Overview

In January 2014, New Mexico implemented Centennial Care, a Section 1115 demonstration waiver approved by the Centres for Medicare and Medicaid Services (CMS). Centennial Care offers Medicaid members an integrated model of care including physical health, behavioural health and long term services and supports.

The State contracts with three MCOs to administer the Centennial Care program:

Blue Cross Blue Shield (BCBS) – 249,313 enrolled members

Presbyterian Health Plan (PHP) - 385,192 enrolled members

Western Sky Community Care (WSCC) – 63,044 enrolled members

Membership statistics as of May 31, 2020.

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Eligibility

New Mexico continues to offer a fee-for-service system for certain short-term eligibility groups and services, home and community-based services for Individuals with Intellectual Disabilities (IID) and Medically Fragile conditions, the Program of All Inclusive Care for the Elderly, Intermediate Care Facilities for Individuals with IID, and Native Americans who choose not to “opt in” to managed care. In addition, the following Medicaid populations are also excluded from Centennial Care, and therefore covered by a FFS payment model:

Qualified Medicare Beneficiaries
Non-citizens only eligible for emergency medical services
Individuals eligible for family planning services only

Native Americans who are eligible for both Medicaid and Medicare or who have long-term care needs are required to enrol in New Mexico Centennial Care. All other Native Americans who are eligible for Medicaid have the choice to opt-in or opt-out of Centennial Care. Native Americans who do not opt-in to Centennial Care receive their health care services through the fee-for service payment system.

Fee-for-service does not cover enhanced care coordination, value-added services, nursing home case or home/community based series or member rewards. Skilled nursing is generally provided only through a HH agency under the Medicaid FFS program. However, an MCO can also provide skilled nursing through private duty nursing.

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Coverage

Managed Care in New Mexico covers most of the services that are in the Medicaid-approved State Plan, including:

Physician/Hospital Services
Pharmacy
Dental Services
Vision Services
Transportation Services
Behavioural Health Services
Long Term Care and Home & Community Based Services

MCOs in New Mexico have the flexibility to offer additional services based on need and the plan selected. Under Centennial Care, members receive additional services such as expanded care coordination and the value added benefits that each MCO offers its members. Value Added Benefits are additional health services and items that are not regular Medicaid benefits that MCOs choose to offer to their members. Each MCO offers a different list of Value Added Benefits. For example, MCOs may offer help paying for some Native American traditional healing and wellness services and/or extended lodging for homeless member following hospitalisation.

Data Considerations

HMS receives both FFS paid claims data and MCO encounter data on behalf of New Mexico Medicaid. The data set claim and encounter data for New Mexico is complete.