Current through Register Vol. 35, No. 18, September 24, 2024
A health care insurer offering basic health care services
through an HMO shall provide or shall arrange for the following medically
necessary basic health care services for its covered persons.
A. An HMO may not provide or arrange to
provide basic health care services if such services:
(1) do not include all the basic health
services set forth in this section; or
(2) are limited as to time or cost except as
prescribed in this section, subject to lifetime policy maximums.
B.
Outpatient medical
services: Outpatient medical services shall include those hospital
services that can reasonably be provided on an ambulatory basis, and those
preventive, medically necessary, and diagnostic and treatment procedures that
are prescribed by a covered person's primary care or attending health care
professional. Such services may be provided at a hospital, a physician's
office, any other appropriate licensed facility, or at any other appropriate
facility if the health care professional delivering the services is licensed to
practice, is certified, and is practicing under authority of the health care
insurer or HMO, a medical group, an independent practice association or other
authority authorized by applicable New Mexico law.
C.
Inpatient hospital services:
Inpatient hospital services shall include, but not be limited to, semi-private
room accommodations, general nursing care, meals and special diets or
parenteral nutrition when medically necessary, physician and surgeon services,
use of all hospital facilities when use of such facilities is determined to be
medically necessary by the covered person's primary care practitioner or
treating health care professional, pharmaceuticals and other medications,
anesthesia and oxygen services, special duty nursing when medically necessary,
radiation therapy, inhalation therapy, and administration of whole blood and
blood components when medically necessary.
D.
Emergency and urgent care
services: Emergency and urgent care services shall include:
(1) acute medical care that is available
twenty-four hours per day, seven days per week, so as not to jeopardize a
covered person's health status if such services were not received immediately;
such medical care shall include ambulance or other emergency transportation; in
addition, acute medical care shall include, where appropriate, transportation
and indemnity payments or service agreements for out-of-service area or
out-of-network coverage in cases where the covered person cannot reasonably
access in-network services or facilities; and
(2) coverage for trauma services at any
designated level I, level II, or other appropriately designated trauma center
according to established emergency medical services triage and transportation
protocols; coverage for trauma services and all other emergency services shall
continue at least until the covered person is medically stable, does not
require critical care, and can be safely transferred to another facility based
on the judgment of the attending physician or health care professional in
consultation with the HMO; if the health care insurer or HMO requests transfer
to a hospital participating in its provider network, the patient must be
stabilized and the transfer effected in accordance with federal law. See
42 CFR 489.20
and
42
CFR 489.24;
(3) reimbursement for emergency care and
emergency transportation shall not be denied by the health care insurer or HMO
when the covered person, who in good faith and who possesses average knowledge
of health and medicine, seeks medical care for what reasonably appears to the
covered person to be an acute condition that requires immediate medical
attention, even if the patient's condition is subsequently determined to be
non-emergent;
(4) in determining
whether care is reimbursable as emergency care, the MHCP shall take the
following factors into consideration:
(a) a
reasonable person's belief that the circumstances required immediate medical
care that could not wait until the next working day or next available
appointment;
(b) the time of day
the care was provided;
(c) the
presenting symptoms; and
(d) any
circumstances which precluded use of the HMO's established procedures for
obtaining emergency care;
(5) reimbursement for emergency care shall
not be denied in those instances when the covered person is referred to
emergency care by the covered person's primary care practitioner or by the
HMO;
(6) no prior authorization
shall be required for emergency care. In addition, appropriate out-of-network
emergency care shall be provided to a covered person without additional cost;
whether out-of-network emergency care is appropriate shall be determined by the
standards of Paragraph (4) of Subsection D of 13.10.21.8 NMAC.
E.
Short-term
rehabilitation services and physical therapy: Short-term rehabilitation
services and physical therapy shall be provided in those instances where the
covered person's primary care practitioner or other appropriate treating health
care professional determines that such services and therapy can be expected to
result in the significant improvement of a covered person's physical condition
within a period of two months. Such services may be extended beyond the two
month period upon recommendation by the primary care practitioner in
consultation with the HMO.
