New Mexico Register / Volume XXXVII, Issue 16 / August 25, 2026

This is an amendment to 8.324.7 NMAC, Sections 1, 8, 10, 12, 13, and 15, effective 9/1/2026.

8.324.7.1 ISSUING AGENCY: New Mexico health care authority (HCA).

[8.324.7.1 NMAC - Rp, 8.324.7.1 NMAC, 1/1/2014; A, 7/1/2024; A, 9/1/2026]

8.324.7.8 MISSION STATEMENT: [To reduce the impact of poverty on people living in New Mexico by providing support services that help families break the cycle of dependency on public assistance.] We ensure that New Mexicans attain their highest level of health by providing whole-person, cost effective, accessible, and high-quality health care and safety net services.

[8.324.7.8 NMAC - Rp, 8.324.7.8 NMAC, 1/1/2014; A, 9/1/2026]

8.324.7.10 Eligible Providers: Health care to a MAP eligible recipient is furnished by a variety of providers and provider groups. Reimbursement and billing for these services are administered by MAD. Upon approval of a New Mexico MAD provider participation agreement (PPA) by MAD or its designee, licensed practitioners, facilities and other providers of services that meet applicable requirements are eligible to be reimbursed for furnishing covered services to a MAP eligible recipient. Providers must be enrolled before submitting a claim for payment to the MAD claims processing contractors. MAD makes available on the [HSD/MAD] HCA/MAD website, on other program specific websites, and in hard copy format, information necessary to participate in health care programs administered by [HSD] HCA or its authorized agents, including program rules, billing instructions, utilization review (UR) instructions, and other pertinent material. When enrolled, a provider receives instruction on how to access these documents. It is the provider’s responsibility to access these instructions, to understand the information provided and to comply with the requirements. Providers must contact [HSD] HCA, or its authorized agents, for answers to billing questions or any of these materials. To be eligible for reimbursement, a provider must adhere to the provisions of the MAD PPA and applicable statutes, regulations, rules, and executive orders. MAD or its selected claims processing contractor issues payments to a provider using electronic funds transfer (EFT) only. Providers must supply necessary information in order for payment to be made. The following providers are eligible to be reimbursed for providing transportation or transportation related services to MAP eligible recipients:

A. air ambulances certified by the state of New Mexico department of health (DOH), emergency medical services bureau;

B. ground ambulance services certified by the New Mexico public regulation commission (NMPRC) or by the appropriate state licensing body for out-of-state ground ambulance services, within those geographic regions in the state specifically authorized by the NMPRC;

C. [non-emergency transportation vendors (taxicab, vans and other vehicles) and certain bus services certified by the NMPRC, within those geographic regions in the state specifically authorized by the NMPRC] non-emergency transportation certified by the NMPRC, within those geographic regions in the state specifically authorized by the NMPRC:

(1) vendors (taxicab, vans and other vehicles);

(2) certain bus services; and

D. transportation network companies that have been issued a permit by the New Mexico department of transportation (DOT) that meets the requirements set forth in the Transportation Network Company Services Act. Transportation network companies’ terms are defined as follows:

(1) "transportation network company" means a corporation, partnership, sole proprietorship or other entity that holds a permit issued pursuant to the Transportation Network Company Services Act and lawfully operating in New Mexico that uses a digital network, but which shall not be deemed to control, direct or manage the personal vehicles or transportation network company drivers that connect to its digital network except where agreed to by written contract, 65-7-2 NMSA (2016);

(2) "digital network" means an internet-supported application, software, program, website or system offered or utilized by a transportation network company that enables the prearrangement of transportation by passengers with transportation network company drivers.

[D.] E. long distance common carriers, that include buses, trains and airplanes;

[E.] F. certain carriers exempted or warranted by the NMPRC within those geographic regions in the state specifically authorized by the NMPRC;

[F.] G. lodging and meal providers; and

[G.] H. when services are billed to and paid by a MAD MAP coordinated services contractor authorized by [HSD] HCA, under an administrative services contract, the provider must also enroll as a provider with the coordinated services contractor and follow that contractor’s instructions for billing and for authorization of services.

[8.324.7.10 NMAC - Rp, 8.324.7.10 NMAC, 1/1/2014; A, 9/1/2026]

8.324.7.12 Covered Services and Service Limitations: MAD reimburses a transportation provider for transportation only when the transport is of a MAP eligible recipient and is subject to the following conditions.

A. Free alternatives: Alternative transportation services that can be provided free of charge include volunteers, relatives or transportation services provided by nursing facilities (NF) or other residential centers.

B. Least costly alternatives: MAD covers the most appropriate and least costly transportation alternatives suitable for the MAP eligible recipient’s medical or behavioral health condition. If a MAP eligible recipient can use a private vehicle or public transportation, those alternatives must be used before a MAP eligible recipient can use more expensive transportation alternatives.

C. Non-emergency transportation service: MAD covers non-emergency transportation services for a MAP eligible recipient who has no primary transportation and who is unable to access a less costly form of public transportation except as described under non-covered services. See 8.324.7.13 NMAC.

D. Long distance common carriers: MAD covers long distance services furnished by a common carrier if a MAP eligible recipient must leave [his or her] their home community to receive medical or behavioral health services. Authorization forms for direct payment to long distance bus common carriers by MAD are available through local county income support division (ISD) offices.

E. Ground ambulance services: MAD covers services provided by ground ambulances when:

(1) an emergency that requires ambulance service is certified by a physician or is documented in the provider’s records as meeting emergency medical necessity criteria: terms are defined as follows:

(a) “emergency” is defined as a medical or behavioral health condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in placing the health of the MAP eligible recipient (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, serious impairment to body function or serious dysfunction of any bodily organ or part;

(b) “medical necessity” is established for ambulance services if the MAP eligible recipient’s physical, or behavioral health condition is such that the use of any other method of transportation is contraindicated and would endanger the MAP eligible recipient’s health.

