2. Jeanelle Romero
PE Program Manager

3. NM Medicaid PE Program JUST Health System & Customer Service Updates
HSD Forms & Applications

4. Presumptive Eligibility (PE)
Short-term Medicaid coverage for eligible individuals
Provides access to immediate coverage to eligible recipients
Ensures assistance with submitting an application for possible ongoing Medicaid coverage
Based on self-attestation
MAD Certified PEDs determine eligibility
If screened correctly, applicant will most likely be approved for ongoing Medicaid coverage
Individuals may only receive one PE approval in a 12 month period (or one PE per pregnancy)

5. Presumptive Eligibility (PE) coverage
Begins on the day the PE is granted by PED
Retroactive coverage not available during PE span
Ends on the last day of the following month unless ongoing Medicaid application is submitted
PE will continue until final determination has been made for ongoing eligibility
PE coverage ends on the last day of the month that final determination is made
If more information is needed to determine ongoing eligibility, ISD will send a Help Us Make A Decision (HUMAD) form to client
Client must supply information within the timeframe specified on the HUMAD

6. Presumptive Eligibility Determiners (PEDs)
PEDs are employees of participating hospitals, clinics, FQHCs, DOH, schools, IHS providers, jails, prisons and community organizations
Two types of PEDs
170 – Determine PE for Children and pregnant women (clinics, FQHCs, DOH, CYFD, schools and community organizations)
171 – Determine PE for children and pregnant women but also for COEs 100 & 200 (employees of hospitals, IHS facilities and prisons and jails)

7. PE Program Trainings PED Certification Trainings
Second Tuesday of the month – full day webinar 8:30am to 4:30pm
PED Certification Trainings for Jails\Prisons
Two-day training at one of our HSD training labs – trainings conducted at request
YESNM-PE Demos
YES Fridays: 3rd Friday of each month

8. PE Program Tools NM Medicaid Web Portal YESNM-PE
Used to check Medicaid eligibility
YESNM-PE
Used exclusively by certified PEDs
Allows PEDs to screen, grant PE and submit ongoing Medicaid applications
After YESNM-PE screening, if PE is granted, there is a direct data feed from YESNM-PE to ASPEN
PED is notified immediately of applicant’s MCO enrollment
If applicant is not immediately enrolled with an MCO, a task is generated for our PE Processors to work
Our PEDs are getting the job done! Screening effectively for ongoing eligibility via YESNM-PE and submitting an app for ongoing coverage AND that is the ultimate goal.

9. YESNM-PE Check Client Benefits
Click “Check Clients’ Benefits; Takes you to Linking Account page.
Enter the SSN or ASPEN ID of the individual who want to view Medicaid benefits for.
**Reminder, you will only be able to view Medicaid benefits**

10. YESNM-PE Check Client Benefits
After you successfully link to the client’s account, you will see their account information, the status of the case, current client contact information (mailing address, phone number), authorized representative (if one exits on case); and if any HUMADs have been sent with details on what has been requested.
Click on “Learn More”

11. YESNM-PE Check Client Benefits
You will be able to review 3 months of potential benefit issuance.
If you click on the hyperlink In this example, the client is not receiving any Medicaid benefits for the month of February 2018, March 2018 and or April 2018.
We are still waiting for proof of income to be received.

12. YESNM-PE Check Client Benefits
You can see if an individual has been sent a HUMAD, what the HUMAD is requesting, when the HUMAD was sent and when it’s due. If you are able to get the requested documents from the client, you can upload them directly into client’s case through YESNM-PE by clicking “upload”.

13. YESNM-PE Check Client Benefits
This individual has been approved for Medicaid. When viewing eligibility, the client’s status will always show for the current month.
This screen shot shows the individual is getting Medicaid for March To get more details on that eligibility you would click “Learn More”
The next screen will give you benefit details like the COE the client is receiving and the MCO. In this scenario the client has MAGI for Adults and the client is enrolled with United Health Care.

14. JUST Health
Justice-Involved Utilization of State Transitioned Healthcare
HSD enters into an agreement with agency/county for data sharing
HSD receives daily interface with correctional facilities to suspend rather than close Medicaid eligibility for individuals defined as inmates (per NMAC)
Release information sent to HSD to reinstate benefits upon release
JUST Health implemented June, 2016 with NMCD; other entities phased in

15. JUST Health Program Numbers
Currently participating counties/agencies:
CY 2017
7,324 suspensions; 5,876 reinstatements
128 Presumptive Eligibility determinations
3,285 ongoing applications filed
3,005 ongoing application approved
New Mexico Department of Corrections (all facilities)
San Juan County
Bernalillo County
Sandoval County
Children Youth and Families Department (juvenile justice facilities)
Santa Fe County
Dona Ana County
New Mexico Department of Health -Forensic Unit
Rio Arriba County

