This rule was filed as 7 NMAC 30.3.

TITLE 7 HEALTH

CHAPTER 30 FAMILY AND CHILDREN HEALTH CARE SERVICES

PART 3 CHILDREN’S MEDICAL SERVICES AND ADULT CYSTIC FIBROSIS

7.30.3.1 ISSUING AGENCY: The Department of Health.

[1937...10/31/96; Recompiled 10/31/01]

7.30.3.2 SCOPE: General public.

[1937...10/31/96; Recompiled 10/31/01]

7.30.3.3 STATUTORY AUTHORITY: The regulations set forth herein are promulgated by the secretary of department of health by authority of Section 9-7-6 (E) and (F) NMSA 1978 and Section 24-2-1 NMSA 1978. Administration and enforcement of these regulations is the responsibility of the public health division of the department of health.

[3/17/19...11/17/81, 10/31/96; Recompiled 10/31/01]

7.30.3.4 DURATION: Permanent.

[10/31/96; Recompiled 10/31/01]

7.30.3.5 EFFECTIVE DATE: October 31, 1996 unless a later date is cited at the end of the paragraph.

[10/31/96; Recompiled 10/31/01]

[Compiler’s note: The words or paragraph, above, are no longer applicable. Later dates are now cited only at the end of sections, in the history notes appearing in brackets.]

7.30.3.6 OBJECTIVE: It is the purpose of the children’s medical services program to maximize the health and well being of New Mexico’s children with or at risk for chronic illness or disability under the age of 21 years and adults with cystic fibrosis by assuring that community-based, coordinated, culturally competent, family-centered preventive, diagnostic, treatment and family support services are accessible.

[9/14/76...10/31/96; Recompiled 10/31/01]

7.30.3.7 DEFINITIONS:

A. “Children’s medical services program” (CMS) activities include the following:

(1) early identification of children with, or at risk for having, special health care needs (CSHCN);

(2) early identification of individuals at risk of having children with special health care needs;

(3) the provision of preventive, diagnostic, treatment services and service coordination toward the attainment of maximum health for children with special health care needs;

(4) promotion of the development of quality health care and outcome measures for this population (children with special health care needs);

(5) monitoring these outcomes and the impact of changes in the health care system for this population;

(6) technical assistance and training for individuals serving this population;

(7) administration of the universal newborn hearing screening program (hear early); children’s chronic conditions registry (CCCR), co-administration of the birth defects prevention and surveillance system (BDPASS), and other necessary administrative services to assess the needs of this population, facilitate access to care, and provide services.

B. “Application” means the written request, on forms prescribed by the division, for enrollment, and provision of supportive documentation of residence, income, age, and medical diagnosis for eligibility determination under children’s medical services program.

C. “Assets” means savings accounts, stocks and bonds, checking accounts, accessible trust funds, real property. Assets do not include loans which need to be repaid, or homestead, acreage used for the production of income if this is the primary source of income, personal property that is used in the production of income if related to the primary source of income.

D. “Child” means a person below the age of twenty-one (21).

E. “Children’s medical services program” means the children’s medical services program unit of the public health division.

F. “Client” means the individual who is applying for or receiving children’s medical services and includes his family or the person legally responsible for his care.

G. “Consultant” means a professional licensed by the appropriate specialty board, such as audiology, ophthalmology, orthodontia, speech or psychology consultant who provides statements of eligibility and approves care plans within the specialty area.

H. “Date of referral” means the calendar date a child or adult in need of services was made known by telephone, mail, written referral or application to a representative of the children’s medical services program.

I. “Department” means the New Mexico department of health.

J. “Diagnostic services” means the provision of professional services for an eligible client to obtain a diagnosis for a complaint within the medical diagnostic categories established for service pursuant to the medical index.

K. “Division” means the public health division of the New Mexico department of health, Post Office Box 26110, Santa Fe, New Mexico 87504-6110.

L. “Eligible individual” means an individual below the age of twenty-one (21) who has or is at increased risk for chronic physical, developmental, behavioral, or emotional conditions and who requires health and related services of a type or amount beyond that required by children generally; an adult with cystic fibrosis; or an individual of any age at risk of having a child with special needs.

M. “Eligibility for clinic only” means eligibility only for services at any specialty clinics sponsored by the children’s medical services program.

N. “Eligibility for the family, infant and toddler program” means eligibility for individuals with Disabilities Education Act, Part H service coordination as defined by the early childhood program of the developmental disabilities division of the department of health, and the state department of education.

O. “Eligibility for medical management” means eligibility for purchase of health care services approved by the children’s medical services program and payment of expenses related to medical care such as lodging, meals and transportation as outlined in the service plan and approved by the children’s medical services program.

P. “Eligibility for service coordination only” means eligibility only for service coordination services as defined in section 7.32 [now Subsection FF of 7.30.3.7 NMAC].

Q. “Enrollment” means a statement, on forms prescribed by the division and signed by the client accepting services and acknowledging that acceptance of these services does not restrict eligibility for any other benefits or services.

R. “Expenditure” means authorization of funds and payment for services to healthcare professionals, institutions and others for eligible individuals.

S. “Financial eligibility” means those clients whose household income is below two hundred percent of the federal poverty guidelines which are published annually.

T. “Health” means a state of physical and mental well-being, not merely the absence of disease.

U. “Household” means those who dwell under the same roof and are related by blood or marriage, excluding those who constitute separate economic units as determined by the service coordinator and documented in the case record.

V. “Income” means earned and non-earned gross income of all persons who reside in the household of the client and have financial responsibility for the client, and any contributions to the household from non-household members with financial responsibility. Irregular and unpredictable contributions in insignificant amounts is not income for the purposes of these regulations.

W. “Medicaid” means medical assistance eligibility, pursuant to Title XIX of the Social Security Act, by the medical assistance division of the New Mexico human services department.

X. “Medical director” means a pediatrician certified by the American board of pediatrics, licensed to practice medicine in the state of New Mexico, who assists the program manager in the determination of medical eligibility for the children’s medical services program and approves service plans for eligible children and adults.

