This rule was filed as NMAC TITLE HEALTH

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					This rule was filed as 7 NMAC 30.3.

TITLE 7           HEALTH
[1937...10/31/96; Recompiled 10/31/01]          SCOPE: General public.
[1937...10/31/96; Recompiled 10/31/01]          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]        DURATION: Permanent.
[10/31/96; Recompiled 10/31/01]           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[Compiler’s note: The words or paragraph, above, are no longer applicable.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.]          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]           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
              (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).

7.30.3 NMAC                                                                                                            1
          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
          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
          P.        “Eligibility for service coordination only” means eligibility only for service coordination
services as defined in section 7.32 [now Subsection FF of 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.

7.30.3 NMAC                                                                                                           2
          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
          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]           ELIGIBILITY:
          A.       Medical management eligibility: To be eligible an applicant must meet all of the following
             (1) the applicant must be an eligible individual as defined in 7.12 [now Subsection L of
             (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
             (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
             (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
          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

7.30.3 NMAC                                                                                                         3
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 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]           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
          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]           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.

7.30.3 NMAC                                                                                                               4
          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
[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]          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 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.

7.30.3 NMAC                                                                                                            5
          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
             (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
             (8) violating any provision of state or federal statutes or any rule or regulation promulgated pursuant
             (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 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 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 NMAC                                                                                                        6          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
              (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 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]         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]          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].          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
          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.

7.30.3 NMAC                                                                                                               7
         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
[9/14/76, 1/21/80, 7/18/86, 10/31/96; Recompiled 10/31/01]         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]          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
             (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]           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 NMAC                                                                                                                8          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]         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]          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]        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]         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
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
Hodgkin Disease
Rhabdomyosarcoma and Other
Soft Tissue Sarcomas
Wilms Tumor
Other Renal Neoplasms

Musculoskeletal Cancers
Ewing Sarcoma
Other Soft Tissue Sarcomas


7.30.3 NMAC                                                                                                             9
Aortic Arch Anomalies
Aortic Atresia
Aortic Stenosis
Atrial Septal Defect
A-V Canal Complete
A-V Canal Partial
Bicuspid Aortic Valve
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

Cardiomyopathy (non-congenital)
Kawasaki Disease-coronary artery aneurysm
Pericarditis/Pericardial Effusion
Rheumatic Carditis, Recurrent
Rheumatic Heart Disease
Subacute Bacterial Endocarditis


Gastrointestinal Anomalies, Congenital
Anal Atresia (Imperforate Anus)
Biliary Artesia
Choledocal Cyst
Esophageal Atresia/Stenosis
Hernia, Diaphragmatic
Hirschsprung Disease
Intestinal Atresia/Stenosis

7.30.3 NMAC                                                       10
Intestinal Malrotation
Necrotizing Enterocolitis
Pyloric Stenosis
Rectovaginal Fistula
Tracheoesophageal Fistula
Vater Syndrome/Vacterl Anamolad

Genitourinary Anomalies, Congenital
Ambiguous Genitalia
Extrophy of the Bladder
Hydronephrosis secondary to a Bladder Neck Obstruction
Hydronephrosis, Unilateral/Bilateral
Infantile Polycystic Kidney Disease
Polycystic Renal Disease
Posterior Urethral Valves
Prune Belly Syndrome
Urachal Anomalies
Ureteropelvic Junction Obstruction
Undescended Testis
Urethral Fistula
Vesicoureteral Reflux

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
Bronchopulmonary Dysplasia

                                    EARS, NOSE AND THROAT (ENT)

Chronic Disease of Tonsils and Adenoids
Chronic Tonsillitis
Hypertrophy of Tonsils and Adenoids
Chronic Sinusitis

Accessory Tragi
Branchial Cleft Sinus or Fistula/Cyst

7.30.3 NMAC                                                       11
Cystic Hygroma
Preauricular Sinus or Fistula/Cyst
Thyroglossal Duct Cyst

Disorders of Middle Ear/Hearing
Degeneration of Ossicular Chain
Discontinuity of Ossicular Chain
Eustachian Tube Dysfunction
Hearing Loss, Conductive
Hearing Loss, Mixed
Hearing Loss, Sensorineural
Traumatic Perforation
Tympanic Membrane Perforation

