary Freedom Of Choice letter for a Home and Community Based Services Waiver?
If, YES, Who? _______________________________
In any applicant a former Foster care recipient under the age of 26? If Yes, Who? ___________________
 Yes  No
 Yes  No
6. Tell Us About Your Earned Income
Note: If you are offered health insurance from any employer please fill out the Employer Coverage form attached to this application.
Have you or has anyone living with you received earned income or expect to receive income
this month? If yes, please complete the chart below.
Person with income
Average
number of
hours worked?
Income from?
(work, selfemployment, odd job)
How Often
Received?
(Yearly, Monthly,
Biweekly, Weekly,
etc)
 Yes  No  Don’t Know
How much do they
receive?
Does this
employer offer
Health
Insurance?
(Y/N)
If yes, fill out the
employer coverage
form attached.
$
$
$
$
Y
Y
Y
Y
MAD100 01/21/2014 Page 4 of 13
Tell Us About Your Other Income:
Examples of unearned income include, but are not limited to: Unemployment, Social Security, pensions, retirement, rental income,
Indian monies, capital gains, dividends/interest, and per capita payments. Note: You don’t need to tell us about child support, veteran’s
payment or Supplemental Security Income (SSI)
Person with income
Unearned Income from?
How Often Received?
How much do they receive?
(Yearly, Monthly, Biweekly, Weekly, etc)
$
$
$
7. Will There be Changes in Income?
Do you or anyone living with you have changes in income that is not steady from month to month?
Examples include: Loss of job, decrease in hours, change in job, change in pay, and/or only working
some of the months, out of the year?
Person
Income
When
 Yes  No
 Don’t know
Why
Deductions?
If you pay for certain things that can be deducted on a federal income tax return, tell us about them.
 Alimony Paid $_________ How Often? _________  IRA Deductions $________ How Often? _________
 Student Loan Interest $_________ How Often? _________
 Other: Type _________________ How Much $_________ How Often? ____________
 Other: Type _________________ How Much $_________ How Often? ____________
8. Parents Not Living with Their Children
By accepting medical assistance for your children, you assign (give) HSD rights to collect child support from an absent parent.
Please list all the information for your children’s parent(s) who are not living with you:
If you think cooperating to collect medical support will harm you or your children, you may not have to cooperate.
Is any applicant a victim of Family Violence?
Child Name
 Yes  No
Absent Parent Name
9. Health Care Information
Has anyone in the household received medical services within the last 3 months that have not been paid?
If yes, please list the members who have the bills and for which months. We may be able to help pay these bills.
a._____________________________; b._____________________________; c._________________________
 Yes  No
Does anyone in your household have health insurance?
 Yes  No
If Yes, please list all public and private health insurance including Medicare information for you and all people living with you.
Medicare Claim # or
Persons Covered
Insurance Company Name
Start Date
Insurance Member ID #
MAD100 01/21/2014 Page 5 of 13
10. Managed Care Organization (MCO) (If you are applying for Medicaid on or after December
1, 2013) This section will ONLY apply if you are found to be eligible for Medicaid.
Beginning January 1, 2014 Medicaid services will provided by the four Managed Care Organizations (MCO(s) listed below. You have a
choice of which MCO provides your services. If you do not choose an MCO by January 1, 2014, you will be automatically assigned to an
MCO by the State. Once you are enrolled with an MCO, you will have the option to change the MCO within 90 days of enrollment.
Special information for Native Americans about Managed Care Organizations
If you are Native American, you are not required to choose an MCO. If you are in need of long- term care services or
have Medicare, you will be required to choose one.
I am a Native American.  Yes  No (If yes, please complete the Native American or Alaskan Native information after this section)
Do you want to enroll in a Managed Care Organization?  Yes  No (If yes, please select an MCO below)


Blue Cross Blue Shield (BCBS)
By checking this box, I wish to enroll all Medicaid recipients in
my household with this MCO.
By checking this box, I wish to enroll all Medicaid recipients in my
household with this MCO.
or
Only the Medicaid recipients from this household that are listed
here should be enrolled with
BCBS:__________________________________

or
Only the Medicaid recipients from this household that are listed here
should be enrolled with
Molina:__________________________________

Presbyterian Health Plan
By checking this box, I wish to enroll all Medicaid recipients in
my household with this MCO.
United Healthcare Community Plan
By checking this box, I wish to enroll all Medicaid recipients in my
household with this MCO.
or
Only the Medicaid recipients from this household that are listed
here should be enrolled with
Presbyterian:__________________________________
Molina Healthcare of New Mexico
or
Only the Medicaid recipients from this household that are listed here
should be enrolled with
United:__________________________________
Native American or Alaska Native
Native American and Alaska Natives who enroll in Medicaid, the Children’s Health Insurance Program (CHIP), and the Health Insurance
Marketplace can also get services from the Indian Health Services, tribal health programs, or urban Indian health programs.
If you or your family members are Native American or Alaska Native, you may not have to pay cost sharing and may get special
monthly enrollment periods. We are asking you to answer the following questions to make sure you and your family get the most help
possible. NOTE: If you need more space please attach another piece of paper.
Is any applicant a member of a federally recognized tribe?
 Yes  No
If yes, Who? ________________________ What Tribe? _______________________
Do these applicants ever get a service from the Indian Health Service, a tribal health program, or urban Indian health
program or through a referral from one of these programs?
 Yes  No
If no, is this person eligible to get services from the Indian Health Service, tribal health programs, or urban Indian health
programs or through a referral from one of these programs?
 Yes  No
Certain money received may not be counted for Medicaid or CHIP.
Does the income reported in Section 6, include money from any of the following sources?
Per capita payments from a tribe that come from natural resources, usage rights,
leases or royalties?
 Yes  No If Yes, Who________________
$____________
How Often? _____________
MAD100 01/21/2014 Page 6 of 13
Payments from natural resources, farming, ranching, fishing, leases or royalties
from land designated as Indian trust land by the Department of Interior (including
reservations and former reservations)?
Money from selling things that have cultural significance?
 Yes  No If Yes, Who________________
$____________
How Often? _____________
 Yes  No If Yes, Who________________
$____________
How Often? _____________
11. Your Signature (Your authorized representative may also sign here)
Your signature makes this application valid and cannot be processed unless signed. Your signature also is an indication of the following:
 I understand that making false statements or hiding information could mean State and Federal penalties and I have given HSD true,
correct and complete information.
 I am declaring the identity of the children under age 16 for whom I am applying.
 I will give proof of things I report to HSD. If I cannot get proof, I know that I can ask HSD to help me and I will let HSD contact other people, and
companies to get proof.
 I will let HSD give limited information to approved agencies which give other related help for which I may be eligible.
 I understand that if I receive benefits for which I am not eligible, that I may have to pay HSD back for those benefits.
 I confirm that no one applying for health insurance on this application is incarcerated (detained or jailed). If not, ______________ is incarcerated.
 I know that HSD will check the information that I give. HSD may use computers or other means to check the information on this form.
 I know that HSD will check the immigration status of people who apply for or get benefits. I understand that immigration status for any household
member that I am applying for may be subject to verification by USCIS (INS), and that it may affect the household's eligibility and level of benefits.
 I understand that I must cooperate with Quality Control (QC). QC is a part of HSD. QC reviews cases to make sure we determine who can get help
correctly.
 TRUSTS - I understand that if I, or the person(s) for whom I am applying, have set up a trust, or are the beneficiaries of a trust, I must give HSD a copy of
the trust document, including all attachments and related information. HSD will analyze the trust to see if it affects the Medicaid benefits for which I am
applying.
 ESTATE RECOVERY- I understand that, after my death, HSD can file a claim against my estate to recover the amounts that the state pays or paid on my
behalf for medical assistance provided under the Medicaid program. This process is called “Estate Recovery.” “Estate Recovery” is required by federal
and state law. “Estate Recovery” is required where Medicaid recipients are fifty-five (55) years of age or older and the state makes medical assistance
payments on their behalf for nursing facilities services, home and community based services, and/or related hospital and prescription drug services. The
amount recovered by HSD will not exceed the amount of medical assistance payments made on behalf of the Medicaid recipient. Some exclusion’s may
apply.
 I understand that I must give HSD any money I receive for medical services which have already been paid for by Medicaid. If I fail to do so, I, or the
person(s) for whom I am applying, may lose Medicaid coverage for at least one year AND until the amount owed to Medicaid has been paid back in full.
 A person who is applying for or receiving Medicaid Assistance shall assign to HSD all rights against any and all individuals for medical support or
payments for medical expenses paid on the applicants’ or client’s behalf and the behalf of any other person for whom application is made or assistance is
received.
 I, as the Authorized Representative, affirm and agree to be legally bound to maintain the confidentiality of any information regarding the applicant or
beneficiary, shall not reassign any provider claims, if applicable, and shall adhere to all requirements set forth in 42 CFR 435.923(d).
 To withdraw your application for any program, initial the box of the program ►
Medicaid
Marketplace
Applicant’s Signature
Name of Witness (Witnessed only if applicant signs by mark or thumbprint)
Date
Signature of Applicant’s Authorized Representative
Signature of Witness (Witnessed only if applicant signs by mark or thumbprint)
Date
SPECIAL NEEDS INFORMATION If you are a person with a disability and you require this information in an alternative format, or
require a special accommodation to participate in any public hearing, program or services, please contact the NM Human Services
Department toll-free at 1-800-432-6217 or through the New Mexico Relay System TDD at 1-800-659-8331 or by dialing 711. The
Department requests at least 10 days advance notice to provide requested alternative formats and special accommodations. (08/22/08)
12. Register to Vote
If YOU are NOT registered to vote where you live now, Would you like to register to vote here today? (Please check one)
YES
NO
IF YOU DO NOT CHECK EITHER BOX, YOU WILL BE CONSIDERED TO HAVE DECIDED NOT TO REGISTER TO VOTE AT THIS TIME.
The NATIONAL VOTER REGISTRATION ACT provides you with the opportunity to register to vote at this location. If you would like help in filling out a voter
registration application form, we will help you. The decision whether to seek or accept help is yours. You may fill out the application form in private.
IMPORTANT: Applying to register or declining to register to vote WILL NOT AFFECT the amount of assistance that you will be provided by this
agency.
Signature
Date
CONFIDENTIALITY: Whether you decide to register to vote or not, your decision will remain confidential. IF YOU BELIEVE THAT SOMEONE HAS
INTERFERED with your right to register or to decline to register to vote, or your right to privacy in deciding whether to register or in applying to
register to vote, or your right to choose your own political party or other political preference, you may file a complaint with the Office of the
Secretary of State, 419 State Capital, Santa Fe, NM, 87503, (phone: 1-800-477-3632).
MAD100 01/21/2014 Page 7 of 13
MAD100 01/21/2014 Page 8 of 13
Program Application Information
1. Special Needs Information
(Applicant Information Pages)
SPECIAL NEEDS INFORMATION If you are a person with a disability and you require this information in an alternative format, or require
a special accommodation to participate in any public hearing, program or services, please contact the NM Human Services Department
toll-free at 1-800-432-6217 or through the New Mexico Relay System TDD at 1-800-659-8331 or by dialing 711. The Department
requests at least 10 days advance notice to provide requested alternative formats and special accommodations. (08/22/08)
2. Your Civil Rights
All programs administered by the Human Services Department (HSD) are equal opportunity programs. If you believe you have been treated unfairly
because of race, color, national origin, age, disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual
orientation, genetic information, political beliefs, reprisal, or because all or part of an individual’s income is derived from any public assistance program,
you may file a complaint. Complaints of discrimination may be filed with the New Mexico Human Services Department central office or the local Human
Services county office.
In accordance with Federal Law and, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, religion,
political beliefs, or disability.
To file a complaint of discrimination, write USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or
call toll free (866) 632-9992 (Voice). Individuals who are hearing impaired or have speech disabilities may contact USDA through the Federal Relay
Service at (800) 877-8339; or (800) 845-6136 (Spanish).
3. Your Privacy
The information you give HSD will be used to determine whether your household is eligible or continues to be eligible to take part in HSD programs. We
will check this information through computer matching programs or other means. This information will also be used to make sure that you meet program
rules and help us to manage the program.
This information may be given to other Federal and State agencies for official examination, and to law enforcement officials for the purpose of picking up
persons fleeing to avoid the law.
If you get benefits that you were not eligible for and have to pay them back, this is called a claim. If your household gets a claim against it, the
information on this application including all Social Security Numbers, may be given to Federal and State agencies, as well as private claims collection
agencies for claims collection action.
Providing the requested information, including Social Security Numbers of each household member is voluntary. However, except for non-citizens
applying for emergency services, HSD will not provide benefits to applicants who do not disclose their immigration status. HSD will not attempt to
determine, via INS, the immigration status of non-applicant household members who do not provide their immigration status. Non-Citizen Immigrants
not requesting assistance for themselves do not need to give immigration status information or Social Security Numbers. Any Social Security Numbers
given will be used and disclosed in the same manner as Social Security Numbers of eligible household members.
We also check with other agencies, the federal Income and Eligibility Verification Service (IEVS) and The Public Assistance Reporting Information
System (PARIS) about the information that you give us. This information may affect your household eligibility and benefit amount.
4. Child Support Enforcement Division
By accepting medical assistance, you assign (give) HSD rights to collect child support from the child’s absent parent(s). You must help HSD find the
absent parent(s) unless there is a good reason not to do so such as domestic violence; ask a caseworker. If it is decided that you have to work with the
Child Support office to establish or enforce child support and you do not, benefits may be eventually lost, and adults may lose their medical assistance.
5. Interview
How soon can I have my required appointment for an interview?

