1. A. Medical management eligibility: To be eligible for medical management through CMS an applicant must meet all of the following requirements:

   (1) the applicant must be a resident of NM;

   (2) the applicant must be financially eligible; (income below 200% of the federal poverty level). CMS is always the payor of last resort; any and all third party payments must be fully utilized before CMS payments are made; clients who have two or more other payor sources such as insurance, medicare, etc., do not meet financial eligibility for payment by the children’s medical services program; and

   (3) the applicant must be medically eligible as defined in the medical index and the treatment protocols and guidelines adopted by the children’s medical services program, and as determined by the medical director.

2. B. Adult cystic fibrosis eligibility: To be eligible for medical coverage and care coordination services through the adult cystic fibrosis program, an applicant must meet all of the following requirements:

   (1) the applicant must be 21 years of age or older;

   (2) the applicant must be diagnosed as having cystic fibrosis by pilocarpine iontophoresis or by genetic studies;

   (3) the applicant must be a resident of NM; and

   (4) the applicant must meet financial eligibility criteria (income below 200% of the federal poverty level); CMS is always the payor of last resort; any and all third party payments must be fully utilized before CMS payments are made; clients who have two or more other payor sources such as insurance, medicare, etc., do not meet financial eligibility for payment by the children’s medical services program.

3. C. Clinic only eligibility: To be eligible for clinic services, an applicant must meet the following requirements:

   (1) the applicant must be under 21 years of age, except for metabolic clinics where applicant may be any age;

   (2) the applicant must be a resident of NM; and

   (3) the applicant must be referred by a physician, physician’s assistant, or pediatric nurse practitioner.

4. D. No fee for clinic: There is no charge for the children’s medical service sponsored clinic, however, there may be a charge for tests ordered by physicians and completed outside of the clinics. Third party payment will be sought if available.
5. E. Care coordination only eligibility: To the extent resources are available, care coordination shall be provided for any child with special health care needs, adult with cystic fibrosis, or individual at risk of having a child with special needs, regardless of income.

[7.30.3.8 NMAC - Rp, 7 NMAC 30.3.8, 10/30/12]