Y. “Medical index” means a listing of medical diagnoses which are eligible for coverage by the children’s medical services program.

Z. “Medical report” means the written report of a provider giving the diagnosis of the individual and the treatment recommended and provided including reports of non-physician health care providers.

AA. “Prior approval” means the requirement of approval for expenditure of funds for services to an eligible individual by the designated service coordinator before the service is rendered by a provider.

BB. “Program manager” means the person or delegate responsible for the provision of services for children with special health care needs, and adults with cystic fibrosis through the children’s medical services program.

CC. “Provider” means any individual or entity furnishing health care under a provider agreement with the children’s medical services program.

DD. “Residence” means place where client lives with the intent to make the place his permanent and principal home.

EE. “Service coordination” means coordination of resources across agency and professional lines to develop and attain the client’s service plan with optimal client/family participation.

FF. “Service coordinator” means the person employed by the children’s medical services program to assist the family in planning, implementing, evaluating and coordinating with other health care professionals to establish and carry out a service plan for the client.

GG. “Service plan” means a statement, developed in partnership with the family/parent/guardian, of the identified health needs of the client, how they will be met, by whom, and within a specified time frame.

HH. “Third party” means any person or entity that is or may be liable to pay all or part of the medical cost of injury, disease, or disability of a children’s medical services client.

[6/1/47…9/14/76, 12/5/77, 1/21/80, 4/17/81, 8/30/82, 7/18/86, 10/31/96; Recompiled 10/31/01]

7.30.3.8 ELIGIBILITY:

A. Medical management eligibility: To be eligible an applicant must meet all of the following requirements:

(1) the applicant must be an eligible individual as defined in 7.12 [now Subsection L of 7.30.3.7 NMAC];

(2) the applicant must be a resident of New Mexico;

(3) the applicant must be financially eligible as defined in 7.19 [now Subsection S of 7.30.3.7 NMAC];

(4) 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.

B. Adult cystic fibrosis eligibility: To be eligible for 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 New Mexico;

(4) there is no financial eligibility, however, third party payment must be utilized fully before CMS payments are made.

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

(1) the applicant must be under twenty one (21) years of age;

(2) the applicant must be a resident of New Mexico;

(3) referred by a physician, physician’s assistant or pediatric nurse practitioner;

(4) 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.

D. Family, infant and toddler service coordination eligibility: To be eligible for these services a child must meet all of the following requirements:

(1) the applicant must be between birth and 3 years of age unless prior arrangements are made with the local education agency;

(2) the applicant must be a resident of New Mexico;

(3) the applicant must have or be at risk of having a development delay as defined by the developmental disabilities division of the department of health.

E. Service coordination only eligibility: To the extent resources are available, service 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. The applicant must be an eligible individual as defined in 7.12 [now Subsection L of 7.30.3.7 NMAC].

[6/1/47…9/14/76, 12/5/77, 1/21/80, 4/17/81, 8/30/82, 7/18/86, 10/31/96; Recompiled 10/31/01]

7.30.3.9 APPLICATION, ENROLLMENT AND REFERRAL: Application must be made in person, by telephone, or by letter from the client or another referral source to any children’s medical services office, located in most counties in New Mexico, generally in the public health division’s county health offices.

A. If an application is submitted within 30 days of referral, eligibility begins on the date of referral. If the application is submitted after the 30 day time limit has expired, eligibility begins on the date the application was submitted.

B. Upon receipt of a completed application, including medical records and documentation of income and assets, the division shall have twenty (20) working days to determine eligibility for children with special health care needs or adults with cystic fibrosis. Written notification of application approval or denial will be sent to the client no later than twenty (20) working days after receipt of a completed application.

C. The application shall include medical and financial information, as appropriate. Medical records and documentation of income and resources such as income tax returns, insurance policies, checks, check stubs, deeds to real property may be required before the application will be deemed complete.

D. The service coordinator shall assist in obtaining medical and financial documentation in so far as she/he will define for the client what information is necessary to complete the application. The service coordinator shall deny any application pending more than thirty (30) days which has not been completed.

[6/1/47...1/21/80, 7/18/86, 10/31/96; Recompiled 10/31/01]

7.30.3.10 CLIENT RESPONSIBILITIES: Clients are responsible for providing the division with accurate information concerning their financial and medical eligibility when requested by the children’s medical services program.

A. Clients must apply for and inform the service coordinator of insurance, medicaid or other possible source of payment for medical expenses. Clients who are eligible to apply for medicaid must do so, remaining eligible for coverage during the application process.

B. Clients must report changes in income exceeding $100.00 per month, including household composition, insurance or medicaid coverage, or address within ten (10) working days of the date the client becomes aware of change.

C. Private donations, if regular and predictable, will be considered income. If irregular or unpredictable, private donations for the care of the child must be reported to the service coordinator within ten (10) working days of receipt of the donation if its exceeds $1000.00.

D. Third party tort liability: The client must notify the service coordinator within five (5) working days of knowledge of potential liability if a third party may be liable for medical expenses. The client must advise the service coordinator of the name of the potentially liable third party, and the names of all attorneys representing the client prior to the filing of a lawsuit to recover from the third party.

(1) Any funds received from a third party because of liability for injuries to a client for which the division is making medical payments must be used to repay the division for money expended on behalf of the client.

(2) Clients must assign to the division any right to recover or cause of action against a liable third party and all proceeds recovered from liable third parties to the extent that the division has made payment on behalf of the client.

(3) Failure to assign any right to recover, cause of action, or proceeds described above shall be grounds for denial of application or termination of payment for services by division for a period not to exceed six (6) months.

(4) Failure to advise the division of anticipated court action as described above shall be grounds for termination of payment for services for a period not to exceed six (6) months, and client shall be liable to the division for any sums expended by the division for which the client receives compensation from a third party.

E. Failure to provide correct and complete information necessary to determine eligibility and failure to report changes, third party resources, including insurance recoveries, potential liability or private donations as required above may result in termination of benefits under these regulations and/or disqualification from receipt of benefits for a period not to exceed six (6) months, criminal prosecution, and/or civil action to recover benefits wrongfully received.