F.
Diagnostic services: Diagnostic services shall include diagnostic
laboratory services, diagnostic and therapeutic radiological services, and
other services in support of comprehensive basic health care
services.
G.
Other mandated
benefits: Any and all mandated benefits pursuant to federal or state law
that apply to HMOs which become effective following promulgation of this rule,
and the following:
(1) dental services:
(a) when determined to be medically necessary
by a participating provider in connection with the following: accidental injury
to sound natural teeth, the jaw bones, or surrounding tissues; the correction
of a non-dental physiological condition which has resulted in a severe
functional impairment; or the treatment for tumors and cysts requiring
pathological examination of the jaws, cheeks, lips, tongue, roof and floor of
the mouth;
(b) general anesthesia
and hospitalization, pursuant to Section 59A-46-48 NMSA 1978;
(2) reconstructive surgery:
surgery from which an improvement in physiologic function could reasonably be
expected, when ordered by a covered person's primary care practitioner or
treating health care professional and performed for the correction of
functional disorders resulting from accidental injury or from congenital
defects or disease;
(3) diabetes
care: for insulin-using individuals, non-insulin-using individuals and those
with elevated blood glucose levels induced by pregnancy, coverage pursuant to
Section 59A-46-43 NMSA 1978;
(4)
medical diets: for genetic inborn errors of metabolism, medical diets pursuant
to Section 59A-46-43.2 NMSA 1978;
(5) craniomandibular and temporomandibular
joint disorders: for surgical and nonsurgical treatment of temporomandibular
joint disorders and craniomandibular disorders, subject to the same conditions,
limitations, prior review and referral procedures as are applicable to
treatment of any other joint in the body, pursuant to Section 59A-16-13.1 NMSA
1978;
(6) cancer clinical trials:
routine patient care costs incurred as a result of the patient's participation
in a phase II, III or IV cancer clinical trial, pursuant to Section 59A-22-43
NMSA.
H.
Children's health care: Children's health care shall include, but not be
limited to:
(1) childhood immunizations,
pursuant to Section 59A-46-38.2 NMSA 1978;
(2) vision and hearing testing for persons
through age 17 to determine the need for vision and hearing
corrections;
(3) well-child care
from birth in accordance with recommendations of the American academy of
pediatrics;
(4) prenatal care,
including medically necessary nutritional supplements prescribed by the
expectant mother's obstetrician-gynecologist, or other health care professional
from whom the expectant mother is receiving prenatal care, if maternity
coverage is provided by the HMO;
(5) availability of educational materials or
consultation from providers to discuss lifestyle behaviors that promote health
and well-being including, but not limited to, the consequences of tobacco use,
nutrition and diet recommendations, exercise plans, and, as deemed appropriate
by the primary care practitioner or as requested by the parents or legal
guardian, educational information on alcohol and substance abuse,
sexually-transmitted diseases, and contraception;
(6) hearing aid coverage, pursuant to Section
59A-46-38.5 NMSA 1978; and
(7)
circumcision for newborn males, pursuant to Section 59A-46-38.4 NMSA
1978.
I.
Women's
health care: Women's health care coverage shall be included in all HMOs,
and shall include, at a minimum, the following:
(1) mammograms, pursuant to Section 59A-46-41
NMSA 1978;
(2) cytologic and human
papillomavirus screening, pursuant to Section 59A-46-42 NMSA 1978;
(3) osteoporosis services, defined as
diagnosis, treatment, and appropriate management of osteoporosis when such
services are determined to be medically necessary by a covered person's primary
care practitioner in consultation with the HMO;
(4) alpha-fetoprotein IV screening, pursuant
to Section 59A-46-46 NMSA 1978;
(5)
limitation on visits: an HMO may limit the number of visits to designated
women's health care providers by female covered persons, provided that it
allows:
(a) at least one routine annual
well-visit per female covered person; and
(b) follow-up treatment within sixty days
following a well-visit for treatment of a condition diagnosed during a
well-visit.
J.