The Medical assistance programs on this application do not require an interview.
6. Proof Information
(a) How many days will I have to give all the required proof I need?



10 days from the date of your application is best to receive benefits faster
45 days from the date of your application is typical – unless you need more time – If you need more time, ask for more time
60 days from the date of your application is the longest – When you ask for up to 3-ten-day extensions
If you do not ask for an extension of time to bring in proof, your case may be denied after 30 days.
(b) What proof should I bring to the interview?
Your caseworker will NOT ask you to give proof of everything. You should be ready to give as many facts about your case as you can. If your
caseworker has unresolved questions about your eligibility, you will be asked to give proof. Your caseworker will give you a list of everything you still
need to give, along with a receipt for proof you provided. If you need help, ask your caseworker for help.
MAD100 01/21/2014 Page 9 of 13
7. Non-Citizen Immigrant Eligibility
(a) What types of Non-Citizen Immigrants are eligible for HSD assistance programs?
For most programs, non-citizens must have a "qualified" immigrant status and meet certain other conditions to qualify. Most non-citizens in the following
categories can get benefits if they meet all other program eligibility requirements:
 Lawful Perm. Res. (LPRs)
 Amerasians
Certain:
 Refugees
 Paroled to U.S. – 1 year
 Battered women and children
 Canada/Mexico born Native American
 Asylees
 Withholding of Deportation
 Veterans, active duty military
 Human Trafficking Victims
 Cuban Haitian Entrants
 Hmong or Laotian Tribe
Certain non-citizens, including undocumented non-citizens may be eligible for emergency medical services including pregnant women’s labor and
delivery.
(b) Is there a waiting period (bar) before non-citizen immigrants can get benefits?
The general rule now is that most qualified immigrant children are eligible to receive Medical Assistance. However some “qualified” immigrant adults can
get benefits after they have been in the United States in “qualified” immigrant status for five years, and some immigrants can get them right away. In
general, adults in certain humanitarian immigration categories (such as Refugees and Asylees), people with military connections lawfully present
pregnant women and children, credit for 10 years of work history in the US, and persons receiving disability benefits may be eligible right away.
8. After your Interview
(a) How soon will my application be approved or denied?

Medical – No later than 45 calendar days after the date of application
(b) If I disagree with the eligibility decision or benefit level, can I have fair hearing?
Yes - If you don't agree with a decision we make about your case, you can ask for a fair hearing in person, by telephone 1-800-432-6217 or (505)
827-8164, or in writing within 90-days of the date that a notice has been sent informing you of any action that has been taken on your case. Please
mail your request to the HSD Hearing’s Bureau at PO Box 2348 Santa Fe, NM 87504. You have a right to look at your case file and any records HSD
used to determine your eligibility before your hearing. You can ask a household member or someone else like a friend or relative to represent your
household at the fair hearing. You also have the right to have an attorney or other legal representative at the hearing.
(c) From what date are my benefits calculated?

Medical – From the 1st day of the month you applied. You may be eligible for up to 3 prior months of Medicaid coverage.
(d) How will I get my benefits?

Medical - A Medicaid card will be mailed to you one working day after the date of approval.
(e) How long can I get benefits before I have to renew them?
Medical – Up to 12 months is typical
(f) Do I have to report changes? Always report address changes within 10 calendar days for all types of assistance programs.


Medical – For adults, report all changes within 10 calendar days. For families with children and pregnant women, you only have to report
address changes within 10 calendar days. All other changes will have to be reported the next time you renew your case.
9. Notice of Rights
CONFIDENTIALITY All information I give to HSD is confidential. This information will be given to HSD employees who need it to manage the programs
for which I have applied. Confidential information may also be released to other federal and state agencies. All information will be used to determine
eligibility and/or to provide services. (03/29/12)
CIVIL RIGHTS STATEMENT All programs administered by the Human Services Department (HSD) are equal opportunity programs. If you believe you
have been treated unfairly because of race, color, national origin, age, disability, and where applicable, sex, marital status, familial status, parental status,
religion, sexual orientation, genetic information, political beliefs, reprisal, or because all or part of an individual’s income is derived from any public
assistance program, you may file a complaint. Complaints of discrimination may be filed with the New Mexico Human Services Department central office,
ATTN: Quality Improvement Section, Pollon Plaza, P. O. Box 2348, Santa Fe, New Mexico 87504-2348 or the local Human Services county office.
Complaints of discrimination about the Supplemental Nutrition Assistance Program may be filed with the USDA, Director, Office of Adjudication, 1400
Independence Ave, S.W. Washington, DC 20250-9410 or call 1-866-632-9992 or 202-401-0216 (TDD). Complaints of discrimination about Medical
Assistance programs may be filed with the Office of Civil Rights, Department of Health & Human Services, 1301 Young Street, Suite 1169, Dallas, TX
75202 or call 1-800-368-1019 (voice) and 1-214-767-8940 (TDD). (08/16/11)
YOUR RIGHT TO A HEARING - You can ask for a hearing if you do not agree with a decision HSD has made regarding your application/benefits. A
hearing will give you a chance to explain why you do not agree. You can ask for an HSD hearing by:
• Completing and returning the bottom of a notice;
• Writing or calling your local HSD office; or
MAD100 01/21/2014 Page 10 of 13
•
•
Writing the department's Hearings Bureau at Human Services Department, P.O. Box 2348, Santa Fe, N.M. 87504-2348, or by calling 1-800432-6217 (press 6) or 505-476-6213. (Revised 08/16/11)
Marketplace HEARING - I know that if I believe the Marketplace has made a mistake about my eligibility, I may appeal the action by contacting
the Health Insurance Exchange at 1-800-318-2596 and properly inform it that I believe their action should be reviewed. I know I may authorize
someone else to represent me in the appeals process.
TIME LIMIT FOR ASKING FOR A HEARING - You have 90 days from the date of this notice to ask for a hearing. If you ask for a hearing within 13 days
from the date of this notice, you will continue to get the same amount of benefits you received before we took the action in this notice. You will continue to
get these benefits until the Department decides your case, unless another change is made to your case. Changes in benefits may be made after you
have asked for a hearing if the reason for the change is not the same as the reason for the hearing. If you lose the hearing, you may have to pay back
any benefits you received while the Department decided your case. (Revised 9/24/02)
THE HEARING PROCESS - After you ask for a hearing, the Department or the Marketplace will send you a letter telling you the date, time and place
where your hearing will be held. The hearing is usually at the HSD county office. The hearing will be conducted by a hearing officer from the HSD
Hearings Bureau or the Marketplace. You or your representative can look at your case record and any proof we used to decide your case. You will tell
why you believe HSD’s or Marketplace action was wrong. You may bring witnesses and present proof. You may question the county office or the
Marketplace about the action taken and proof presented. You may represent yourself. You may be represented by a friend, household member or an
attorney. For information on where you can get free legal help, call 1-800-340-9771. After the hearing, the hearing officer will make a report. The HSD
Division Director or Marketplace Executive Director will decide whether the action was right or wrong. After the Director has decided your case, you will
be sent a letter telling you of the decision and why the decision was made. (Revised 04/02/03)
MAD100 01/21/2014 Page 11 of 13
Employer Coverage Form
Applying for help with health insurance costs from the Health Insurance marketplace?
The Health Insurance Marketplace application asks questions about any health coverage available through a current job (even
if it’s from another person’s job, like a parent or spouse) to figure out if you might be able to get help paying for health
insurance. Use this form to get the information you need from the employer who offers health coverage. We’ll verify this
information, so it’s important to be accurate. If you have more than one job that offers health coverage, use a separate form for
each employer.
Employee Information
The employee needs to fill out this section. Write down the employee’s information then you may request the information
below from the employer. Use this completed form when you fill out a Health Insurance Marketplace application.
Employee Name (First, Middle, Last)
Social Security Number
Employer Information
Ask the employer for this information
Employer name
Employer Identification Number (EIN)
Employer Address
Employer Phone Number
( )
–
State
Zip code
City
Who can we contact about employee health coverage at this job?
Name:____________________________ Phone:_________________ Email:_______________________
Tell us about the health plan offered by this employer.