F. Eligibility review: The client receiving benefits must have his/her eligibility reviewed annually. If the client does not respond to a request for review, services may be denied, and the case may be closed thirty (30) days after the first letter of request is sent.

G. If a client does not follow treatment recommendations or directions made by a children’s medical services service coordinator, consultant or provider, services may be terminated and the children’s medical services program manager may refuse to pay for services because of the failure to follow treatment recommendations or directions.

[9/14/76, 12/5/77, 1/21/80, 4/17/81, 8/30/82, 7/18/86, 10/31/96; Recompiled 10/31/01]

7.30.3.11 PROVIDER PARTICIPATION: Any person wishing to provide health care in the children’s medical services program must be a medicaid provider and should obtain a children’s medical services provider agreement from the local CMS office.

A. Upon receipt of a completed medicaid provider application, if the provider is eligible for participation, the provider and the division must sign a CMS provider agreement. Failure to comply with terms of the agreement may result in termination of provider status and immediate cessation of payment for services rendered to the client.

B. The provider participation application shall be granted where the application indicates qualification for medical reimbursement under the guidelines established by the medical assistance division, of the New Mexico human services department, pursuant to Title XIX of the Social Security Act, and where the application indicates compliance with the children’s medical services regulations. A provider may be approved by children’s medical services only for services within the program and not serve clients within the medicaid program.

C. Providers must seek payment from insurance, medicaid, and other sources, if known, prior to billing the children’s medical services program. This includes billing the medicaid program using the child’s recipient medicaid identification number and not the CMS billing number.

D. Inpatient care shall be paid at the negotiated per diem rate, and under the term established by the provider participation agreement. For other services covered under the program, including approved inpatient covered days, providers must agree to accept as payment in full the amounts established by the division. If a provider receives a payment from a source other than the program which is equal to or exceeds the amount of the program fee schedule for the authorized services rendered, the provider is prohibited from seeking additional payment from either the client or the division.

E. Providers must submit all bills to the fiscal agent for payment on forms prescribed by the program and within the billing time limits established by the program. Unless the provider receives a waiver of the time limit from the program manager, failure to comply with the time limits may result in denial of the claim. Providers may not hold clients responsible for bills denied because of failure to meet time limits. Providers must also follow all billing instructions in submitting claims for payment to the fiscal agent. If claims are denied due to not following instructions, providers may not hold clients responsible for payment of these bills.

F. Providers must submit legible and complete medical reports for each service or set of related services authorized by the program to the service coordinator. Failure to submit medical reports may result in termination of the provider agreement. Medical reports submitted to the program are the property of the program. The program shall not release these reports except under the following circumstances:

(1) Reports shall be given to the client themselves, if requested.

(2) Reports shall be given to a client’s legal guardian upon receipt of a written release.

(3) Reports shall be given to other providers when necessary to assure continuity of treatment or provision of services to the client, if the client consents to such release.

(4) Reports shall be used by the program as necessary to collect for services paid for by the children’s medical services program from liable third parties.

G. All services must have prior approval as defined in 7.27 [now Subsection AA of 7.30.3.7 NMAC] before rendered. Failure to receive prior approval may result in denial of payment for the services rendered. If a provider disagrees with a prior approval decision made by the service coordinator, the provider may seek review of this decision by the program manager. Request for such review must be in writing and must be received by the program manager within sixty (60) days of the service coordinator’s decision. The program manager shall confer with the medical director and/or other consultants. The program manager shall make a decision within 60 days and the decision shall be final.

H. Providers must meet standards of care established by appropriate licensing boards, certifying bodies and standards as may be established by the children’s medical services program manager.

I. Violations: Sanctions may be imposed by the single state agency against a provider for any one or more of the following reasons:

(1) knowingly and willfully making or causing to be made any false statement or misrepresentation of a material fact by:

(a) presenting or causing to be presented for payment under children’s medical services any false or fraudulent claim for services or merchandise;

(b) submitting or causing to be submitted false information for the purpose of obtaining greater compensation than that to which the provider is legally entitled;

(c) submitting or causing to be submitted false information for the purpose of meeting prior approval status;

(d) submission of a false or fraudulent application for provider status.

(2) failure to disclose or make available to the department or its authorized agent records of services provided to children’s medical services clients and records of payments for those services;

(3) Failure to provide and maintain quality services which meet professionally recognized standards of care;

(4) engaging in a course of conduct or performing an act that is unreasonably improper, or abusive of the children’s medical services program or continuing such conduct following notification that said conduct should cease;

(5) breach of the terms of the provider agreement;

(6) over utilizing the children’s medical services program by inducing, furnishing or otherwise causing a recipient to receive service(s) or merchandise substantially in excess of the needs of the recipient;

(7) rebating or accepting a fee or portion of a fee or charge for a children’s medical services patient referral;

(8) violating any provision of state or federal statutes or any rule or regulation promulgated pursuant thereto;

(9) violating of any laws, regulations or code of ethics governing the conduct of occupations or professions or regulated industries directly relating to children’s medical services;

(10) conviction of a criminal offense relating to performance of a provider agreement with the state or for negligent or abusive practice resulting in death or injury to patients;

(11) failure to meet standards required by state or federal law for participation, as a given type of provider (e.g.,licensure or certification);

(12) soliciting, charging, or accepting payments from recipients for services for which the provider has billed the children’s medical services program;

(13) failure to correct deficiencies in provider operations within time limits specified by program guidelines after receiving written notice of these deficiencies from the human services department;

(14) formal reprimand or censure by a professional association of the provider’s peers for unethical practices or malpractice;

(15) suspension or termination from participation in another governmental medical program such as, but not limited to, worker’s compensation, medicaid, rehabilitation services and medicare;

(16) indictment for fraudulent billing practices, or negligent practice resulting in physical, emotional or psychological injury or death to the provider’s patients;

(17) failure to repay or make arrangements for the repayment of identified overpayments or otherwise erroneous payments.

