New Jersey Administrative Code
Title 11 - INSURANCE
Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS
Subchapter 6 - PROVIDER NETWORK
Section 11:24-6.2 - Primary, specialty and ancillary providers

Universal Citation: NJ Admin Code 11:24-6.2

Current through Register Vol. 56, No. 24, December 18, 2024

(a) The HMO shall maintain an adequate network of primary care providers, specialists, and other ancillary health care personnel to serve the enrolled population at all times. For certificate of authority applications to initiate operations within a service area, this adequacy shall be evaluated based on enrollment projections at the end of 12 months of operation. At a minimum, the network of providers shall include:

1. Medical and other professional staff, as follows:
i. There shall be a sufficient number of licensed primary care providers (PCPs) under contract with the HMO to provide basic comprehensive health care services;

ii. There shall be a sufficient number of licensed medical specialists available to HMO members to provide medically necessary specialty care. The HMO shall have a policy assuring access to the specialists identified in (a)1ii(1) through (13) below within 45 miles or one hour driving time, whichever is less, of 90 percent of members within each county or approved sub-county service area:
(1) Cardiologist;

(2) Dermatologist;

(3) Endocrinologist;

(4) ENT;

(5) General surgeon;

(6) Neurologist;

(7) Obstetrician/gynecologist;

(8) Oncologist;

(9) Ophthalmologist;

(10) Orthopedist;

(11) Oral surgeon;

(12) Psychiatrist; and

(13) Urologist;

iii. For specialists not identified in (a)1ii above, the HMO shall have a policy assuring access to such specialists within 45 miles or one hour driving time, whichever is less, of 90 percent of members within each county or approved sub-county service area;

iv. There shall be a sufficient number of other health professional staff including but not limited to licensed nurses and other professionals available to HMO members to provide basic health care services;

v. There shall be sufficient licensed optometrists associated with or available to the HMO to assure that, unless referral to an ophthalmologist is determined by the PCP to be medically required and outside the scope of practice of an optometrist, the member can choose to have vision care services provided by a licensed optometrist. The HMO shall have a policy assuring access to these providers, as set forth above in N.J.A.C. 11:24-6.2(a)1 ii.

vi. If the HMO provides pharmacy services, prescription drugs, or a prescription drug plan, no registered pharmacy or pharmacist shall be denied the right to participate as a preferred provider pursuant to the terms of N.J.S.A. 26:2J-4.7.

(b) Physicians qualified to function as primary care providers include the following categories:

1. Licensed physicians who have successfully completed a residency program accredited by the Accreditation Council for Graduate Medical Education or approved by the American Osteopathic Association in family practice, internal medicine, general practice, obstetrics and gynecology or pediatrics;

2. Licensed physicians who do not meet the qualifications in 1 above, but who have been evaluated by the committee required at N.J.A.C. 11:24-4.2(a)7 and found to demonstrate through training, education and experience, equivalent expertise in primary care;

3. At the discretion of the HMO, exceptions may be made for appropriate licensed medical specialists to be designated as primary care provider for specified individual members or patient groups who, due to health status or chronic illness, would benefit from medical care management by such a medical specialist.

(c) Health care professionals qualified as primary care providers include the following categories:

1. Nurse practitioners/clinical nurse specialists certified by the State Board of Nursing in accordance with N.J.S.A. 45:11-45 et seq. in advance practice categories comparable to family practice, internal medicine, general practice, obstetrics and gynecology or pediatrics; and in hospitals or other facilities;

2. Physician assistants licensed by the New Jersey Board of Medical Examiners; and

3. Certified nurse midwives registered by the New Jersey Board of Medical Examiners.

(d) Geographic access and availability standards for primary care providers (PCPs) shall be as follows:

1. There shall be at least two physicians within 10 miles or 30 minutes average driving time or public transit (if available), whichever is less, of 90 percent of the enrolled population.

2. The HMO shall demonstrate that the projected PCP network is sufficient to meet adult, pediatric and primary ob/gyn needs of the projected enrollment on the basis of the following assumptions:
i. Four primary care visits per year per member, averaging one hour per year per member; and

ii. Four patient visits per hour, per PCP;

3. In order to demonstrate PCP availability, an HMO shall verify that the PCP has committed to provide a specific number of hours for new patients that cumulatively add up to projected clinic hour needs of projected enrollment by county or service area.

4. The HMO shall demonstrate that the network of PCPs is sufficient to assure that the following criteria will be met:
i. Emergencies shall be triaged immediately through the PCP or by a hospital emergency room through medical screening or evaluation;

ii. Urgent care shall be provided within 24 hours of notification of the PCP or HMO;

iii. In both emergent and urgent care, PCPs shall be required to provide seven day, 24 hour access to triage services;

iv. Routine appointments shall be scheduled within two weeks; and

v. Routine physical exams shall be scheduled within four months.

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