This employee isn’t eligible for coverage under this employer’s plan.
The employee is eligible for coverage under this employer’s plan on___________________ (Start Date).
What’s the name of the lowest cost self-only health plan this employee could enroll in at this job? (Only consider plans that
meet the “minimum value standard” set by the Affordable Care Act.)
Name:_______________________________________________________
 No plans meet the “minimum value standard”
How much would the employee have to pay in premiums for that plan?
$__________ How Often?  Weekly  Every 2 weeks  Twice a month  Monthly  Yearly  Other___________
MAD100 01/21/2014 Page 12 of 13
Register to Vote
PERSONAL INFORMATION
NAME: Last
First
Middle Name or Initial
1
PHYSICAL STREET ADDRESS WHERE YOU LIVE NOW
Street Address
Apartment, Unit, or Lot #
Gender
M
This information not to be copied
Birth Date
Social Security Number
City
Zip
2
ADDRESS WHERE YOU GET YOUR MAIL
Address
(If different from above)
City
Zip
Site Code
3
If you are changing your name on this application, under what
Last Name
First Name
Middle Name or Initial
4
full name were you previously registered?
POLITICAL PARTY
POLL WORKER
DAY TIME TELEPHONE NUMBER (Optional)
NOTE: You must name a major
Party
If you choose NO PARTY,
May the County Clerk make this
Would you like to serve
political party to vote in primary
Check this box 
6
telephone number public for
as an election day
Democrat
5
elections.
election purposes?  Yes  No precinct worker?  Yes
I hereby authorize you to cancel my previous
City or Township
County
State
7
registration in the following county and state.
Please answer the following questions:
ATTESTATION OF QUALIFICATION
8
I swear/affirm that I am a citizen of the United States and a resident of
the state of New Mexico; that I have not been denied the right to vote by
a court of law by reason of mental incapacity; that I am, or will be at the
time of the next election, 18 years of age; and if I have been convicted of
a felony, I have completed all conditions of parole and supervised
probation, served the entirety of sentence or have been granted a pardon
by the governor. I further swear/affirm that I am authorizing cancellation
of any prior registration to vote in the jurisdiction of my prior residence;
and that all the information I have provided is correct.
Are you a citizen of the United States? …………………………………  Yes
 No
Will you be 18 years of age on or before election day? ………………  Yes
 No
If you checked “No” to any of the questions above, do not complete this form.
If you have been convicted of a felony and are currently on parole or supervised
probation do not complete this form.
TODAY’S DATE
Month Day
Year
______/ ______ /______
SIGN YOUR FULL NAME OR MARK ON THE LINE BELOW:.
Name of agent who assisted you in filling out this form.
VRA ID #
9
DO NOT WRITE IN SHADDED AREAS – FOR OFFICIAL USE ONLY
Accepted for filing in County Registration Records:
___________ / _________________________________ / _________________________________
Date
County Clerk
Filing Clerk
ID
PCT
MUN
SCHOOL CC
PRG DIST
REP
DIST SEN
DIST
HSD Site Code I-
Registrarse para Votar
Esta información no se debe copia
INFORMACION PERSONAL
NOMBRE: Apellido
Su Nombre de Pila
Otro Nombre o Inicial Género
Fechade Nacimiento
Número de Seguro Social
H
1
DIRECCION DONDE UD. VIVE AHORA
Número y Nombre de la Calle
Departamento, Unidad o # de Lote
Ciudad
Zona Postal
2
DIRECCION DONDE UD. RECIBE SU CORRESPONDENCIA
Dirección
Ciudad
Zona Postal
Site Code
3
¿Si Ud. Va cambier su nombre en esta solicitud, bajo que
Apellido
Nombre de Pila
Otro Nombre o Inicial
nombre completo estaba Ud. Matriculado antes?
4
EMPLEADO / A EN URNA ELECTORAL
PARTIDO POLITICO
NUMERO DE TELEFONO EN EL DIA (Opcional)
AVISO: Ud. tiene que indicar Partido
Si Ud. NO ELIGE
¿Con motivo del elecciones
¿Quiere Ud. trabajar en recinto
5
partido politico principal para
Partido marque aquí 
electoral el dia de la elección?
6 puede divulgar el escribano
votar en la elección primaria
de Condado esté núm. De
 Si
Democrata
teléfono?  Si  No
Por la presente autorizo que Ud. cancele mi matrícula
Ciudad o División
Condado
Estado
7
previa en el condado y estado a continuación.
Favor de contestar las preguntas a continuación:
TESTIMONIO DE CALIFICACION
Ud. ciudadano / a de los Estados Unidos? ……………….……  Si  No
¿Habrá cumplido Ud. 18 años en o antes del dia de la elección?  Si  No
Si Ud. marcó “NO” en cualquiera de las preguntas más arriba no termine de
rellenar este formulario.
Si usted fue condenado de un delito grave y actualmente esta en libertad
condicional o probación supervisada, no llene esta forma.
¿Es
8
FECHA:
Mes
Dia
Año
______/______ /______
9
Nombre de la persona que le ayudó a llenar este formulario:
Yo juro/afirmo que soy ciudadano de los Estados Unidos y residente del
Estado de Nuevo México; que la corte no me ha denegado el derecho de votar
por motivo de incapacidad psicológica; que tengo o tendré 18 años de edad en
la fecha de la próxima elección y si he sido condenado de delito grave he
cumplido todas las condiciones de libertad a prueba o el gobernador me ha
concedido indulto. Ademas, juro o afirmo que autorizo la cancelación de toda
matrícula anterior con el fin de votar en el territorio de mi residencia previa; y
que la informacion proveido esta correcto.
FIRME SU NOMBRE COMPLETO O MARQUE LA LÍNEA ABAJO:
VRA ID #
NO ESCRIBA EN LOS ESPACIOS EN COLOR GRIS – SOLO PARA USO OFICIAL
ID
PCT
MUN
PRG DIST
Accepted for filing in County Registration Records
SCHOOL
CC
________ / ______________________________ / _____________________________
Date
County Clerk
Filing Clerk
REP
DIST SEN
DIST
ISDB 720 Issued 3/5/12
MAD100 01/21/2014 Page 13 of 13
Hoja de Información para la Solicitud de Asistencia de Medicaid
Beneficios del Departamento de Servicios
Humanos:
Mercado de Seguros Médicos

Medicaid: provee atención médica para ciertas personas
y familias con bajos ingresos y recursos. Dependiendo de sus
ingresos y recursos usted puede calificar para los beneficios
completos o parciales. (Si usted no califica para Medicaid, su
solicitud será enviada automáticamente al mercado de
seguros médicos donde usted puede ser elegible para otros

programas de seguro de salud de bajo costo.)
Dependiendo de sus ingresos, usted puede calificar para
beneficios completos o parciales. Los siguientes son los tipos
de Medicaid para cual usted puede calificar:






Recién Nacidos
Niños hasta la edad de 18
Padres(s)/Guardián(s)
Mujeres Embarazadas
Adultos con bajos ingresos
Servicios de Emergencia para Extranjeros
Solicite los beneficios mencionados
anteriormente en línea al:
www.yes.state.nm.us/selfservice.
O
Mande su solicitud completa y firmada a su
oficina local de la División de Asistencia
Económica o envíela a:
Central ASPEN Scanning Area (CASA)
PO BOX 830
Bernalillo, NM 87004

El Mercado es una manera de
comprar y comparar los planes de
seguro de salud para los
individuos y las familias que no
son elegibles para Medicaid.
Usted puede calificar para un
programa que le puede ayudar a
pagar por seguro de salud, incluso
si usted gana hasta $94,000 al
año (para una familia de 4).
Nuevos subsidios de impuestos
que pueden ayudar a pagar
inmediatamente las primas para la
cobertura de salud pueden estar
disponibles.
Para solicitar un seguro médico a
través del Mercado de Seguros
Médicos, usted puede ir a:
https://www.healthcare.gov/
O
Llame 1-800-318-2596
TTY: 1-855-889-4325
MAD 100 Page 1 of 13
SOLICITUD PARA ASISTENCIA DE MEDICAID
Intérpretes están disponibles gratuitamente.
Seleccione los programas de
asistencia cuales usted está
solicitando: (adultos que no buscan
Programas de Asistencia
ayuda para sí mismos pueden solicitar de
parte de otros miembros del hogar)
Dependiendo de los ingresos y recursos un individuo puede calificar para los
beneficios completos o parciales. Los siguientes son los tipos de Medicaid
para cuál usted puede calificar:






