Common use of Alternative Benefit Plan Clause in Contracts

Alternative Benefit Plan. A. The Contractor shall determine a recipient’s exemption from the New Mexico Medicaid Expansion Alternative Benefit Plan (ABP) based on criteria and procedures established by HSD. B. The following individuals are exempt from mandatory participation in an ABP and may choose to receive full Medicaid State Plan benefits: 1. Individuals who qualify for medical assistance on the basis of being blind or disabled (or being treated as being blind or disabled) without regard to whether the individuals are eligible for Supplemental Security Income benefits; 2. Individuals who are terminally ill and are receiving benefits for hospice care; 3. Individuals who are medically frail or who have special medical needs. The following individuals are considered to be medically frail: a) Individuals with disabling mental disorders, including adults with serious mental illness; b) Individuals with chronic substance use disorders; c) Individuals with serious and complex medical conditions; d) Individuals with a physical, intellectual or developmental disability that significantly impairs their ability to perform one or more activities of daily living; and e) Individuals with a disability determination based on Social Security criteria. C. The Contractor shall perform utilization reviews of HSD-specified ABP Services according to the applicable Method and Categories of Reviews currently in place for Medicaid services (see sections 1.1(2) M and 1.1(2) N of this PSC).

Alternative Benefit Plan. A. The Contractor shall determine a recipient’s exemption from the New Mexico Medicaid Expansion Alternative Benefit Plan (ABP) based on criteria and procedures established by HSDHCA. B. The following individuals are exempt from mandatory participation in an ABP and may choose to receive full Medicaid State Plan benefits: 1. Individuals who qualify for medical assistance on the basis of being blind or disabled (or being treated as being blind or disabled) without regard to whether the individuals are eligible for Supplemental Security Income benefits; 2. Individuals who are terminally ill and are receiving benefits for hospice care; 3. Individuals who are medically frail or who have special medical needs. The following individuals are considered to be medically frail: a) Individuals with disabling mental disorders, including adults with serious mental illness; b) Individuals with chronic substance use disorders; c) Individuals with serious and complex medical conditions; d) Individuals with a physical, intellectual intellectual, or developmental disability that significantly impairs their ability to perform one or more activities of daily living; and e) Individuals with a disability determination based on Social Security criteria. C. The Contractor shall perform utilization reviews of HSDHCA-specified ABP Services according to the applicable Method and Categories of Reviews currently in place for Medicaid services (see sections 1.1(2) M and 1.1(2) N of this PSC).