J. Sanctions: One or more of the following sanctions may be invoked against providers based on the grounds specified in Section 11.9 [now Subsection I of 7.30.3.11 NMAC]:

(1) termination from participation in the children’s medical services program;

(2) suspension of participation in the children’s medical services program;

(3) suspension or withholding of payments to a provider;

(4) referral to peer review;

(5) one-hundred percent review of the provider’s claims prior to payment; and

(6) referral to the appropriate state licensing board or other appropriate authority for investigation.

K. A provider found by the division to have committed a violation contained in Section 11.9 [now Subsection I of 7.30.3.11 NMAC] shall be given notice and an opportunity for hearing in general accordance with the procedures set forth in Sections 15, 16 and 17 [now Sections 15, 16 and 17 of 7.30.3 NMAC].

[1/21/80, 4/17/81, 8/30/82, 7/18/86, 10/31/96; Recompiled 10/31/01]

7.30.3.12 EXPENDITURE OF FUNDS: Expenditure of children’s medical services program funds are based on the availability of funds and the eligibility of the client for services.

A. While expenditure of funds for services is generally subject to receipt of eligibility determination from the medical director and prior approval of the service coordinator, eligible emergency services may be paid for if:

(1) The service coordinator is notified of the services rendered and the necessity of the services before the end of the fifth working day after the emergency expense is incurred; and

(2) The medical director determines that the services were consistent with the service plan, if applicable, are eligible for payment, were rendered in an emergency and otherwise approves the expenditure.

B. Children’s medical services program shall not expend more than $15,000.00 per client per year for medical management (exception contained in Section 20) [now 7.30.3.20 NMAC].

C. Purchase of services related to educational activities are excluded under these regulations.

D. Purchase of services related to psychiatric disorders are excluded under these regulations except for psychological problems specifically related to an eligible condition, and with approval from the psychological consultant and medical director. The exception is the adult with cystic fibrosis for whom inpatient psychiatric hospitalization is eligible.

E. Children’s medical services program shall be the last resource after other available sources of payment, such as insurance, medicaid, tortfeasors, the New Mexico department of education.

F. Children’s medical services program shall not pay for any eligible services provided more than five working days before the date of referral.

G. Resources available from the Indian health services will be utilized in the provision of services to an eligible individual on the basis of voluntary cooperation agreements entered into between children’s medical services program and the Indian health service on a periodic basis.

[6/1/47…12/5/77, 1/21/80, 4/17/81, 8/30/82, 7/18/86, 10/31/96; Recompiled 10/31/01]

7.30.3.13 OUT-OF-STATE PROVIDER POLICY: Services must be purchased within the state of New Mexico, unless the need to purchase services elsewhere is documented.

A. Services may be purchased outside the state of New Mexico when:

(1) The specific service is not available in New Mexico; or

(2) An eligible client is temporarily out of state and does not qualify for medical assistance in the state of temporary residence, and the health of the client would be endangered if services were postponed until return to New Mexico or by travel to New Mexico; or

(3) Excessive time, distance and expense would be involved in order to obtain outpatient services in New Mexico. Inpatient services are eligible out of state if urgent or emergency hospitalization is needed when distance is excessive or in-state tertiary centers are full.

B. Services may not, under any circumstances, be purchased out of state without approval of the medical director or designee.

C. Out-of-state providers are subject to the same fee schedule, time limitations, standards and requirements as in-state providers.

[9/14/76, 12/5/77, 1/21/80, 10/31/96; Recompiled 10/31/01]

7.30.3.14 CONFIDENTIALITY: Information shall be released by the program manager or his/her designee only upon receipt of a release of information form signed by the client indicating the client’s approval for the release of specified medical information.

[9/14/76...10/31/96; Recompiled 10/31/01].

7.30.3.15 NOTICE AND APPEALS PROCEDURE: Every applicant or client shall be informed in writing at the time of denial of application or services and at the time of any action affecting the applicant/client’s benefits:

A. Of the applicant/client’s right to an evidentiary hearing;

B. That the applicant/client’s request for hearing must be written and must be given to the applicant/client’s service coordinator or the program manager, and must be made within 30 days of the denial;

C. That the applicant/client may be represented by an authorized representative, such as legal counsel, relative, friend, or other spokesman, or the applicant/client may represent himself/herself.

D. In cases of intended action to discontinue, terminate, suspend or reduce benefits, the program must give written notice that the proposed action will occur no sooner than ten (10) days after the date of the notice, however if a client fails to meet the responsibilities listed in sections 10, 12, 13, 14, 15, 16 and 17 [now Sections 10, 12, 13, 14, 15, 16 and 17 of 7.30.3 NMAC] of these regulations, the program will not be obligated to cover services obtained during the 10 days period.

E. The notice must include:

(1) a statement of what action the agency intends to take;

(2) the reasons for the intended action;

(3) the specific regulation(s) supporting such action;

(4) explanation of right to request an evidentiary hearing;

(5) an explanation that the client must request a hearing within thirty (30) days of the date of the notice.

[9/14/76, 1/21/80, 7/18/86, 10/31/96; Recompiled 10/31/01]

7.30.3.16 OPPORTUNITY FOR HEARING: An opportunity for a hearing shall be granted, upon request, to:

A. an applicant whose application is denied;

B. an applicant whose application is not acted upon within twenty (20) working days of completion;

C. a client who is aggrieved by any program action resulting in suspension, reduction, discontinuance or termination of benefits.

D. No hearing is required if the program action results from exhaustion of program funds.

[9/14/76, 1/21/80, 10/31/96; Recompiled 10/31/01]

7.30.3.17 CONDUCT OF HEARING:

A. The hearing shall be conducted at a reasonable time, date and place. The notice of time, date and place of hearing shall be mailed to the applicant or client at least ten (10) days prior to the hearing.

B. The hearing officer shall be appointed by the secretary of the department of health and shall not have been involved in the initial determination of the action in question.

(1) The hearing officer shall administer oaths or affirmations to witnesses, take testimony, rule on the admissibility of evidence, schedule rehearings and assure full development of the issues involved in the program action.