MEDICAID
(Si usted o su familia no califican para
Medicaid, su solicitud será enviada
automáticamente al mercado de seguros
médicos donde usted o su familia puede ser
elegible para otros programas de seguros
médicos de bajo costo.)
Recién Nacidos
Los niños de hasta 18 años
Padre(s)/Guardián(es)
Mujeres embarazadas
Adultos con bajos ingresos
Servicios de Emergencia para Extranjeros
MERCADO DE SEGUROS MÉDICOS
El Mercado es una manera comprar y comparar los planes de seguro de
salud. Los individuos y las familias que no son elegibles para Medicaid,
pueden ser elegibles para recibir un nuevo subsidio de impuesto que puede
ayudar a pagar inmediatamente las primas de seguro de salud.
1. Díganos sobre usted:
Si necesita ayuda para llenar esta solicitud o para obtener la información necesaria, póngase en contacto con su oficina local de ISD. Si usted solicita
de parte de otra persona, complete esta sección para esa persona.
Primer nombre, inicial del segundo nombre, Apellido
Correo electrónico
Mejor hora para llamar
Manana
Dirección Física
Ciudad
Condado
Estado
Código
Postal
Número de Teléfono
(
)
Si su dirección postal es diferente, por favor llene a continuación. Si no, deje en blanco.
Dirección Física o de PO Box
Ciudad
Estado
Código Postal
¿Es usted un residente de Nuevo México? ¿Tiene la intención quedarse en Nuevo México?
¿Es usted una persona sin hogar?
 SÍ  NO
 SÍ  NO
 SÍ  NO
¿Quiere recibir información por vía electrónica? Si quiere recibir, por favor, rellene su dirección de correo
 SÍ  No
electrónico arriba.
2. Persona Que lo Representa (Representante Autorizado o Tutor Legal)
El representante autorizado podría ser o no ser la misma persona designada como representante autorizado para el procesamiento de la solicitud o
para cumplir con los requisitos de reportes. La designación de un representante autorizado debe hacerse por escrito.
¿Usted quiere que esta
persona:
Nombre de la persona(s) autorizada(s)
 ¿Solicite beneficios en su nombre?
Dirección de Correo
# de Teléfono Preferido / TDD
(
)
(
)
MAD 100 Page 2 of 13
3. Díganos sobre la gente que vive con usted:
Por favor, liste a todos que viven en su hogar, incluso si usted no desea solicitar para ellos. Sólo tiene que dar información de ciudadanía de los
EE.UU. y el número de seguro social para los miembros de la familia para quien está solicitando. Recuerde que usted no tiene que ser ciudadano de
los EE.UU. para solicitar. Recibir SNAP/comida, asistencia de energía o médica no evitará que usted se convierta en un residente permanente legal
o ciudadano de los EE.UU.. Inmigrantes que no son ciudadanos que no solicitan asistencia por sí mismos no tienen que dar información de estatus
migratorio, números de Seguro Social, u otras pruebas similares, sin embargo, deben dar prueba de sus ingresos y cosas que poseen debido a que
parte de sus ingresos y cosas que poseen pueden contar hacia la elegibilidad del hogar para recibir asistencia. Ciertos beneficios pueden ser
disponibles para las personas sin número de Seguro Social, pregúntele a ISD. Si es necesario, use una hoja de papel adicional para los miembros del
hogar adicionales que no caben en esta página.
Anote los nombres y la información para usted y todas las
personas que viven con usted:
Nombre
(Primer Nombre y
Apellido)
1.
Parentesco
(sí mismo)
Sexo
M/F
Fecha
de
Nacimiento
Raza y
etnicidad
(Opcional)
Llene esta sección SÓLO para cada persona que está
solicitando beneficios.
¿Estatus
de
Ciudadano
SSN #
de EE.UU. inmigrante
(Opcional para
S/N
legal?
no-solicitantes)
S/N
¿Va a declarar
sus impuestos
federales del
año en curso?
S/N
¿Va a
reclamar a
esta persona
en la
declaración
de impuestos
del año en
curso?
S/N
H
S
S
S
S
2.
H
S
S
S
S
3.
H
S
S
S
S
4.
H
S
S
S
S
5.
H
S
S
S
S
6.
H
S
S
S
S
7.
H
S
S
S
S
8.
H
S
S
S
S
Datos raciales y étnicos en los hogares participantes son voluntarios, no afectará a la elegibilidad o la cantidad de beneficios que su hogar va a recibir.
Se les recomienda a los indígenas americanos a identificarse como tal porque los indígenas americanos tienen derecho a ciertas protecciones
especiales bajo la ley. La razón por la cual le pedimos a todos por información racial y étnica es para asegurar que los beneficios se distribuyen sin
distinción de raza, color u origen nacional.
4. Por favor conteste estas preguntas de ingresos de impuestos federales sobre la gente
listada en la sección 3 que NO será reclamada como dependiente de impuestos si están
en otra declaración de impuestos del solicitante * Solicitante todavía puede obtener Medicaid si no
declara los impuestos federales.
Enumere cada individuo con declaración de impuestos y sus dependientes que están indicados en la solicitud, a continuación.
Pagador de impuestos 1.__________________ Nombre del dependiente:_________________; Parentesco:___________________
Nombre del dependiente:_________________; Parentesco:___________________
Pagador de impuestos 2.__________________ Nombre del dependiente:_________________; Parentesco:__________________
Nombre del dependiente:_________________; Parentesco:___________________
Pagador de impuestos 3.__________________ Nombre del dependiente:_________________; Parentesco:___________________
Nombre del dependiente:_________________; Parentesco:___________________
MAD 100 Page 3 of 13
5. Por favor conteste estas preguntas sobre la gente listada en la sección 3 que solicita
cobertura de seguro médico.
Liste a todas las personas que solicitan cobertura que tienen el estatus de inmigrante legal y llene la información a continuación.
¿Quién?____________________; Tipo de Documento_________________; Número de ID:___________________
¿Quién?____________________; Tipo de Documento_________________; Número de ID:___________________
¿Quién?____________________; Tipo de Documento_________________; Número de ID:___________________
¿El solicitante que no es ciudadano ha vivido en los EE.UU. desde 1996? ¿Quién? ________________________
¿Hay un solicitante que no es ciudadano o hay un cónyuge o padre que es un veterano o en servicio activo en el ejército de EE.UU.?
¿Quién? ______________
¿Hay un solicitante que recibe beneficios en otro estado? Si, Sí, ¿Quién? ________________________
 Sí  No
¿Está alguno de los solicitantes viviendo o está por entrar a un hogar de ancianos, enfermos, hospital o centro de
 Sí  No
tratamiento? ¿Quién? _________________
Casa/ institución de
Si, Sí, que tipo de institución:
PACE

 Hospital

ancianos/enfermos
Centro de Atención Intermedia para Personas con Retraso
Si otro ¿dónde? _________________________

 Otro:
Mental (ICFMR)
 Sí  No
¿Hay alguien incapacitado? ¿Quién? _______________________________
¿Hay un solicitante en el hogar que recibe Seguridad de Ingreso Suplementario (SSI)?
 Sí  No
¿Quién? ______________________________¿Cuál Estado? _____________________________
¿Hay alguien en el hogar que está embarazada? ¿Quién? _____________________________
 Sí  No
¿Cuantos bebés se esperan de este embarazo? ______ Fecha Prevista del Parto ______________
¿Nombre del padre del bebé no nacido? (opcional) _____________________
¿Hay alguien que ha recibido una carta de Libertad Primaria de Selección para una Exención de Servicios Basados
en la Comunidad y el Hogar?
 Sí  No
Si hay, ¿Quién? _______________________________
¿Hay algún solicitante que fue receptor del cuidado de crianza bajo la edad de 26 años? Si lo hay, ¿Quién?
___________________
 Sí  No
6. Díganos sobre sus ingresos ganados
Nota: Si se le ofrece un seguro médico de un empleador, por favor rellene el siguiente formulario de Cobertura de Empleador adjunta a
esta solicitud
¿Usted o alguien que vive con usted ha recibido ingreso del trabajo o espera recibir
ingresos este mes? Si es así, por favor completar la tabla siguiente.
Persona con ingresos
¿Promedia de
Horas
Trabajadas?
¿Ingresos de?
(trabajo, trabajo por
cuenta propia, otro
trabajo)
¿Cada cuando
recibido?
(Anual, Mensual,
Bisemanal, Semanal,
etc)
 Sí  No  No sé
¿Este empleador
ofrece Seguro de
Salud? (S/N)
¿Cuánto reciben?
$
$
$
$
Si contestó sí complete
el formulario de la
cobertura del
empleador en la página
16.
S
S
S
S
MAD 100 Page 4 of 13
Díganos Sobre Sus Otros Ingresos:
Ejemplos de ingresos no devengados del trabajo incluyen, pero no están limitados a: el desempleo, Seguro Social, pensiones, la
jubilación, los ingresos de rentas, el dinero indígena, ganancias de capital, dividendos / intereses y los pagos per cápita. Note: No es
necesario que nos diga de sostenimiento de niños, los pagos de veteranos o Seguridad de Ingreso Suplementario (SSI)
¿De dónde viene el
¿Cada cuando recibido?
Persona con ingreso
Ingreso no devengado de
¿Cuánto reciben?
(Anual, Mensual, Bisemanal, Semanal, etc)
un trabajo?
$
$
$
7. ¿Habrá Cambios en los Ingresos?
¿Usted o alguien que vive con usted tiene cambios en los ingresos que no son constantes de mes a mes?
Ejemplos incluyen: pérdida de empleo, reducción de horas, cambio de trabajo, cambio de pago y / o
trabajando sólo algunos de los meses del año
Persona
Ingresos
Cuando
 Sí  No
 No sé
Por qué
¿Deducciones?
Si usted paga por ciertas cosas que se pueden deducir en la declaración de impuestos federales, díganos acerca de esas cosas.
 Pensión alimenticia pagada $_______ ¿Con qué frecuencia?_______  Deducciones IRA $_______ ¿Con qué frecuencia?_______
 Interés de préstamo de estudiante $_________ ¿Con qué frecuencia?_________
 Otro: Tipo _________________ ¿Cuánto? $_________ ¿Con qué frecuencia?____________
 Otro: Tipo _________________ ¿Cuánto? $_________ ¿Con qué frecuencia?____________
8. Padres que no viven con sus hijos
Con la aceptación de la asistencia médica para sus hijos, usted asigna (otorga) HSD derechos para cobrar manutención de un padre
ausente. Por favor escriba toda la información para los padres de sus hijos que no viven con usted:
Si usted piensa que cooperar para recolectar apoyo médico le hará daño a usted o a sus hijos, es posible que no
 Sí  No
tenga que cooperar.
¿Es algún solicitante una víctima de violencia familiar?
Nombre del niño
Nombre de padre ausente (opcional)
9. Información de Atención Médica
¿Alguien en su hogar ha recibido servicios médicos en los últimos 3 meses que no han sido pagados?
Si es sí, indique los miembros que tienen las cuentas y para cuales meses. Puede ser que nosotros podamos ayudar a
pagar estas cuentas.
a._____________________________; b._____________________________; c._________________________
 Sí  No
 Sí  No
¿Alguien en su hogar tiene seguro de salud?
Si es así, indique la información de los seguros de salud privados y públicos incluyendo a Medicare para usted y todas las personas que
viven con usted.
# de Reclamo de Medicare
Personas Cubiertas
Nombre de la compañía de seguros
o
# de ID de Miembro de
Seguro
Fecha de
inicio
MAD 100 Page 5 of 13
10. Organización de Cuidado Administrado (MCO) (Si usted está solicitando Medicaid a
partir del 01 de diciembre 2013) Esta sección SÓLO aplica si se encuentra ser elegible para Medicaid.
A partir del 1 de enero 2014 los servicios de Medicaid serán proporcionados por las cuatro organizaciones de cuidado administrada
(MCO (s) se enumeran a continuación. Usted tiene la opción de cual MCO proporciona sus servicios. Si usted no elige una MCO antes
del 1 de enero de 2014, se le asignará automáticamente a una MCO por el Estado. Una vez que está inscrito con una MCO, usted
tendrá la opción de cambiar de MCO dentro de 90 días de inscripción.
Información especial para indígenas Americanos sobre organizaciones de cuidado administrado
Si usted es un indígena Americano, usted no es requerido a escoger una MCO. Si usted está con la necesidad de
servicios de atención a largo plazo o tiene Medicare tendrá que escoger una MCO.
Yo soy indígena americano.  Sí  No (Si es así, por favor llene la sección de información de indígena americano o indígena de
Alaska después de esta sección )
¿Quiere inscribirse en una organización de cuidado administrado?  Sí  No (Si quiere inscribirse, favor de seleccionar un
MCO a continuación)