Otitis, Chronic
Otitis Externa
Otitis Media, Chronic Serous
Otitis Media, Chronic Purulent



Disorders of the Adrenal Gland
Addison Disease
Adrenogenital Syndrome
Congenital Adrenal Hyperplasia
Cushing Syndrome
Familial Glucocorticoid Deficiency
Feminizing Adrenal Tumors, Benign
Feminizing Adrenal Tumors, Malignant
Inborn Defects of Steroid Production
Premature Adrenarche
Virilizing Adrenocortical Tumors, Benign
Virilizing Adrenocortical Tumors, Malignant

Disorders of the Gonads
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

7.30.3 NMAC                                               12
Cerebral Gigantism
Diabetes Insipidus
Inappropriate Secretion of Antidiuretic Hormone (post-Transphenoidal Surgery for Pituitary Tumors)
Pituitary Dwarfism
Pituitary Gigantism
Pituitary Tumors, Benign
Pituitary Tumors, Malignant
Precocious Puberty
Primary Amenorrhea
Prolactin Deficiency

Disorders of the Pancreas
Diabetes Mellitus, Types I and II

Disorders of the Parathyroid Gland
Autoimmune Hypoparathyroidism
Familial Congenital Hypoparathyroidism

Disorders of the Thyroid Gland
Acquired Hypothyroidism
Benign Tumors of the Thyroid Gland
Carcinoma of the Thyroid Gland
Graves Disease
Hashimoto Thyroiditis

                                       GASTROINTESTINAL DISORDERS

Diseases of Esophagus, Stomach and Duodenum
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

7.30.3 NMAC                                                                                          13
Portal Vein Thrombosis

Diverticula of Intestine
Meckel Diverticulum

Disorders of the Gallbladder
Choledocal Cyst

Diseases of the Pancreas
Chronic Pancreatitis
Cyst and Pseudocyst of Pancreas
Pancreatic Insufficiency

Intestinal Malabsorption
Celiac Disease
Short Gut Syndrome


Newborn Screening
Congenital hypothyroidism
Biotinidase Deficiency

Inborn Errors of Metabolism
Disorders of Amino Acid Transport and Metabolism
Disorders of Carbohydrate Transport and Metabolism

Disorders of Calcium Metabolism

Disorders of Phosphorus Metabolism
Familial Hypophosphatemia (Vitamin D-Resistant Rickets
X-linked Hypophosphatemia)

Chromosomal Disorders
5p-Syndrome (Cri-du-chat)
Cat Eye Syndrome
Recombinant 8
Trisomy 4
Trisomy 8
Trisomy 9 Mosiac Syndrome

7.30.3 NMAC                                               14
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
Facioscapulohumeral Muscular Dystrophy
Marfan Syndrome
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
Inborn Errors of Metabolism
Neural Tube Defects


Hereditary Hemolytic Anemias
Hereditary Spherocytosis
Hereditary Elliptocytosis
Hemolytic Anemias due to Enzyme Deficiency
G-6-PD Deficiency, Favism
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

7.30.3 NMAC                                                                                                     15
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
            Infantile Genetic
            Kostmann Syndrome
            Cyclic Neutropenia
Functional Disorders of PMNs
            Chronic Granulomatous Disease
            Job Syndrome
Genetic Anomalies of Leukocytes
            Hereditary Hyper/Hyposegmentation
            Eosinophilic Leukocytosis

Other Eligible Conditions
Familial Polycythemia

                                         IMMUNE SYSTEM DISORDERS

Deficiency of Humoral Immunity
Selective IgA Immunodeficiency
Selective IgM Immunodeficiency
Selective IgG Immunodeficiency
Bruton Disease
Immunodeficiency w/increased IgM

7.30.3 NMAC                                                        16
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
Elevated Lead level(persistent)


Cerebral Palsy
Chronic Inflammation/Infection


Degenerative Diseases of the Central/Peripheral Nervous System
Cerebral Lipidoses
Hereditary Chorea
Spinocerebellar Ataxia (Friedrich Ataxia)

