(a) The HMO
shall maintain contracts or other arrangements acceptable to the Department
with institutional providers which have the capability to meet the medical
needs of members and are geographically accessible. The network of providers
shall include:
1. At least one licensed acute
care hospital including at least licensed medical-surgical, pediatric,
obstetrical, and critical care services in any county or service area no
greater than 20 miles or 30 minutes driving time, whichever is less, from 90
percent of members within the county or service area;
2. Surgical facilities including acute care
hospitals, licensed ambulatory surgical facilities, and/or Medicare-certified
physicians surgical practices available in each county or service area no
greater than 20 miles or 30 minutes driving time, whichever is less, from 90
percent of members within the county or service area;
3. Tertiary and specialized services as
follows:
i. The HMO shall have a contract or
otherwise agree to cover medically necessary trauma services at a reasonable
cost with all Level I or II trauma centers designated by the New Jersey
Department of Health and Senior Services pursuant to N.J.A.C. 8:33P. The member
may not be balance billed for any covered trauma services provided by such
designated trauma centers.
ii. The
HMO must have a policy assuring access, as evidenced by contract or other
agreement acceptable to the Department, to the following specialized services,
as determined to be medically necessary. Such services will be available within
45 miles or 60 minutes average driving time, whichever is less, of 90 percent
of members within each county or approved sub-county area:
(1) At least one hospital providing regional
perinatal services;
(2) A hospital
offering tertiary pediatric services;
(3) In-patient psychiatric services for
adults, adolescents and children;
(4) Residential substance abuse treatment
center;
(5) Diagnostic cardiac
catheterization services in a hospital;
(6) Specialty out-patient centers for
HIV/AIDS, sickle cell disease, hemophilia, and cranio facial and congenital
anomalies; and
(7) Comprehensive
rehabilitation services.
iii. The HMO shall have a policy assuring
access, as evidenced by contract or other agreement acceptable to the
Department, to the following specialized services, as determined to be
medically necessary. Such services will be available within 20 miles or 30
minutes average driving time, whichever is less, of 90 percent of members
within each county or approved sub-county area:
(1) A licensed long term care facility with
Medicare-certified skilled nursing beds;
(2) Therapeutic radiation provider;
(3) Magnetic resonance imaging
center;
(4) Diagnostic radiology
provider, including x-ray, ultrasound, and CAT scan;
(5) Emergency mental health service,
including a short term care facility for involuntary psychiatric
admissions;
(6) Out-patient therapy
providers for mental health and substance abuse conditions; and
(7) Licensed renal dialysis
provider.
4.
At least one home health agency licensed by the Department to serve each county
where 1,000 or more members reside; and
5. At least one hospice program certified by
Medicare in any county where 1,000 or more members reside.