Al marcar esta casilla, quiero inscribir a todos los beneficiarios
de Medicaid en mi hogar con esta MCO.
o
Sólo los beneficiarios de Medicaid de este hogar que están
listados aquí deben estar inscritos con
BCBS:__________________________________


Blue Cross Blue Shield (BCBS)
Al marcar esta casilla, quiero inscribir a todos los beneficiarios de
Medicaid en mi hogar con esta MCO.
o
Sólo los beneficiarios de Medicaid de este hogar que están listados
aquí deben estar inscritos con
Molina:__________________________________

Presbyterian Health Plan
Al marcar esta casilla, quiero inscribir a todos los beneficiarios
de Medicaid en mi hogar con esta MCO.
o
Sólo los beneficiarios de Medicaid de este hogar que están
listados aquí deben estar inscritos con
Presbyterian:__________________________________
Molina Healthcare of New Mexico
United Healthcare Community Plan
Al marcar esta casilla, quiero inscribir a todos los beneficiarios de
Medicaid en mi hogar con esta MCO.
o
Sólo los beneficiarios de Medicaid de este hogar que están listados
aquí deben estar inscritos con
United:__________________________________
Indígena Americano o Indígena de Alaska
Indígenas Americanos e Indígenas de Alaska que se inscriben en Medicaid, el Programa de Seguro de Salud de Niños (CHIP), y el
Mercado de Seguros Médicos también pueden recibir servicios de Servicios Médicos para Indígenas, programas de salud tribal, o
programas de salud de indígenas urbanos.
Si usted o sus miembros de su familia son Indígenas Americanos o Indígenas de Alaska, puede ser que no tengan que pagar reparto
de costos y pueden recibir periodos especiales de inscripción. Le pedimos que conteste las siguientes preguntas para asegurar que
usted y su familia reciban toda la ayuda posible. NOTA: Si necesita más espacio adjunte otra hoja de papel.
¿Algún solicitante es miembro de una tribu reconocida por el gobierno federal?
 Sí  No
Si es así, ¿Quién? ________________________. ¿Cuál Tribu? _______________________
¿Estos solicitantes reciben servicio del Servicio de Salud Indígena, un programa de salud tribal, o el programa de salud
 Sí  No
para indígenas urbanos o a través de una referencia de uno de estos programas?
Si no ¿Es esta persona elegible para recibir servicios del Servicio de Salud Indígena, programas de salud tribal, o
programas de salud para indígenas urbanos o a través de una referencia de uno de estos programas?
 Sí  No
Cierto dinero recibido no se puede contar para Medicaid o CHIP.
¿El ingreso reportado en la Sección 6, incluye dinero de cualquiera de las siguientes fuentes?
¿Pagos per cápita de una tribu que provienen de los recursos naturales, los derechos de uso, los arrendamientos y las
regalías?
¿Los pagos de los recursos naturales, la agricultura, la ganadería, la pesca, los arrendamientos y regalías de la tierra
designada como tierras fiduciarias india por el Departamento de Interior (incluidas las reservas y las reservas
anteriores)?
¿Dinero de la venta de las cosas que tienen importancia cultural?
 Sí  No
 Sí  No
 Sí  No
MAD 100 Page 6 of 13
11. Su Firma (Su representante autorizado también puede firmar aquí)
Su firma hace que esta solicitud sea válida y no puede ser procesada sin la firma. Su firma también es una indicación de lo siguiente:
 Entiendo que hacer declaraciones falsas u ocultar información podría significar penas estatales y federales y he dado a HSD
información verdadera, correcta y completa.
 Estoy declarando la identidad de los niños menores de 16 años para quien estoy solicitando.
 Voy a dar prueba de lo que yo reporte a HSD. Si no puedo conseguir la prueba, sé que puedo pedir que me ayude HSD y dejaré que HSD contacte a
otras personas y empresas para obtener pruebas.
 Voy a dejar que HSD dé información limitada a las agencias aprobadas que dan otro tipo de ayuda relacionada con lo que puedo ser elegible.
 Entiendo que si recibo beneficios para los que no soy elegible, que voy a tener que pagarle a HSD esos beneficios.
 Yo confirmo que nadie que solicita un seguro de salud en esta solicitud está encarcelado (detenido o encarcelado). Si no, ______________ está
encarcelado.
 Yo sé que HSD verificará la información que yo provea. HSD puede utilizar las computadoras u otros medios para verificar la información en este
formulario.
 Yo sé que HSD verificará el estatus migratorio de las personas que solicitan o reciben beneficios. Entiendo que el estatus migratorio de cualquier
miembro de la casa que estoy solicitando puede ser objeto de verificación por parte de USCIS (INS), y que puede afectar la elegibilidad del hogar y el
nivel de beneficios.
 Entiendo que debo cooperar con el control de calidad (QC). QC es una parte de HSD. QC revisa casos para asegurarnos que determinamos
correctamente quién puede obtener ayuda.
 FIDEICOMISOS - Entiendo que si yo o la persona (s) para quien estoy solicitando, he creado un fideicomiso, o son beneficiarios de un fideicomiso, debo
dar a HSD una copia del documento de fideicomiso, incluyendo todos los accesorios e información relacionada. HSD analizará el fideicomiso para ver si
afecta a los beneficios de Medicaid para los que estoy solicitando.
 RECUPERACIÓN DE BIENES - Entiendo que, después de mi muerte, HSD puede presentar una reclamación en contra de mi patrimonio para recuperar
las sumas que el Estado paga o pago en mi nombre por la asistencia médica proporcionada bajo del programa de Medicaid. Este proceso se llama
"recuperación de bienes." "Recuperación de Bienes" es requerido por la ley federal y estatal. "Recuperación de Bienes" es necesario cuando los
beneficiarios de Medicaid tienen cincuenta y cinco (55) años de edad o más y el Estado hace pagos de asistencia médica en su nombre por los servicios
de institución de enfermería, servicios basados en el hogar y en la comunidad, y/o servicios de hospitalización y medicamentos recetados. La cantidad
recuperada por HSD no superará la cantidad de pagos de asistencia médica realizada en nombre del beneficiario de Medicaid. Se pueden aplicar
algunas exclusiones.
 Entiendo que debo dar a HSD dinero que recibo por los servicios médicos que ya han sido pagados por Medicaid. Si yo no lo hago, yo o la persona(s)
para quien estoy solicitando, podría perder la cobertura de Medicaid por lo menos durante un año y hasta que el monto adeudado a Medicaid ha sido
pagado en su totalidad.
 Una persona que está solicitando o recibiendo Asistencia de Medicaid debe asignar a HSD todos los derechos contra cualquier y todos los individuos de
apoyo médico o pagos por gastos médicos pagados en nombre del cliente y en nombre de cualquier otra persona para la que se solicite o se recibe
ayuda.
 Para retirar su solicitud de cualquier programa, iníciale en la casilla del programa ►
Medicaid
Mercado
Firma del solicitante
Nombre del Testigo (Atestiguado sólo si el solicitante firma con una marca o
huella)
Fecha
Firma del representante del solicitante
Firma del Testigo (Atestiguado sólo si el solicitante firma con una marca o
huella)
Fecha
INFORMACIÓN DE NECESIDADES ESPECIALES Si Ud. es una persona que tiene incapacidad y Ud. requiere esta información en
un formato alternativo o requiere un acomodamiento especial para poder participar en cualquier audiencia pública, programa o servicio,
comuníquese con el departamento de servicios humanos de NM gratis al número 1-800-432-6217, o a través del sistema de relaís de
Nuevo México TDD en 1-800-659-8331 o puede oprimir 711. El departamento solicita la comunicación previa por lo menos de 10 días
por anticipado para poder proporcionar los formatos alternativos a y acomodamientos especiales que Ud. solicite. (08/22/08)
12. Registrar para votar
Si USTED NO está registrado para votar en el lugar donde vive ahora ¿Quiere registrarse para votar aquí hoy? (Escoja uno)
SÍ
NO
La LEY NACIONAL DE REGISTRO DE VOTANTES pone a su disposición la oportunidad de registrase para votar en este lugar. Si desea ayuda para llenar
el formulario para registrarse, nosotros le ayudaremos. La decisión de buscar o aceptar ayuda es suya. Usted puede llenar el formulario de solicitud en
privado.
IMPORTANTE: Solicitar para registrar o declinar para registrar a votar NO AFECTARÁ la ayuda que se le proporcionará por esta agencia.
Firma
Fecha
CONFIDENCIALIDAD: Si Ud. decide registrarse o no, la decisión que Ud. tome permanecerá confidencial. SI UD. CREE QUE ALGUNA PERSONA HA
INTERVENIDO con su derecho de registrarse para votar o declinar de registrarse para votar, o ha intervenido con su derecho a la privacidad en
decidir si se registra para votar o al indicar que desea registrare, o su derecho a elegir el partido político, Ud. puede presentar su queja a la Oficina
de la Secretaria de Estado, 419 State Capitol, Santa Fe, NM, 87503 (teléfono: 1-800-477-3632).
MAD 100 Page 7 of 13
MAD 100 Page 8 of 13
Información de la Solicitud del Programa
(Páginas de Información del Solicitante)
1. Información de Necesidades Especiales
INFORMACIÓN DE NECESIDADES ESPECIALES: Si Ud. es una persona que tiene incapacidad y Ud. requiere esta información en un
formato alternativo o requiere un acomodamiento especial para poder participar en cualquier audiencia pública, programa o servicio,
comuníquese con el departamento de servicios humanos de NM gratis al número 1-800-432-6217, o a través del sistema de relaís de
Nuevo México TDD en 1-800-659-8331 o puede oprimir 711. El departamento solicita la comunicación previa por lo menos de 10 días
por anticipado para poder proporcionar los formatos alternativos a y acomodamientos especiales que Ud. solicite. (08/22/08)
2. Sus Derechos Civiles
Todos los programas administrados por el Departamento de Servicios Humanos (HSD) son programas de oportunidades iguales. Si usted cree que ha
sido tratado injustamente debido a la raza, el color, origen nacional, la edad, la incapacidad, y donde aplicable, el sexo, el estado civil, estatus familiar,
estatus paternal, la religión, orientación sexual, información genética, las creencias políticas, la represalia, o porque todo o la parte de los ingresos de
un individuo son derivados de cualquier programa de ayuda estatal, puede presentar una queja. Las quejas de discriminación se pueden presentar en
la oficina central del Departamento de Servicios Humanos de Nuevo México o en la oficina de Servicios Humanos local de su condado. .
De acuerdo con Ley Federal, esta institución tiene prohibido discriminar por motivos de raza, color, origen nacional, sexo, edad, religión, creencias
políticas o incapacidad.
Para presentar una queja por discriminación, escriba a USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, D.C.
20250-9410 o llame gratuitamente a (866) 632-9992 (Voz). Las personas con dificultades auditivas o incapacidades del habla pueden comunicarse
con el USDA a través de los Servicios de Relais Federal al (800) 877-8339; o (800) 845-6136 (Español).
3. Su Privacidad
La información que usted da a HSD será utilizada para determinar si su hogar tiene elegibilidad o continúa a tener elegibilidad para participar en los
programas de HSD. Verificaremos esta información por programas de computadora. Esta información también será utilizada para asegurar de que
usted sigue las reglas del programa y para ayudarnos a manejar el programa. Esta información puede ser dada a otras agencias Federales y del
Estado para examen oficial, y a oficiales de la ley para el propósito de encontrar a personas que huyen para evitar la ley.
Si usted recibe beneficios de que usted no fue elegible y tiene que pagarlos, esto se llama un reclamo. Si su casa recibe un reclamo contra su casa, la
información en esta solicitud, incluyendo todos los números del seguro social, pueden ser dados a agencias Federales y del Estado, así como
agencias privadas de colección de reclamos, para la acción de colección de reclamos.
Dar la información solicitada, incluyendo números del seguro social de cada miembro de la casa es voluntario. Sin embargo, cada persona solicitando
para asistencia debe dar un número de seguro social o resultará en la negación de beneficios del programa a cada individuo que no da un número del
seguro social. Inmigrantes no ciudadanos que no están solicitando asistencia para sí mismos, no necesitan dar información de su estatus migratoria o
número de seguro social. Cualquier número de seguro social proporcionado será utilizado y será revelado en la misma manera que números de
seguro social de miembros de la casa que son elegibles. Nosotros también verificamos con otras agencias, el Servicio de Verificación de Elegibilidad
e Ingresos Federales (IEVS) y el Sistema de Información Reportada de Asistencia Pública (PARIS) acerca de la información que usted nos da. Ésta
información puede afectar su elegibilidad de la casa y cantidad de beneficio.
4. División de Sostenimiento de Niños
Al aceptar asistencia médica, usted asigna (otorga) a HSD derechos para cobrar sostenimiento de niños al padre ausente del niño (s). Usted debe
ayudar a HSD a encontrar al padre ausente (s) a menos que haya una buena razón para no hacerlo, como la violencia doméstica, pregúntele a un
trabajador. Si se decide que usted tiene que cooperar con la Oficina de Sostenimiento de Niños para establecer o hacer cumplir la manutención y usted
no lo hace, los beneficios pueden ser eventualmente perdidos, y los adultos pueden perder su asistencia médica.
5. Entrevista
¿En cuánto tiempo puedo tener mi cita requerida para una entrevista?