(2) The hearing officer shall prepare a report, consisting of statement of issues, findings of fact, conclusions, a recommended determination and regulations supporting his recommendations.

(3) Recommendations of the hearing officer shall be based exclusively on evidence and other material introduced at the hearing.

C. The applicant or client shall have adequate opportunity:

(1) to examine the contents of the applicant/client’s case file and all documents to be used by the program at the hearing;

(2) to bring witnesses;

(3) to establish all pertinent facts;

(4) to advance arguments without undue interference;

(5) to question or refute any testimony or evidence, including opportunity to confront or cross-examine adverse witnesses.

D. The final decision shall be made by the secretary of the department of health based upon the evidence and other material introduced at the hearing and the hearing officer’s report. The decision must be mailed to the applicant/client within ninety (90) days of receipt of the written request for hearing.

E. The technical rules of evidence and civil procedure shall not apply in these hearings.

[9/14/76, 1/21/80, 10/31/96; Recompiled 10/31/01]

7.30.3.18 FINANCIAL ELIGIBILITY: The division shall periodically issue an index of financial eligibility at 200 percent of poverty. The index shall be revised annually according to the federal poverty guidelines. The index of financial eligibility criteria shall be issued in a quick reference format and shall show that it is the current official list and shall specify its effective date. The division shall supply the current index to all persons or entities on request.

[9/14/76...10/31/96; Recompiled 10/31/01]

7.30.3.19 ELIGIBLE MEDICAL CONDITIONS: The division shall periodically issue an index of children’s medical services eligible conditions which identifies eligible medical conditions. The index shall be reviewed at least annually and revised as necessary. Coverage is provided subject to the further guidelines in the index of children’s medical services eligible conditions and treatment protocols. The index of children’s medical services eligible conditions is attached hereto as attachment A.

[6/1/47...10/31/96; Recompiled 10/31/01]

7.30.3.20 PEDIATRIC SUBSPECIALISTS: For children age 18 years and under with chronic, complex cardiac, endocrine, neurology, and pulmonary conditions, the children’s medical services program will authorize payment for consultation and follow up services only to board certified pediatric subspecialists when they are available within the state.

[1/21/80, 8/30/82, 10/31/96; Recompiled 10/31/01]

7.30.3.21 EXCEPTIONS TO REGULATIONS: The children’s medical services program manager in concurrence with the medical director, and maternal and child health bureau chief, may raise the $15,000 financial limit to provide additional coverage for good cause when monies are available.

[8/3/82...10/31/96; Recompiled 10/31/01]

7.30.3.22 VOLUNTEERS: The children’s medical services pogram may use volunteers as allowed by program, division and department guidelines.

[8/30/82, 10/31/96; Recompiled 10/31/01]

7.30.3.23 SEVERABILITY: If any part or application of the children’s medical services program Regulations is held invalid, the remainder, or its application to other situations or persons, shall not be affected.

[1/21/80, 8/30/82, 10/31/96; Recompiled 10/31/01]

ATTACHMENT A

INDEX OF CHILDREN’S MEDICAL SERVICES ELIGIBLE CONDITIONS:

Coverage is provided subject to the guidelines contained in the CMS Medical Director’s Medical Appendix and CMS Treatment Protocols. Conditions that are similar in course and outcome may be eligible pending review by the Medical Director.

CANCERS OF CHILDHOOD

Common Childhood Cancers

Hepatoblastoma

Hodgkin Disease

Leukemia

Lymphoma

Lymphosarcoma

Neuroblastoma

Rhabdomyosarcoma and Other

Soft Tissue Sarcomas

Wilms Tumor

Other Renal Neoplasms

Retinoblastoma

Musculoskeletal Cancers

Chondroblastoma

Ewing Sarcoma

Osteosarcoma

Rhabdomyosarcoma

Other Soft Tissue Sarcomas

CARDIAC

CONGENITAL CARDIAC

Aortic Arch Anomalies

Aortic Atresia

Aortic Stenosis

Arrhythmia

Atrial Septal Defect

A-V Canal Complete

A-V Canal Partial

Bicuspid Aortic Valve

Cardiomyopathy-Hypertrophic

Coarctation-Aorta

Coarctation-Pulmonary Artery

Cor Pulmonale

Double Outlet R Ventricle

Ebstein Anomaly

Hypoplastic L Heart

Malposition Syndrome

Mitral Valve Prolapse

Other Acyanotic Congenital Heart Disease

Other Cyanotic Congenital Heart Disease

Patent Ductus Arteriosus

Primary Pulmonary Hypertension (Persistent Fetal Circulation)

Pulmonary Atresia

Pulmonary Vascular Disease

Pulmonic Stenosis

Single Ventricle

Tetralogy of Fallot

Total Anomalous Pulmonary Venous Return

Transposition of Great Vessels

Tricuspid Atresia

Truncus Arteriosus

Ventricular Septal Defect

Vascular Anomaly

Wolf-Parkinson White

ACQUIRED CARDIAC

Cardiomyopathy (non-congenital)

Kawasaki Disease-coronary artery aneurysm

Pericarditis/Pericardial Effusion

Rheumatic Carditis, Recurrent

Rheumatic Heart Disease

Subacute Bacterial Endocarditis

CONGENITAL INTERNAL ORGAN ANOMALIES

Gastrointestinal Anomalies, Congenital

Anal Atresia (Imperforate Anus)