16. 11/15/2018
Suspended Benefits
The suspension will be viewable in the New Mexico Medicaid Portal with the original Category of Eligibility (COE) the individual is eligible for.
Suspensions in the Portal
The example shows the suspension effective 04/02/2017 – meaning that the individual had been incarcerated for more than 30 days so the Booking date for this individual is 03/03/2017.
Now in this example, we can also see that the suspension was from 4/2/17 through 8/31/ Well, we’re in October, so this individual’s suspension has ended meaning he has been released from incarceration. If the individual were still in a suspended status, the date 8/31/2017 would instead show today’s date, meaning they are currently suspended as of today.

17. Suspended Benefits MCO Enrollments
11/15/2018
Suspended Benefits MCO Enrollments
Another way you’ll see when an individual has been or is currently Suspended is by looking at their MCO enrollment information. Here you can see this individual was enrolled in BCBS from 8/1/16 through 3/31/2017 when their benefits were suspended due to being incarcerated for more then 30 days. But now you can see that coverage began again 9/1/17 and is currently ongoing. This means the individual was released, and their benefits resumed.

18. Short Term Medicaid for Incarcerated Individuals (STMII) Program
11/15/2018
Short Term Medicaid for Incarcerated Individuals (STMII) Program
The incarcerated individual must be approved for Medicaid and have benefits suspended for services to be covered under STMII program
STMII claims may only be Medicaid-covered services for inpatient hospital stays of 24 hours or more
STMII claims: the individual may be eligible for STMII multiple times a year
STMII is only covered for correctional facilities that have a GSA contract with HSD
contact MAD PE Program Staff for STMII questions
Regular PEDs don’t grant PE or submit app for Incarcerated individuals.
This is only for those who are contracted. HSD will not pay for STMII claims for individuals who are incarcerated in a facility that is not contracted with HSD.

19. JUST Health New Counties
Next Phase “Live” Spring/Summer, 2018
Chaves County
Curry County
Eddy County
Roosevelt County
Quay County
Discussions have occurred; verbal commitment for counties; MOA in process

20. PE Program Numbers January – December, 2017
Access to YESNM-PE is ONLY available to certified PEDs
635 Current PEDs statewide
PE Type 170:
PE Type 171:
2,661 PEs Granted in 2017
2,593 PEs (or 97%) of all PEs granted had an ongoing Medicaid application submitted
23,519 individuals have been assisted with Medicaid applications through YESNM-PE
19,981 individuals (84.96%) were approved for ongoing Medicaid
YESNM-PE utilized for PE screening and application submission; Number of PEDs includes correctional facility-based PED

21. NM Systems & Customer Service Updates
System Updates:
November through December 2017 – Expanded Conduent Call Center to assist with ISD Customer Service Center calls
Medicaid Call Center
ISD Customer Service
December 2017 – Movement of Medicaid enrollment functions to ASPEN
PE approvals feed directly into ASPEN instead of Omnicaid

22. NM Systems & Customer Service Updates
Medicaid ID Cards
Hard-plastic, blue Medicaid ID Card no longer issued
FFS clients
Receive heavy-weight paper version of card
Request replacement cards through YESNM or the Conduent Call Center
Managed Care enrollees
Only receive MCO-issued cards
Request replacement cards directly from MCOs

23. HSD Forms & Applications
PED & Provider Forms
Current forms should always be utilized
Most up to date versions of forms on the NM Medicaid Web Portal:

24. Applications & Information for Clients
YESNM
Apply for benefits
Renew Benefits
Request Change of MCO (if in allowable switch period)
FFS Clients may Request Replacement Medicaid ID card
HSD Paper Applications
MAD 100 (Medicaid Only Application)
HSD 100 (All HSD Programs)
Available on the HSD web site benefits.aspx

25. PED & JUST Health Information
Request YES-NM demo session schedules
Request PED Training session schedules
For information on PED enrollment status
Questions regarding JUST Health

26. Opt In/Out of MCO Enrollment
Conduent Call Center
HSD/MAD/CEB
Armando Muñoz
Orlando Vasquez

27. MAD/CEB PE Program Staff
PE Program Unit
Jeanelle Romero – PE Program Unit Manager
Vanessa Medina – PE Program Trainer\Auditor
Edmundo Barraza – Enrollment\Reporting Specialist
Roberta Roybal – Enrollment Specialist
Pam Champion – PE Program Auditor
Kimberly Lucero – Application Processing Manager
Esli Ornelas- Application Processor
Elaine Martinez- Application Processor
Carol Baca – Application Processor

28. Questions?