Los programas de asistencia médica en esta solicitud no requieren una entrevista.
6. Información de Pruebas
(a) ¿Cuántos días voy a tener para dar toda la prueba necesaria que necesito?



10 días a partir de la fecha de la solicitud es lo mejor para recibir los beneficios más rápido
45 días a partir de la fecha de su solicitud es típico - a menos que necesite más tiempo - Si usted necesita más tiempo, pida más tiempo
60 días a partir de la fecha de su solicitud es los más largo – Cuando Ud. pide hasta 3 extensiones de 10 días
Si no solicita una extensión de tiempo para presentar la prueba, su caso puede ser negado después de 30 días.
(b) ¿Qué pruebas debo llevar a la entrevista?
Su trabajador NO le pedirá que dé prueba de todo. Usted debe estar preparado de presentar todos los datos de su caso que pueda. Si el trabajador
tiene preguntas sin resolver acerca de su elegibilidad, se le pedirá a dar pruebas. Su trabajador le dará una lista de todo lo que todavía tiene que
dar, junto con un recibo como prueba que usted proporcionó. Si usted necesita ayuda, pídale ayuda a su trabajador.
MAD 100 Page 9 of 13
7. Elegibilidad de Inmigrantes No Ciudadanos
(a) ¿Qué tipos de Inmigrantes no ciudadanos son elegibles para programas de asistencia de HSD?
Para la mayoría de los programas, las personas que no son ciudadanos deben tener un estatus de inmigrante "calificado" y tienen otras ciertas
condiciones para calificar. La mayoría de los no ciudadanos en las siguientes categorías pueden obtener beneficios si cumplen todos los demás
requisitos de elegibilidad del programa
 Residente Permanente Legal
(LPR)
 Amerasiáticos
Ciertos:
 Refugiados
 Libertad condicional a EE.UU. - 1 año
 Mujeres y niños maltratados
 Indígena Americano nacido en Canadá
 Asilados
 Retención de la deportación
 Veteranos, militares en
servicio activo
 Entrantes cubanos haitianos
 Tribu Hmong o de Laos
/México
 Las víctimas de tráfico de personas
Algunos no ciudadanos, incluidos los no ciudadanos indocumentados pueden ser elegibles para los servicios médicos de emergencia, incluyendo el
parto y alivio de las mujeres embarazadas.
(b) ¿Existe un período de espera (bar) antes de que los inmigrantes no ciudadanos pueden obtener beneficios?
La regla general es que ahora la mayoría de los niños inmigrantes calificados son elegibles para recibir Asistencia Médica. Sin embargo, algunos adultos
inmigrantes "calificados" pueden recibir beneficios después de haber estado en los Estados Unidos en condición de inmigrante "calificado" durante cinco
años y algunos inmigrantes pueden obtener de inmediato. En general, los adultos en ciertas categorías de inmigración humanitarias (como refugiados y
asilados), las personas con conexiones militares, mujeres embarazadas y niños presente legalmente, crédito por 10 años de historia de trabajo en los
EE.UU., y las personas que reciben beneficios por incapacidad pueden ser elegibles de inmediato.
8. Después de su entrevista
(a) ¿En cuánto tiempo será mi solicitud aprobada o negada?

Médica – No más de 45 días naturales después de la fecha de solicitud
(b) Si no estoy de acuerdo con la decisión de elegibilidad o beneficio ¿puedo tener una audiencia justa?
Sí - Si no está de acuerdo con una decisión que tomamos sobre su caso, usted puede solicitar una audiencia justa en persona, por teléfono 1-800432-6217 o (505) 827-8164, o por escrito dentro de 90 - días siguientes a la fecha en que la notificación ha sido enviada para informarle de cualquier
acción que se ha tomado en su caso. Por favor envíe su solicitud a la Oficina de la Audiencia HSD al PO Box 2348 Santa Fe, NM 87504. Usted tiene
derecho a revisar el archivo de su caso y cualquier registro que HSD usa para determinar su elegibilidad antes de su audiencia. Usted puede pedir a
un miembro de la familia u otra persona como un amigo o pariente que lo represente a su hogar en la audiencia justa. Usted también tiene el
derecho de tener un abogado u otro representante legal en la audiencia.
(c) ¿A partir de cual fecha se calculan mis beneficios?

Médicos – A partir del primer día del mes en que solicitó. Usted puede ser elegible para recibir hasta 3 meses antes de la cobertura de
Medicaid.
(d) ¿Cómo voy a recibir mis beneficios?

Médicos - Una tarjeta de Medicaid se le enviará a usted un día de trabajo después de la fecha de aprobación.
(e) ¿Cuánto tiempo puedo recibir beneficios antes que tenga que renovarlos?

Médicos – Hasta 12 meses es típico. l
(f) ¿Tengo que reportar cambios? Siempre reporte cambios de dirección dentro de 10 días naturales para todos tipos de programas de
asistencia.

Médicos – Para adultos, reporte todos los cambios dentro de 10 días naturales. Para familias con niños y mujeres embarazadas, solo tiene
que reportar cambios dentro de 10 días naturales. Todos los demás cambios se reportan la próxima vez que renueve su caso.
MAD 100 Page 10 of 13
9. Aviso de Derechos
CONFIDENCIALIDAD Toda la información que doy a HSD es confidencial. Esta información se dará a los empleados de HSD que la necesitan para
administrar los programas que he solicitado. La información confidencial puede ser revelada a otras agencias federales y estatales. Toda la información
se utilizará para determinar la elegibilidad y / o prestación de servicios. (03/29/12)
SUS DERECHOS CIVILES Todos los programas administrados por el Departamento de Servicios Humanos (HSD) son programas de oportunidades
iguales. Si usted cree que ha sido tratado injustamente debido a la raza, el color, origen nacional, la edad, la incapacidad, y donde aplicable, el sexo, el
estado civil, estatus familiar, estatus paternal, la religión, orientación sexual, información genética, las creencias políticas, la represalia, o porque todo o
la parte de los ingresos de un individuo son derivados de cualquier programa de ayuda estatal, puede presentar una queja. Las quejas de discriminación
se pueden presentar en la oficina central del Departamento de Servicios Humanos de Nuevo México, ATTN: Quality Improvement Section, Pollon Plaza,
P. O. Box 2348, Santa Fe, New Mexico 87504-2348 o en la oficina local de Servicios Humanos de su condado. Las quejas de discriminación sobre el
Programa de Ayuda de Nutrición Suplemental se pueden presentar con el USDA, Director, Office of Adjudication, 1400 Independence Ave. SW,
Washington, DC 20250-9410 o llame 1-866-632-9992 o 202-401-0216 (TDD). Las quejas de discriminación sobre el programa de Asistencia Médica se
pueden presentar con la Office of Civil Rights, Department of Health and Human Services, 1301 Young Street, Suite 1169, Dallas, TX 75202 o llame 1800-368-1019 (voz) o 1-214-767-8940 (TDD). (08/16/11)
SU DERECHO A UNA AUDIENCIA - Usted puede solicitar una audiencia si no está de acuerdo con una decisión HSD ha hecho respecto a su solicitud /
beneficios. Una audiencia le dará la oportunidad de explicar por qué no está de acuerdo. Usted puede solicitar una audiencia de HSD :
 Completando y regresando la parte inferior de un aviso;
 Escribir o llamar a su oficina local de HSD, o
 Escribir a la Oficina de Audiencias del Departamento de Servicios Humanos, P.O. Box 2348, Santa Fe, N.M. 87504-2348, o llamando al 1-800432-6217 (presione 6) o 505-476-6213. (Revised 08/16/11)
 AUDIENCIA del Mercado - Sé que si yo creo que el Mercado de Seguros Médicos ha cometido un error sobre mi elegibilidad, puedo apelar la
acción si contacto al Intercambio de Seguros Médicos al 1-800-318-2596 e informar adecuadamente que creo que su acción debe ser
revisada. Sé que puedo autorizar a otra persona para que me represente en el proceso de apelación.
PLAZO PARA SOLICITAR UNA AUDIENCIA - Usted tiene 90 días a partir de la fecha de este aviso para solicitar una audiencia. Si usted solicita una
audiencia dentro de los 13 días a partir de la fecha de este aviso, usted continuará recibiendo la misma cantidad de beneficios que recibió antes de
llegar a la acción en este aviso. Usted continuará recibiendo estos beneficios hasta que el Departamento decida el caso, a menos que se haga otro
cambio en su caso. Los cambios en los beneficios se pueden hacer después de haber solicitado una audiencia si el motivo del cambio no es el mismo
que el motivo de la audiencia. Si usted pierde la audiencia, tendrá que devolver los beneficios que recibió mientras el Departamento decidió su caso.
(Revised 9/24/02)
EL PROCESO DE AUDIENCIA - Después de pedir una audiencia, el Departamento o el Mercado le enviará una carta informándole la fecha, hora y
lugar donde se realizará la audiencia. La audiencia es por lo general en la oficina del condado HSD. La audiencia será dirigida por un oficial de
audiencias de la Oficina de Audiencias de HSD o del Mercado. Usted o su representante pueden ver su expediente y cualquier prueba que usamos para
decidir su caso. Usted dirá por qué cree que la acción de HSD o del Mercado estaba equivocada. Usted puede presentar testigos y presentar pruebas.
Usted puede cuestionar la oficina del condado o al Mercado acerca de las medidas adoptadas y la prueba presentada. Usted puede representarse a sí
mismo. Usted puede ser representado por un amigo, un familiar o un abogado. Para obtener información sobre dónde puede obtener ayuda legal
gratuita, llame a 1-800-340-9771. Después de la audiencia, el oficial de la audiencia hará un informe. El Director de la División HSD o al Director
Ejecutivo del Mercado decidirá si la acción fue correcta o incorrecta. Después de que el Director decida su caso, se le enviará una carta informándole de
la decisión y por qué se tomó la decisión. (Revised 04/02/03)
MAD 100 Page 11 of 13
Formulario de Cobertura del Empleador
¿Solicita ayuda con los gastos de seguro de salud del Mercado de Seguros Médicos?
La solicitud del Mercado de Seguros Médicos hace preguntas acerca de cualquier cobertura de salud disponible a través de
un trabajo en curso (aunque sea de un trabajo de otra persona, como un padre o cónyuge) para averiguar si es posible que
pueda obtener ayuda para pagar el seguro de salud. Utilice este formulario para obtener la información que necesita del
empleador que ofrece cobertura de salud. Vamos a verificar esta información, así que es importante ser preciso. Si usted
tiene más de un trabajo que ofrece cobertura de salud, use un formulario separado para cada empleador.
Información de Empleado
El empleado debe llenar esta sección. Anote la información del empleado, luego puede solicitar la siguiente información del
empleador. Utilice este formulario completo al llenar una solicitud del mercado de Seguros de Médicos.
Nombre de Empleado (Primer, Medio, Apellido)
Número de Seguro Social
Información del Empleador
Pídale al empleador esta información
Nombre del Empleador
Número de Identificación de Empleador
(EIN)
Dirección del Empleador
Número de Teléfono de Empleador
(
)
–
Estado
Código postal
Ciudad
¿A quién podemos contactar acerca de la cobertura de salud de los empleados en este trabajo?
Nombre:_________________________ Teléfono:________________ Correo Electrónico:___________________
Díganos sobre el plan de salud que ofrece este empleador.