Biliary Artesia

Choledocal Cyst

Esophageal Atresia/Stenosis

Gastroschisis

Hernia, Diaphragmatic

Hirschsprung Disease

Intestinal Atresia/Stenosis

Intestinal Malrotation

Necrotizing Enterocolitis

Omphalocoele

Pyloric Stenosis

Rectovaginal Fistula

Tracheoesophageal Fistula

Vater Syndrome/Vacterl Anamolad

Genitourinary Anomalies, Congenital

Ambiguous Genitalia

Epispadias

Extrophy of the Bladder

Hydronephrosis secondary to a Bladder Neck Obstruction

Hydronephrosis, Unilateral/Bilateral

Hypospadias

Infantile Polycystic Kidney Disease

Polycystic Renal Disease

Posterior Urethral Valves

Prune Belly Syndrome

Urachal Anomalies

Ureteropelvic Junction Obstruction

Undescended Testis

Urethral Fistula

Vesicoureteral Reflux

Other

Choanal Atresia

Laryngeal Malformations, Congenital

Subglottic Hemangioma

Laryngeal Malformations, Acquired

Laryngeal Papilloma

Tracheal Stenosis

Vocal Cord Paralysis

Pulmonary Malformations, Congenital

Agenesis, Hypoplasia, Dysplasia of the Lung

Congenital Bronchiectasis

Congenital Cystic Lung

Pulmonary Disease of the Newborn, Acquired

IRDS

Bronchopulmonary Dysplasia

EARS, NOSE AND THROAT (ENT)

Chronic Disease of Tonsils and Adenoids

Chronic Tonsillitis

Hypertrophy of Tonsils and Adenoids

Chronic Sinusitis

Cysts/Sinuses/Fistulas/Lymphangiomas

Accessory Tragi

Branchial Cleft Sinus or Fistula/Cyst

Cystic Hygroma

Preauricular Sinus or Fistula/Cyst

Thyroglossal Duct Cyst

Disorders of Middle Ear/Hearing

Cholesteatoma

Degeneration of Ossicular Chain

Discontinuity of Ossicular Chain

Eustachian Tube Dysfunction

Hearing Loss, Conductive

Hearing Loss, Mixed

Hearing Loss, Sensorineural

Mastoiditis-Chronic

Otosclerosis

Traumatic Perforation

Tympanic Membrane Perforation

Tympanosclerosis

Otitis, Chronic

Otitis Externa

Otitis Media, Chronic Serous

Otitis Media, Chronic Purulent

Miscellaneous

Ankyloglossia

ENDOCRINE

Disorders of the Adrenal Gland

Addison Disease

Adrenogenital Syndrome

Adrenoleukodystrophy

Congenital Adrenal Hyperplasia

Cushing Syndrome

Familial Glucocorticoid Deficiency

Feminizing Adrenal Tumors, Benign

Feminizing Adrenal Tumors, Malignant

Hyperaldosteronism

Inborn Defects of Steroid Production

Pheochromocytoma

Premature Adrenarche

Virilizing Adrenocortical Tumors, Benign

Virilizing Adrenocortical Tumors, Malignant

Disorders of the Gonads

Hermaphroditism

Klinefelter Syndrome

Polycystic Ovaries

Puberty, Delayed

Tumors of the Testes, Benign

Tumors of the Testes, Malignant

Turner Syndrome

Virilizing Ovarian Tumors

Disorders of the Hypothalamus and Pituitary Gland

Cerebral Gigantism

Diabetes Insipidus

Inappropriate Secretion of Antidiuretic Hormone (post-Transphenoidal Surgery for Pituitary Tumors)

Panhypopituitarism

Pituitary Dwarfism

Pituitary Gigantism

Pituitary Tumors, Benign

Pituitary Tumors, Malignant

Precocious Puberty

Primary Amenorrhea

Prolactin Deficiency

Prolactinoma

Disorders of the Pancreas

Diabetes Mellitus, Types I and II

Disorders of the Parathyroid Gland

Autoimmune Hypoparathyroidism

Familial Congenital Hypoparathyroidism

Hypoparathyroidism

Hyperparathyroidism

Pseudohypoparathyroidism

Disorders of the Thyroid Gland

Acquired Hypothyroidism

Benign Tumors of the Thyroid Gland

Carcinoma of the Thyroid Gland

Goiter

Graves Disease

Hashimoto Thyroiditis

Hyperthyroidism

Thyroiditis

GASTROINTESTINAL DISORDERS

Diseases of Esophagus, Stomach and Duodenum

Esophagitis

Achalasia

Gastric Ulcer

Duodenal Ulcer

Peptic Ulcer

Gastrojejunal Ulcer

Non-infectious Enteritis and Colitis

Nonspecific Enteritis

Regional Enteritis

Ulcerative Colitis

Chronic Liver Disease and Cirrhosis

Chronic Hepatitis

Cirrhosis (non-alcoholic)

Disorders of Amino Acid, Carbohydrate

Lipid, Bile Acid, Metal and Bilirubin Metabolism

Esophageal Varices

Portal hypertension

Portal Vein Thrombosis

Diverticula of Intestine

Meckel Diverticulum

Disorders of the Gallbladder

Cholelithiasis

Choledocal Cyst

Diseases of the Pancreas

Chronic Pancreatitis

Cyst and Pseudocyst of Pancreas

Pancreatic Insufficiency

Intestinal Malabsorption

Celiac Disease

Short Gut Syndrome

GENETIC

Newborn Screening

Congenital hypothyroidism

Galactosemia

Hyperphenylalanemia

Phenylketonuria

Biotinidase Deficiency

Inborn Errors of Metabolism

Disorders of Amino Acid Transport and Metabolism

Disorders of Carbohydrate Transport and Metabolism

Lipidoses

Disorders of Calcium Metabolism

Nephrocalcinosis

Pseudohypoparathyroidism

Pseudopseudohypoparathyroidism

Disorders of Phosphorus Metabolism

Familial Hypophosphatemia (Vitamin D-Resistant Rickets

X-linked Hypophosphatemia)

Chromosomal Disorders

4p-Syndrome

5p-Syndrome (Cri-du-chat)