Inborn Errors of Metabolism of Central and Peripheral Nervous System

Epilepsy - Idiopathic
Focal Motor
Grand Mal
Infantile Spasms
Minor Motor
Petit Mal
Partial Seizures-Complex
Chronic seizure disorder resulting from CNS infection, trauma or hemorrhage

Malformations of the CNS
Agenesis of the Corpus Callosum
A-V Malformations


7.30.3 NMAC                                                                   17
Neuromuscular Disorders
Amyotonia Congenita
Hypo/Hyer/Normokalemic Periodic Paralysis
Kearns Sayre Syndrome
Multiple Sclerosis
Muscular Dystrophy, Progressive
Myasthenia Gravis
Myotonia Congenita
Myotonic Dystrophy

Guillain-Barre Residual Plegia

Other Plegias
Peripheral Neuropathy
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
Tuberous Sclerosis

Anisometropia >2.0D
Anterior Chamber Foreign Body
Anterior Dislocation of Lens
Anterior Synechiae
Benign Neoplasm Lower Lid
Benign Neoplasm of Orbit
Canthal Tumor, Benign
Cataract, Congenital
Cataract, Traumatic
Chalazion/Meibomian Abscess
Conjunctival Cyst
Conjunctival Hemorrhage
Conjunctival/Episcleral Tumor, Benign

7.30.3 NMAC                                                         18
Conjunctivitis, Traumatic
Corneal Abrasion
Corneal Foreign Body
Corneal Opacities/Scarring
Corneal Ulcer
Corneal Vascularization
Diabetes Mellitus
Diabetic Retinopathy
Dry Eye Syndrome
Convergence insufficiency-symptomatic
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
Intra Corneal Foreign Body
Laceration Eyelid, Full Thickness
Laceration, Eye
Laceration, Orbit
Lid Tumor, Benign
Malignant Conjunctival/Episcleral Tumor
Malignant Eyelid Tumor
Malignant Neoplasm of the Eye
Neoplasm of Eye, Primary, Secondary
Ocular Foreign Body
Ocular Hypertension
Ocular Trauma
Optic Nerve Neuropathy
Orbital Fracture
Orbital Trauma

7.30.3 NMAC                               19
Pterygium, Recurrent
Pupil Deformity
Pupillary Occlusion
Refractive Error with underlying CMS condition
Retinal Detachment
Retinal Scarring
Retinal Tear
Ruptured Globe
Subluxation of Lens
Thickened Lens Capsule
Vitreous Bands
Vitreous Hemorrhage
Vitreous Opacities

                                       PLASTIC SURGICAL CONDITIONS
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
Nevus, Congenital Giant
Port Wine Stain

Asthma, Moderate to Severe

Bronchopulmonary Dysplasia

Cystic Fibrosis

                               RENAL AND URINARY TRACT DISORDERS

7.30.3 NMAC                                                               20
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


                                         RHEUMATIC DISEASE
Ankylosing Spondylitis
Juvenile Rheumatoid Arthritis
Mixed Connective Tissue Disease
Polyarteritis Nodosa
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

7.30.3 NMAC                                                     21

Hypopigmented Lesions
Chediak-Higashi Syndrome
Tuberous Sclerosis
Waardenberg Syndrome

Vesicobullous Disorders
Dermatitis Herpetiformis
Epidermolysis Bullosa

Atopic Dermatitis

Bloom Syndrome
Cockayne Syndrome
Hartnup Disease
Hydroa Vacciniforme
Polymorphous Light Eruption
Rothmund-Thomsom Syndrome
Xeroderma Pigmentosum

Diseases of the Epidermis
Acanthosis Nigrecans
Ichthyosis Syndromes
Psoriasis Porokeratosis

Diseases of the Dermis
Cutis Laxa
Pseudoxanthoma Elasticum
Urticaria Pigmentosa

Disorders of Subcutaneous Tissue
Partial Lipodystrophy
Seip-Lawrence Syndrome

Tumors of the Skin
Nevoid Basal Cell Carcinoma Syndrome

Cystic (scarring), Congoblotta Acne

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.

7.30.3 NMAC                                                                                                    22
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]

7.30.3 NMAC                                                                                23

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