Este empleado no es elegible para la cobertura bajo el plan del empleador.
El empleado es elegible para la cobertura bajo el plan del empleador el ___________________ (Fecha de inicio).
¿Qué es el nombre del plan de salud solo para sí mismo de menos costo que este empleado podría inscribirse en este
trabajo? (Sólo considerar los planes que cumplan con el "estándar de valor mínimo" establecido por la Ley de Cuidado de
Salud A Bajo Precio.)
Nombre:_______________________________________________________
 No hay planes que cumplen con el "estándar de valor mínimo"
¿Cuánto tendría que pagar el empleado en primas correspondientes a ese plan?
$__________ ¿Con qué frecuencia?  Semanal  Cada 2 semanas  2 veces al mes  Mensual  Anual  Otro______
MAD 100 Page 12 of 13
Register to Vote
PERSONAL INFORMATION
NAME: Last
First
Middle Name or Initial
1
PHYSICAL STREET ADDRESS WHERE YOU LIVE NOW
Street Address
Apartment, Unit, or Lot #
Gender
M
This information not to be copied
Birth Date
Social Security Number
City
Zip
2
ADDRESS WHERE YOU GET YOUR MAIL
Address
(If different from above)
City
Zip
Site Code
3
If you are changing your name on this application, under what
Last Name
First Name
Middle Name or Initial
4
full name were you previously registered?
POLITICAL PARTY
POLL WORKER
DAY TIME TELEPHONE NUMBER (Optional)
NOTE: You must name a major
Party
If you choose NO PARTY,
May the County Clerk make this
Would you like to serve
political party to vote in primary
Check this box 
6
telephone number public for
as an election day
Democrat
5
elections.
election purposes?  Yes  No precinct worker?  Yes
I hereby authorize you to cancel my previous
City or Township
County
State
7
registration in the following county and state.
Please answer the following questions:
ATTESTATION OF QUALIFICATION
8
I swear/affirm that I am a citizen of the United States and a resident of
the state of New Mexico; that I have not been denied the right to vote by
a court of law by reason of mental incapacity; that I am, or will be at the
time of the next election, 18 years of age; and if I have been convicted of
a felony, I have completed all conditions of parole and supervised
probation, served the entirety of sentence or have been granted a pardon
by the governor. I further swear/affirm that I am authorizing cancellation
of any prior registration to vote in the jurisdiction of my prior residence;
and that all the information I have provided is correct.
Are you a citizen of the United States? …………………………………  Yes
 No
Will you be 18 years of age on or before election day? ………………  Yes
 No
If you checked “No” to any of the questions above, do not complete this form.
If you have been convicted of a felony and are currently on parole or supervised
probation do not complete this form.
TODAY’S DATE
Month Day Year
______/ ______ /______
SIGN YOUR FULL NAME OR MARK ON THE LINE BELOW:.
Name of agent who assisted you in filling out this form.
VRA ID #
9
DO NOT WRITE IN SHADDED AREAS – FOR OFFICIAL USE ONLY
Accepted for filing in County Registration Records:
___________ / _________________________________ / _________________________________
Date
County Clerk
Filing Clerk
ID
PCT
MUN
SCHOOL CC
PRG DIST
REP
DIST SEN
DIST
HSD Site Code I-
Registrarse para Votar
01
Esta información no se debe copia
INFORMACIÓN PERSONAL
NOMBRE: Apellido
Primer Nombre
Medio Nombre o Inicial
Género
Fecha de Nacimiento
Número de Seguro Social
1
H
DIRECCIÓN DONDE UD. VIVE AHORA
Número y Nombre de la Calle
Departamento, Unidad o # de Lote
Ciudad
Zona Postal
2
DIRECCIÓN DONDE UD. RECIBE SU CORRESPONDENCIA (Si es diferente del anterior)
Dirección
Ciudad
Zona Postal
Site Code
3
¿Si Ud. Va cambiar su nombre en esta solicitud, bajo que
Apellido
Primer Nombre
Medio Nombre o Inicial
nombre completo estaba Ud. Matriculado antes?
4
EMPLEADO / A EN URNA ELECTORAL
PARTIDO POLÍTICO
NUMERO DE TELÉFONO EN EL DÍA (Opcional)
AVISO: Ud. tiene que indicar Partido
Si Ud. NO ELIGE
¿Puede el Secretario del
¿Quiere Ud. trabajar en recinto
5
partido politico principal para
Partido marque aquí 
electoral el día de la elección?
6 Condado hacer público este
votar en la elección primaria
núm. de teléfono para fines
 Si
Democrata
electorales ?  Sí  No
Por la presente autorizo que Ud. cancele mi matrícula
Ciudad o División
Condado
Estado
7
previa en el condado y estado a continuación.
Favor de contestar las preguntas a continuación:
TESTIMONIO DE CALIFICACIÓN
Ud. ciudadano / a de los Estados Unidos? ……………….……  Sí  No
¿Habrá cumplido Ud. 18 años en o antes del día de la elección?  Sí  No
Si Ud. marcó “NO” en cualquiera de las preguntas más arriba no termine de
rellenar este formulario.
Si usted fue condenado de un delito grave y actualmente está en libertad
condicional o probación supervisada, no llene esta forma.
¿Es
8
FECHA DE HOY:
Mes
Día
Año
______/______ /______
9
Nombre de la persona que le ayudó a llenar este formulario:
Yo juro/afirmo que soy ciudadano de los Estados Unidos y residente del
Estado de Nuevo México; que la corte no me ha denegado el derecho de votar
por motivo de incapacidad psicológica; que tengo o tendré 18 años de edad en
la fecha de la próxima elección y si he sido condenado de delito grave he
cumplido todas las condiciones de libertad a prueba o el gobernador me ha
concedido indulto. Además, juro o afirmo que autorizo la cancelación de toda
matrícula anterior con el fin de votar en el territorio de mi residencia previa; y
que la información proveída está correcta.
FIRME SU NOMBRE COMPLETO O MARQUE LA LÍNEA ABAJO:
VRA ID #
NO ESCRIBA EN LOS ESPACIOS EN COLOR GRIS – SOLO PARA USO OFICIAL (FOR OFFICIAL USE ONLY)
ID
PCT
MUN
PRG DIST
REP
DIST SEN
Accepted for filing in County Registration Records
SCHOOL
CC
________ / ______________________________ / _____________________________
Date
County Clerk
Filing Clerk
DIST
ISDB 720 Issued 3/5/12
MAD 100 Page 13 of 13
PRESUMPTIVE ELIGIBILITY (PE)
APPLICANT INFORMATION FORM
Person Supplying Information on Behalf of Applicants and/or Household Members Listed Below
First Name
Middle
Last
Home Address
City
State
Zip
Phone
Email
State
Zip
Mailing Address (if different than above)
Address
City
Family Members in the Household
US Citizen,
Relationship
Name
(First, Middle, Last)
Applying
For PE?
Y
Y
Y
Y
Y
Y
Y
Y
to Person
Supplying
Information
Date of
Birth
N
N
N
N
N
N
N
N
SSN
(not required)
US National or
Eligible
Immigrant?
(not required)
Living in
New
Mexico?
Pregnant?
Receiving
Income
from
Work or
Job?
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
How
Often?
Enrolled in
Medicaid or
Medicare?
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
Other Household Income per Month (before taxes):
By signing below, you are swearing that all information you have
supplied for the completing of this Presumptive Eligibility
application is true and correct to the best of your knowledge.
DO Include: Unemployment, Alimony, and Disability from the Social Security Administration
DO NOT Include: SSI Payments, or Child Support Received
All information supplied will be kept secure and private.
Total Household Job Income per Month (before taxes):
MAD 011 Revised 5/2/14
Signature of Person Supplying Info on Behalf of This Household
FORMULARIO DE INFORMACIÓN PARA LA SOLICITUD DE
PROBABLE ELIGIBILIDAD (SIGLAS EN INGLÉS: PE)
Persona que proporciona la información en nombre del solicitante y/o los miembros de su familia que figuran más abajo
Nombre
Apellido
Domicilio
Ciudad
Teléfono
Correo Electrónico
Estado
Código Postal
Estado
Código Postal
Dirección Postal (si es diferente a la de arriba)
Dirección
Ciudad
Miembros que componen la familia
¿Ciudadano
de EE.UU,
Relación
Nombre y Apellido
Solicitar
PE?
Con la persona
que
proporciona la
información
Fecha de
Nacimiento
SI
N
SI
N
SI
N
SI
N
SI
N
SI
N
SI
N
SI
N
Total del Ingreso de la Familia por mes (antes de impuestos):
Número
de Seguro
Social
Residente de
EE.UU o
Inmigrante
Elegible?
(no necesario)
(no necesario)
¿Reside en
el Estado
de Nuevo
México?
¿Embarazada?
¿Recibe un
ingreso de
un
trabajo?
SI
SI
SI
SI
SI
SI
SI
SI
SI
SI
SI
SI
SI
SI
SI
SI
SI
SI
SI
SI
SI
SI
SI
SI
SI
SI
SI
SI
SI
SI
SI
SI
N
N
N
N
N
N
N
N
Otro Ingreso de la Familia por mes (antes de impuestos):