9p-Syndrome

10q-Syndrome

13q-Syndrome

18q-Syndrome

18p-Syndrome

20p-Syndrome

Cat Eye Syndrome

Recombinant 8

Trisomy 4

Trisomy 8

Trisomy 9 Mosiac Syndrome

Trisomy 13 Syndrome

Trisomy 18 Syndrome

Trisomy 21 (Down) Syndrome

Sex Chromosomal Syndromes

Fragile X

xyy Syndrome

xxy Klinefelter Syndrome

xxxxy Syndrome

xxxx Syndrome

Penta X Syndrome

Turner Syndrome

CMS Eligible Autosomal Dominant Conditions

Apert Syndrome

Aniridia

Facioscapulohumeral Muscular Dystrophy

Marfan Syndrome

Neurofibromatosis

Noonan Syndrome

Polycystic Kidney

Tuberous Sclerosis

CMS Eligible Autosomal Recessive Conditions

Adrenogenital Syndrome

Alpha 1 -- Antitrypsin Deficiency

Cystic Fibrosis

(See conditions under inborn errors of metabolism)

Prenatal Diagnosis

Chromosomal Disorders

Cystic Fibrosis

Familial Hereditary Diseases

Fetal Congenital Anomalies

Hemoglobinopathies

Inborn Errors of Metabolism

Neural Tube Defects

HEMATOLOGIC

Hereditary Hemolytic Anemias

Hereditary Spherocytosis

Hereditary Elliptocytosis

Hemolytic Anemias due to Enzyme Deficiency

G-6-PD Deficiency, Favism

Thalassemias

Sickle Cell Anemia

Sickle Cell/SC Disease

Other Hemoglobinopathies

Ineligible conditions: transient hemolytic, hemorrhagic and aplastic anemias, nutritional anemias and hemorrhagic disorders due to defibrination syndrome and acquired coagulation factor deficiency.

Aplastic Anemias

Constitutional Aplastic Anemia

Blackfan-Diamond Syndrome

Fanconi Anemia

Aplastic Anemia due to Chronic Illness

Other Anemias

Sideroblastic Anemia

Infantile Pseudoleukemia

Coagulation Defects

Congenital Factor VIII Disorder (Hemophilia)

Congenital Factor IX Disorder

Congenital Factor XI Disorder

Congenital Afibrinogenemia

Von Willebrand Disease

Thrombocytopenic Purpura, Thrombocytopenia

Congenital, Hereditary

Chronic Idiopathic

Hereditary Capillary Fragility

Vascular Pseudohemophilia

Familial Hemorrhagic Diathesis

Diseases of White Blood Cells

Agranulocytosis

Infantile Genetic

Kostmann Syndrome

Cyclic Neutropenia

Functional Disorders of PMNs

Chronic Granulomatous Disease

Job Syndrome

Genetic Anomalies of Leukocytes

Alder-Reilly

Chediak-Sgeinbrinck-Higashi

Hereditary Hyper/Hyposegmentation

Leukomelanopathy

Eosinophilia

Hereditary

Idiopathic

Eosinophilic Leukocytosis

Other Eligible Conditions

Hypersplenism

Familial Polycythemia

Methemoglobinemia

Porphyria

IMMUNE SYSTEM DISORDERS

Deficiency of Humoral Immunity

Hypogammaglobulinemia

Selective IgA Immunodeficiency

Selective IgM Immunodeficiency

Selective IgG Immunodeficiency

Bruton Disease

Immunodeficiency w/increased IgM

Common Variable Immunodeficiency

Deficiency of Cell Mediated Immunity

Immunodeficiency w/T-Cell Defect

DiGeorge Syndrome

Wiscott-Aldrich Syndrome

Nezelof Syndrome

Combined Immune Deficiency

LEAD SCREENING AND TREATMENT

Plumbism

Elevated Lead level(persistent)

NEUROLOGIC

Cerebral Palsy

Chronic Inflammation/Infection

Cysticercosis

Craniosynostosis

Coronal

Lambdoidal

Metopic

Sagittal

Degenerative Diseases of the Central/Peripheral Nervous System

Cerebral Lipidoses

Gangliosidoses

Hereditary Chorea

Leukodystrophies

Spinocerebellar Ataxia (Friedrich Ataxia)

Inborn Errors of Metabolism of Central and Peripheral Nervous System

Epilepsy

Epilepsy - Idiopathic

Focal Motor

Grand Mal

Infantile Spasms

Minor Motor

Petit Mal

Partial Seizures-Complex

Psychomotor

Chronic seizure disorder resulting from CNS infection, trauma or hemorrhage

Malformations of the CNS

Agenesis of the Corpus Callosum

A-V Malformations

Hydrocephalus

Myelodysplasia

Encephalocele

Encephalomyelocele

Meningocele

Meningomyelocele

Neuromuscular Disorders

Amyotonia Congenita

Dermatomyositis

Hypo/Hyer/Normokalemic Periodic Paralysis

Kearns Sayre Syndrome

Multiple Sclerosis

Muscular Dystrophy, Progressive

Myasthenia Gravis

Myotonia Congenita

Myotonic Dystrophy

Polymyositis

Plegia

Hemiplegia

Monoplegia

Paraplegia

Quadriplegia

Guillain-Barre Residual Plegia

Other Plegias

Peripheral Neuropathy

Charcot-Marie-Tooth

Plegias due to Trauma to Cranium

Sequelae caused by Trauma to Nerve

Facial Nerve Palsy (excluding Bell palsy; Volkmann contracture)

Peripheral/Spinal, resulting in loss of motor function

Treatment for acute head, spinal or nerve injury is not eligible.

