New Mexico

New Mexico’s Medicaid program is currently in transition.

  • Before January 2014, physical and oral health services were provided to almost all categories of Medicaid-enrolled children and adults in the state through comprehensive managed care organizations (MCOs) under a 1915(b) waiver program known as Salud! There were a total of 551,017 beneficiaries enrolled in New Mexico Medicaid as of July 2011. Of these 401,318  were enrolled in MCOs. Some subpopulations were excluded, such as American Indian/Alaska Natives (though this group had the choice to opt in) and children in out-of-state foster care or adoption placement.
  • Behavioral health services were delivered through a pre-paid inpatient health plan (PIHP). 374,013 beneficiaries received services through the state’s PIHP. The PIHP served the same populations as the MCOs.
  • The state has received approval for an 1115 Demonstration waiver to implement Centennial Care beginning in January 2014. Under this program, four managed care organizations will provide physical health, behavioral health, long-term care and community benefits.

As of 2012, 380,612 individuals (aged 0-20) were eligible for New Mexico’s Medicaid benefit for children and adolescents (also known as the Early Periodic Screening, Diagnostic and Treatment benefit, or EPSDT) benefit. According to CMS data from 2012, New Mexico achieved a screening ratio of 79% and a participation ratio of 60%. 189,863 children received dental services, with 176,185 receiving preventive dental services.

Last updated December 2013.

Medical Necessity
In New Mexico, medically necessary services are defined in regulation as clinical and rehabilitative physical or behavioral health services that:
  • Are essential to prevent, diagnose or treat medical conditions or are essential to enable the individual to attain, maintain or regain functional capacity;
  • Are delivered in the amount, duration, scope and setting that is clinically appropriate to the specific physical, mental and behavioral health care needs of the individual;
  • Are provided within professionally accepted standards of practice and national guidelines; and
  • Are required to meet the physical and behavioral health needs of the individual and are not primarily for the convenience of the individual, the provider or the payer”

The state does not have distinct definitions for children, oral health services, or behavioral health services.

Initiatives to Improve Access
The Human Services Department (home to Medicaid) is a partner in a children’s health care quality initiative spearheaded by the University of New Mexico, Envision New Mexico, that includes telehealth programs linking pediatric sub-specialists at the university with primary care providers throughout the state.
Reporting & Data Collection

The New Mexico Human Services Department (HSD) completes the CMS Form-416, using encounter data submitted by managed care organizations (MCOs) and the state’s fee-for-service third party administrator. Managed care organizations in the state transmit encounter data to the HSD electronically on a weekly basis. Data and system requirements for Medicaid managed care organizations are laid out in a MCO/CSP Systems Manual. The state’s Medicaid Management Information Systems edits the incoming data: the system verifies the validity of the recipient, as well as the validity of the diagnosis and the procedure. Data from fee-for-service claims and from managed care encounter data is housed together in the same database. However, each claim is marked as fee-for-service or managed care inside the data warehouse and tagged with information identifying the specific managed care organization that submitted it.

New managed care contracts under Centennial Care require that MCOs use the most recent version of the CAHPS Adult and Child Survey Instruments, including the Children with Chronic Conditions to assess member satisfaction as part of Health Effectiveness Data and Information Set (HEDIS) reporting requirements and report on them to the Human Services Department. The contracts also include performance measures that pertain to Medicaid services for children, such as a measure of the percentage of members ages 5-11 and 12-18 who are identified as having persistent asthma and who were appropriately prescribed medication during the measurement year.

Behavioral Health


New Mexico permits pediatricians to bill for developmental/behavioral screening at the 30-month well child visit.  Physicians may bill for use of a validated screening tool using the 96110 code, in addition to a well child code on the same day.

The state’s Medicaid periodicity schedule and preventive services guidance for children is based on the American Academy of Pediatrics’ Bright Futures guidelines, which recommend the following screening tools: Pediatric Symptom Checklist, Strengths and Difficulties Questionnaire, Checklist for Autism in Toddlers, Modified Checklist for Autism in Toddlers, and the CRAFFT (Car, Relax, Alone, Forget, Friends, Trouble) Screening Questionnaires for substance abuse.

Cross-agency treatment options

In 2004 New Mexico created the Behavioral Health Purchasing Collaborative to coordinate resources being used for behavioral health prevention, treatment and recovery. While 15 state agencies are participate in the Collaborative, funds are contributed primarily by five agencies: the Human Services Department Medical Assistance Division (Medicaid); the Behavioral Health Services Division; the Children, Youth and Families Department; the Corrections Department; and the Department of Health. Funding from these agencies is combined, but managed separately to ensure compliance with reporting and other requirements.

Braided behavioral health funding allows the state to integrate and coordinate services: children have coordinated access to services funded by Medicaid as well as other state agencies.  In addition, children with serious needs can access Comprehensive Community Support Services through the state’s system of Core Service Agencies (CSAs).

CSAs are typically Community Mental Health Centers that are enrolled as Medicaid providers and licensed by the Children, Youth and Families Department. They are responsible for coordinating a wraparound planning process that connects families to providers and resources in the local community necessary to implement an individualized plan of care. The CSAs serve as a single point of contact and entry to the state’s behavioral health system for children with serious behavioral health needs, including children with substance abuse or juvenile justice involvement. Medicaid managed care contracts require managed care organizations to make best efforts to contract with entities designated as CSAs.

Support to Providers and Families

Managed care contracts and a draft quality strategy for Centennial Care, the state’s new managed care program, require that managed care organizations provide member handbooks that include information on how to access services under the EPSDT benefit, including dental services, non-emergency transportation, and behavioral health services.

The Medicaid agency’s website has an overview of the children’s benefit that includes anticipatory guidance (in English and Spanish), as well as preventive health guidelines.

Each of the four MCOs participating in Centennial care is providing training to providers on Medicaid benefits.

Care Coordination

In 2009, New Mexico enacted Chapter 143 of the 2009 Laws, intended to provide medical homes for members of the state’s Medicaid, Children’s Health Insurance Program (CHIP), and State Coverage Initiative (SCI) program (SCI is a public-private managed care program in New Mexico that targets low-income adults without insurance working for small employers).  The statute directed the New Mexico Human Services Department to apply for a waiver or state plan amendment to implement a medical home program, and to work with managed care contractors to “promote, and if practicable, develop” a medical home program.

In amendments to the state’s MCO contracts that took effect in July of 2009, HSD encouraged the development of Patient-Centered Medical Homes (PCMH) via financial assistance to select provider groups to begin the PCMH certification process. New managed care contracts under Centennial Care also require MCOs to establish patient-centered medical home initiatives.

Managed care contracts also require that Medicaid MCOs work with the Child, Youth and Families Department (CYFD) to coordinate services with CYPD Protective Services, Family Services, and Juvenile Justice Services divisions.

Oral Health
Managed care organization performance measures under Centennial Care include a measure of the percentage of enrolled members ages 2-21 who have at least one dental visit during the year.