POR FAVOR, incluir: Desempleo, Pensiones Alimenticias, y Incapacidad de la Administración de Seguro Social
NO incluya: Pagos SSI o Manutención de niños
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
¿Cada
cuánto
tiempo?
N
N
N
N
N
N
N
N
¿Está
registrado
en
Medicaid o
Medicare?
SI
SI
SI
SI
SI
SI
SI
SI
Al firmar abajo, Ud. jura que la información proporcionada al
completar esta solicitud es verdadera y correcta según sus
conocimientos.
Toda la información proporcionada es confidencial y privada..
MAD 011 Revised 5/2/14
Firma de la persona solicitando en favor de su famila
N
N
N
N
N
N
N
N
MEDICAID
PRESUMPTIVE ELIGIBILITY
AUTHORIZATION
Determiner Name:
Determiner Fax Number:
1-877-285-6790
Fax this form to:
PE Determiner: List ONLY the individuals who are Eligible for PE. Type all information directly into this form. The PE eligibility End Date is the last day of the month following the PE
approval. If an application for ongoing Medicaid eligibility is submitted by the PE Eligibility End Date, the PE will remain in effect until a final application determination has been made.
FOR FISCAL
AGENT USE
ONLY
ALL SPACES MUST BE COMPLETED
NAME – Last, First, Middle
Race
Sex
Date of
Birth
Social Security
Number
Geo/
Adm
MCO
Choice
Children's
Cat.
(select one)
Adult
Cat.
(select one)
Eligibility
Begin
Date
End
Date
MAILING ADDRESS – Street, PO Box R. Rte.
None Select One Select One
Select
City, State, Zip
Added
Eligibility
YES
NO
FOR FISCAL
AGENT USE
ONLY
ALL SPACES MUST BE COMPLETED
NAME – Last, First, Middle
Race
Sex
Date of
Birth
Social Security
Number
Geo/
Adm
MCO
Choice
Children's
Cat.
(select one)
Adult
Cat.
(select one)
Eligibility
Begin
Date
End
Date
MAILING ADDRESS – Street, PO Box R. Rte.
Added
Eligibility
YES
NO
None Select One Select One
Select
City, State, Zip
FOR FISCAL
AGENT USE
ONLY
ALL SPACES MUST BE COMPLETED
NAME – Last, First, Middle
Race
Sex
Date of
Birth
Social Security
Number
Geo/
Adm
MCO
Choice
Children's
Cat.
(select one)
Adult
Cat.
(select one)
MAILING ADDRESS – Street, PO Box R. Rte.
Eligibility
Begin
Date
End
Date
Added
Eligibility
YES
Select
None Select One Select One
City, State, Zip
TO BE COMPLETED BY PE DETERMINER
PE Determiner Name
PE Determiner’s Signature
PE Determiner’s Number
PE Determiner Phone Number
PE Determiner’s Agency
Agency’s Business Address
Determiner’s Fax Number:
Determiner’s E-Mail:
Agency’s Phone Number:
Date
Determiner’s Comments:
Fiscal Agent’s Comments:
MAD 070 Revised 3/6/14
Medicaid Fiscal Agent Staff
Date
NO
How tto determine aa houseehold sizze Start Here Does the Indiviidual pect to file taaxes? exp
YES
Y
Does the individual expect to b
be claimed as a tax de
ependent by anyone else?
N
o YES Does tthe individuaal meet anyy of the folloowing Exceptions?
? Does the Indiviidual expect to be claaimed as a
a tax depend
dent? N
o No
YES Does the D
In
ndividual exp
pect to be claim
med as a tax dep
pendent by so
omeone ou
utside the home? Y
E
S
Thee Household with no
o tax filing status cconsists of th
he in
ndividual and
d, if lliving with th
he individual……
….. ‐Expectts to be claim
med as a tax dep
pendent of ssomeone other than a spouuse or a parent.
No
‐A child (under age 19) living with bo
oth parents,, but the paren
nts won’t filee a joint return. ‐ A child
d (under agee 19) who expectts to be claim
med by a non‐‐custodial paarent. YYES
Th
he Indiviiduals spouse; Th e individuals natuural, adopteed, andd step childreen undder the age o
of 19.
The Hou
usehold con
nsists of the Taxpayer, a spousee living with the payer, and all taxp
perso
ons whom th
he taxpaayer expects to claaim as a tax depend
dent. A pregn
nant woman is counted
d as herself plus the num
mber of ch
hildren she iis expeccted to deliver. No The Houssehold is of a taxpayeer, claiming him/her as a dependent, and all peersons whom the taxpayyer expects to claim as a taax dependent. ‐A pregnaant woman is counted as herself and the numbeer of children she is exxpected to deeliver. ‐If the in
ndividual is married an
nd living with the spouse, the d includes the Household
spouse. A pregn
nant woman
n is countted as herself and thee number off child
dren she is expecteed to deliverr.
In the
e case of individuals undder age 19; th
he household includes tthe individuaal’s parents aand natural, adopted, an
nd step‐siblings under age 19. HOUSEHOLD SIZE AND
INCOME CALCULATION WORKSHEET
STEP 1: Identify the Head of
Household (HOH) and who
is part of that household
STEP 2:
Identify
individual’s
relationship
to Head of
Household
Individuals in Household
Relationship
STEP 3:
Identify
individual’s
income
Monthly
Gross Income
STEP 4: Identify
individual’s tax
status
Tax Filer,
Dependent,
Non-Filer
STEP 5: Refer to “How to Determine a Household
Size” flow chart and mark a ”1” if the individual
is included in the budget group
HOH
Ind. 2
Ind. 3
Ind. 4
Ind. 5
Ind. 6
STEP 6: List the
number of unborn
children for all
pregnant women
included in the
Budget Group
STEP 7: Add number
of individuals in
Budget Group (Add
figures in STEP 5 to
figure in STEP 6)
Number of Unborn
Children
Total Individuals in
Budget Group
HOH
SELF
0
Ind. 2
0
Ind. 3
0
Ind. 4
0
Ind. 5
0
Ind. 6
0
STEP 8: List all individuals
requesting assistance
STEP 9: List
individual’s
age
Name
Age
STEP 10: List
household Budget
Group size from
STEP 7
STEP 11: Add monthly gross
income for each individual
included in the
household/Budget Group
STEP 12: Refer to the
MAD 222 to determine
the category of eligibility
Household Size
(Budget Group)
Total Monthly Gross
Income for Budget Group*
Medicaid
Category of Eligibility**
STEP 13: Apply
disregard if
applicable
Subtract 5%
Disregard
(if applicable)
STEP 14: Subtract disregard
from total monthly gross
income based on household
size (if applicable)
Total Monthly Gross Income
for Budget Group with 5%
Disregard (if Applicable)
0
0
0
0
0
0
MAD 008 Revised 6/25/14
*Subtract Federal Pre-Tax Deductions (dependent care accounts, health insurance premiums, flexible
spending accounts, retirement accounts and/or commuter expenses) from Monthly Gross Income.
** Refer to MAD 222 for Categories of Eligibility and income guidelines.
Manual Presumptive Eligibility Submission Checklist
For Applicants Who Wish to Apply for Ongoing Medicaid Coverage
If applicant is PE eligible and submitting an application for ongoing Medicaid coverage:
FAX:
 Presumptive Eligibility Authorization Form (MAD 070; Rev 3/6/14)
to Xerox: 877-285-6790
AND
FAX:
 Presumptive Eligibility Authorization Form (MAD 070; Rev 3/6/14);
 NM Medicaid-Only Application (MAD 100; Rev 1/21/14);
 Household Comp and Income Calculation Worksheet (MAD 008) and
 Any proofs of income, citizenship & identity the applicant may have supplied
to Central ASPEN Scanning Area (CASA): 855-804-8960
___________________________________________________________________________
If applicant is NOT PE eligible but wishes to submit an application for ongoing Medicaid
coverage:
FAX:
 NM Medicaid-Only Application (MAD 100; Rev 1/21/14);
 Household Comp and Income Calculation Worksheet (MAD 008) and
 Any proofs of income, citizenship & identity the applicant may have supplied
to Central ASPEN Scanning Area (CASA): 855-804-8960
____________________________________________________________________________
Manual Presumptive Eligibility Submission Checklist
For Applicants Who DO NOT Wish to Apply for Ongoing Medicaid Coverage
If applicant is PE eligible but is NOT submitting an application for ongoing Medicaid
FAX:
 Presumptive Eligibility Authorization Form (MAD 070; Rev 3/6/14)
to Xerox: 877-285-6790
AND
FAX:
 Presumptive Eligibility Authorization Form (MAD 070; Rev 3/6/14)
 Presumptive Eligibility Applicant Information Form (MAD 011);
 Household Comp and Income Calculation Worksheet (MAD 008)
 Any proofs of income, citizenship & identity the applicant may have supplied
to MAD PE Program Staff: 505-827-7200
_____________________________________________________________________________
If applicant is NOT PE eligible and NOT submitting an application for ongoing Medicaid
FAX:
 Presumptive Eligibility Applicant Information Form (MAD 011);
 Household Comp and Income Calculation Worksheet (MAD 008)
 Any proofs of income, citizenship & identity the applicant may have supplied
to MAD PE Program Staff: 505-827-7200