Tumor of the CNS

Cranial/Spinal - Benign, Malignant

Neurofibromatosis

Tuberous Sclerosis

OCULAR

Amaurosis

Amblyopia

Anisometropia >2.0D

Anterior Chamber Foreign Body

Anterior Dislocation of Lens

Anterior Synechiae

Aphakia/Pseudophakia

Benign Neoplasm Lower Lid

Benign Neoplasm of Orbit

Blepharitis

Canthal Tumor, Benign

Cataract

Cataract, Congenital

Cataract, Traumatic

Chalazion/Meibomian Abscess

Choroiditis

Conjunctival Cyst

Conjunctival Hemorrhage

Conjunctival/Episcleral Tumor, Benign

Conjunctivitis, Traumatic

Corneal Abrasion

Corneal Foreign Body

Corneal Opacities/Scarring

Corneal Ulcer

Corneal Vascularization

Dacryocystitis

Dacryostenosis

Diabetes Mellitus

Diabetic Retinopathy

Diplopia

Dry Eye Syndrome

Endophthalmitis

Ectropion

Entropion

Epiphora

Episcleritis

Esophoria

Esotropia

Exophoria

Convergence insufficiency-symptomatic

Exotropia

Exposure Keratitis

Facial Nerve Paresis

Glaucoma, Suspect

Glaucoma, Acute

Glaucoma, Angle Closure

Glaucoma, Secondary

Hematoma, Orbital

Hematoma, Traumatic

High Myopia >-5.0D under 12

>-8.0D 12-21

Hyalopathy

Hypertropia

Hyphema

Intra Corneal Foreign Body

Iritis

Keratitis

Keratopathy

Laceration Eyelid, Full Thickness

Laceration, Eye

Laceration, Orbit

Lid Tumor, Benign

Maculopathy

Malignant Conjunctival/Episcleral Tumor

Malignant Eyelid Tumor

Malignant Neoplasm of the Eye

Neoplasm of Eye, Primary, Secondary

Nystagmus

Ocular Foreign Body

Ocular Hypertension

Ocular Trauma

Optic Nerve Neuropathy

Orbital Fracture

Orbital Trauma

Pinguecula

Pterygium

Pterygium, Recurrent

Ptosis

Pupil Deformity

Pupillary Occlusion

Refractive Error with underlying CMS condition

Retinal Detachment

Retinal Scarring

Retinal Tear

Retinitis

Retinopathy

Ruptured Globe

Scotoma

Strabismus

Subluxation of Lens

Synechiae

Thickened Lens Capsule

Trachoma

Trichiasis

Uveitis

Vitreous Bands

Vitreous Hemorrhage

Vitreous Opacities

PLASTIC SURGICAL CONDITIONS

Burns

Electrical, Chemical, Thermal Burns requiring burn unit hospitalization

Lesser burns in patients with significant,

pre-existing disease.

Congenital Deformities of the Ear

Microtia or Pinna Deformity

Atresia or Deformity of External Auditory Canal

Congenital Dento-Facial Anomalies

Cleft Lip/Palate

Congenital Malformation of Mandible and Maxilla

Hemifacial Microsomia

Temporomandibular Ankylosis

Dermal Lesions

Hemangioma

Lymphangioma

Nevus, Congenital Giant

Port Wine Stain

PULMONARY

Asthma, Moderate to Severe

Bronchopulmonary Dysplasia

Cystic Fibrosis

RENAL AND URINARY TRACT DISORDERS

Chronic Renal Disease

Chronic Glomerulonephritis/Glomerulosclerosis

Nephrolithiasis, Chronic

Nephrotic Syndrome, Recurrent/Chronic

Renal Tubular Disorders

Proximal and Distal Renal Tubular Acidosis

Renal Cysts with Impaired Renal Function

Disorders of the Bladder and Ureters

Recurrent Urinary Tract Infections

Vesicoureteral Reflux

Disorders of the Urethra

Meatal Stenosis

Paraphimosis

Other

Varicolele

RHEUMATIC DISEASE

Ankylosing Spondylitis

Dermatomyositis

Juvenile Rheumatoid Arthritis

Mixed Connective Tissue Disease

Polyarteritis Nodosa

Polymyositis

Scleroderma

Sjogren Syndrome

Systemic Lupus Erythematosus

Takayasu Arteritis

Wegner Granulomatosis

SKIN DISEASES, CHRONIC

Cutaneous Defects

Ectodermal Dysplasias

Goltz Syndrome

Vascular Lesions

Capillary Hemangioma

Cavernous Hemangioma

Disseminated Hemangiomatosis

Fabry Disease

Kasaback-Merritt Syndrome

Klippel-Trenaunay-Weber Syndrome

Osler-Weber-Rendu Syndrome

Cutaneous Nevi

Congenital Pigmented Nevus

Nevus Sebaceous

Spitz Nevus

Hyperpigmented Lesions

Incontinentia Pigmenti

Neurofibromatosis

Hypopigmented Lesions

Albinism

Chediak-Higashi Syndrome

Tuberous Sclerosis

Vitiligo

Waardenberg Syndrome

Vesicobullous Disorders

Dermatitis Herpetiformis

Epidermolysis Bullosa

Eczema

Atopic Dermatitis

Photosensitivity

Bloom Syndrome

Cockayne Syndrome

Hartnup Disease

Hydroa Vacciniforme

Poikiloderma

Polymorphous Light Eruption

Porphyrias

Rothmund-Thomsom Syndrome

Xeroderma Pigmentosum

Diseases of the Epidermis

Acanthosis Nigrecans

Ichthyosis

Ichthyosis Syndromes

Psoriasis Porokeratosis

Diseases of the Dermis

Cutis Laxa

Ehlers-Danlos

Mastocytosis

Mucopolysaccharidosis

Pseudoxanthoma Elasticum

Urticaria Pigmentosa

Disorders of Subcutaneous Tissue

Partial Lipodystrophy

Seip-Lawrence Syndrome

Tumors of the Skin

Nevoid Basal Cell Carcinoma Syndrome

Acne

Cystic (scarring), Congoblotta Acne

HISTORY OF 7.30.3 NMAC:

Pre-NMAC History: The material in this part was derived from that previously filed with the State Records Center:

HSSD 76-5, Regulations Governing Crippled Children’s Services, 9/14/76.

HSSD 77-9, Regulations Governing Crippled Children’s Services, 12/5/77.

HED-79-7 (HSD), Regulations Governing the Crippled Children’s Services Program, 1/11/80.

HED-81-1 (HSD), Regulations Governing the Crippled Children’s Services Program, 4/17/81.

HED-82-9 (HSD), Regulations Governing the Children’s Medical Services, 8/30/82.

HED 86-8 (HSD), Regulations Governing the Children’s Medical Services, 7/18/86.

HED-81-8 (HSD), Regulations Governing the Adult Cystic Fibrosis Program, 11/17/81.

History of Repealed Material: [RESERVED]