Exemptions from Medicaid Work or Activity Requirements for Hospitalized or Institutionalized Individuals
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This document explains exemptions from Medicaid work or activity requirements for members who are hospitalized, institutionalized, receiving similar residential care, traveling for treatment, or actively participating in substance use treatment programs. It affects New Mexico Medicaid members covered by the New Mexico Health Care Authority.
No material clinical or coverage changes in this revision.
Exemption Eligibility Criteria
Exemption criteria
Exemptions are available in the following circumstances and subject to the noted conditions:
Requests, Attestation, and Duration
Exemption request and allowed self-attestation
Members must request the exemption; HCA permits member self-attestation while institutionalized. Providers should inform members of the requirement, assist with submitting the member's request when needed, and document the member's attestation in the medical record or case file.
- Ensure the member submits an exemption request while institutionalized.
- Accept and record the member's self-attestation as permitted by HCA.
- Include the attestation and request details in the member's chart or case notes.
Exemption duration — ends at discharge
The exemption is short-term and applies only during the institutional stay; it ends when the member is no longer institutionalized. Providers must monitor institutional status and notify HCA or update records when the member is discharged or no longer meets the institutionalized condition.
- Track and document the member's institutionalized status during the stay.
- Notify HCA or update eligibility records when the member is discharged or no longer institutionalized so the exemption ends.
Substance use treatment exempts member for treatment duration
Members actively participating in a drug addiction or alcohol treatment and rehabilitation program are exempt from work or activity rules for the duration of their treatment; providers should verify and document active participation.
- Document the member's active participation in the treatment or rehabilitation program (program name, start date, ongoing attendance or participation).
- Provide confirmation of treatment participation to HCA or include it in the member's record to support continued exemption for the treatment period.
Key Definitions
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