(2) Scheduled, non-emergency ambulance services are ordered by a primary care provider (PCP) who certifies that the use of any other method of non-emergency transportation is contraindicated by the MAP eligible recipient’s physical, or behavioral health condition. MAD covers non-reusable items and oxygen required during transportation, if needed; coverage for these items is included in the base rate reimbursement for ground ambulance.

F. Air ambulance services: MAD covers services provided by air ambulances, including private airplanes, if an emergency exists and the PCP certifies the medical necessity for the service.

(1) An emergency that would require air over ground ambulance services is defined as a medical or behavioral health condition, including emergency labor and delivery, manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in one of the following:

(a) a MAP eligible recipient’s death;

(b) placement of a MAP eligible recipient’s health is in serious jeopardy (or with respect to a pregnant woman, the health of the woman or her unborn child);

(c) serious impairment of bodily functions; or

(d) serious dysfunction of any bodily organ or part.

(2) Coverage for the following is included in the base rate reimbursement for air ambulance:

(a) non-reusable items and oxygen required during transportation;

(b) professional attendants required during transportation;

(c) detention time or standby time; and

(d) use of equipment required during transportation.

G. Lodging services: MAD covers lodging services if a MAP eligible recipient is required to travel to receive medical services more than four hours one way and an overnight stay is required due to medical necessity or cost considerations. If medically justified and approved, lodging is initially set for up to five continuous days. For a longer stay, the need for lodging must be re-evaluated by the fifth day to authorize up to an additional 15 days. Re-evaluation must be made every 15 days for extended stays, prior to the expiration of the existing authorization. Approval of lodging is based on the medical or behavioral health provider’s statement of need. Authorization forms for direct payment by MAD to its lodging providers are available through local county ISD offices.

H. Meal services: MAD covers meals if a MAP eligible recipient is required to leave [his or her] their home community for eight hours or more to receive medical or behavioral health services. Authorization forms for direct payment to MAD meal providers by MAD are available through local county ISD offices.

I. Coverage for attendants: MAD covers transportation, meals and lodging for one attendant if the medical necessity for the attendant is certified in writing justified by the MAP eligible recipient’s medical provider or the MAP eligible recipient who is receiving medical service is under 18 years of age. The attendant for a child under 18 years of age should be the parent or legal guardian. If the medical appointment is for an adult MAP eligible recipient, MAD does not cover transportation services or related expenses of children under 18 years of age traveling with the adult MAP eligible recipient.

J. Coverage for medicaid home and community-based services waiver recipients: Transportation of a medicaid waiver recipient to or from a provider of waiver service is only covered when the service is a physical therapy, occupational therapy, speech therapy or a behavioral health service.

[8.324.7.12 NMAC - Rp, 8.324.7.12 NMAC, 1/1/2014; A, 9/1/2026]

8.324.7.13 Noncovered Services: Transportation services are subject to the same limitations and coverage restrictions that exist for other MAD services. See [8.301.3] 8.310.2 NMAC. Payments for transportation for any non-covered service is subject to retroactive recoupment.

A. MAD does not pay to transport a MAP eligible recipient to a medical or behavioral health service or provider that is not covered under the MAD program.

B. A provider will not be eligible to seek reimbursement from a MAP eligible recipient if the provider fails to notify the MAP eligible recipient or [his or her] their authorized representative that the service is not covered by MAD. See 8.302.1 NMAC.

C. Transportation services will not be provided when other alternatives are available, such as mail delivery or free delivery. Retail pharmacies may mail, ship or deliver prescriptions to medicaid recipients consistent with applicable state and federal statutes and regulations.

D. MAD does not pay to transport a MAP eligible recipient to a pharmacy provider with the exception of justice-involved MAP eligible recipients who are released from incarceration at a correctional facility within the first seven days of release.

[8.324.7.13 NMAC - Rp, 8.324.7.13 NMAC, 1/1/2014; A, 9/1/2026]

8.324.7.15 Prior AUTHORIZATION and Utilization Review: All MAD services are subject to utilization review (UR) for medical necessity and program compliance. Reviews can be performed before services are furnished, after services are furnished, and before payment is made or after payment is made. See [8.302.5] 8.310.2 NMAC. The provider must contact [HSD] HCA or its authorized agents to request UR instructions. It is the provider’s responsibility to access these instructions or request hard copies to be provided, to understand the information, to comply with the requirements, and to obtain answers to questions not covered by these materials. When services are billed to and paid by a MAD fee-for-service coordinated services contractor, the provider must follow that contractor’s instructions for authorization of services.

A. Prior authorization: Certain procedures or services may require prior authorization from MAD or its designee. Services for which prior authorization is received remain subject to UR at any time during the payment process.

B. Referrals for travel outside the home community:

(1) If a MAP eligible recipient must travel over [65] 120 miles from [his or her] their home community to receive medical or behavioral health care, the transportation provider must obtain and retain in its billing records written verification from the referring provider or the service provider containing the following:

(a) the medical, behavioral health or diagnostic service for which the MAP eligible recipient is being referred;

(b) the name of the out of community provider; and

(c) justification that the medical or behavioral health care is not available in the home community.

(2) Referrals and referral information must be obtained from a MAD provider. For continued out-of-community, non-emergency transportation, the required information must be obtained every [six] 12 months.

C. Eligibility determination: Prior authorization does not guarantee that individuals are eligible for MAD services. Providers must verify that an individual is eligible for MAD services at the time services are furnished and determine if the MAP eligible recipient has other health insurance.

[8.324.7.15 NMAC - Rp, 8.324.7.15 NMAC, 1/1/2014; A, 9/1/2026]