HMOs providing maternity
coverage: If an HMO provides maternity benefits, the coverage shall
include:
(1) medically necessary prenatal,
intrapartum, and perinatal care;
(2) smoking cessation treatment, pursuant to
Section 59A-46-45 NMSA 1978; and 13.10.18.8 NMAC;
(3) maternity transport, pursuant to Section
59A-46-39 NMSA 1978; and
(4)
minimum hospital stays and postpartum care, pursuant to federal law and 13.10.2
NMAC.
K.
HMOs
providing mastectomy coverage: Each HMO which provides mastectomy
coverage shall also cover mammography for screening and diagnostic purposes,
prosthetic devices, and reconstructive surgery, as mandated by federal or state
laws.
L.
Direct access to
women's health care practitioners: A female covered person whose primary
care practitioner is not a women's health care practitioner shall have direct
and timely access to an in-network, participating women's health care
practitioner for women's health care coverage, as defined at Subsection I of
13.10.21.7 NMAC. Direct access shall also be offered by an HMO that offers
additional obstetric and gynecological services beyond those required under
this rule, or that offers maternity coverage.
(1)
Disclosure. Each managed
health care plan shall disclose to covered persons in clear, accurate language,
the right of female covered persons age 13 and over of direct access to an
in-network, participating women's health care practitioner of her choice. The
information shall include, at a minimum, any specific women's health care
services excluded from coverage, and shall include reference to the HMO's right
to limit coverage to medically necessary and appropriate women's health care
services.
(2)
Co-payments. No HMO shall impose additional copayments, co-insurance, or
deductibles for female covered persons' direct access to in-network,
participating women's health care providers when acting as a PCP.
(3)
Choice to become a PCP.
Nothing in this section requires any women's health care provider to enter into
a contract with an HMO whereby he or she must act as a primary care
practitioner (PCP) rather than as a referral specialist.
(4)
Criteria for PCP
acceptance. An HMO's criteria for accepting women's health care
providers as PCPs must be the same as the criteria utilized by the HMO for
other specialists seeking to act as PCPs.
(5)
Procedure for direct
access. Any female covered person age 13 or older shall have direct
access to women's health care by:
(a)
including qualified women's health care providers as primary care practitioners
(PCPs), which means that the women's health care provider has met the HMO's
general eligibility criteria for a specialist seeking PCP status, and agrees
with the HMO to comply with its coordination and referral policies;
(b) allowing female covered persons to select
a qualified women's health care practitioner as their PCP; and
(c) allowing female covered persons who have
not chosen a women's health care provider as their PCP to self-refer, without
requiring prior authorization or pre-approval from the plan or their PCP, to an
in-network, participating women's health care practitioner for women's health
care and, if offered as a covered benefit under the plan, for maternity care
and additional obstetric and gynecological services, subject to the following:
(i) self-referrals shall be limited to those
services defined by the published recommendations of the American college of
obstetrics and gynecology;
(ii) the
HMO may require the women's health care practitioner to discuss with the female
covered person's PCP any services or treatment the women's health care
practitioner recommends for the covered person.
(iii) the women's health care practitioner
must comply with the HMO's coordination and referral policies.
M.
Health promotion program: Each HMO that provides coverage for
comprehensive basic health care services in this state shall provide a
preventative health services program and shall make the following services
available to a covered person only in those instances where the covered
person's primary care practitioner determines that such services are medically
necessary:
(1) periodic tests to determine
blood hemoglobin, blood pressure, blood glucose level, and blood cholesterol
level or, alternatively, a fractionated cholesterol level including a
low-density lipoprotein (LDL) level and a high-density lipoprotein (HDL) level,
in accordance with recommendations of the U.S. preventive services task
force;
(2) periodic glaucoma eye
tests for all persons 35 years of age or older, in accordance with
recommendations of the U.S. preventive services task force;
(3) periodic stool examinations for the
presence of blood for all persons 50 years of age or older, in accordance with
recommendations of the U.S. preventive services task force;
(4) colorectal cancer screening, in
accordance with the recommendations of the U.S. preventive services task force,
pursuant to Section 59A-46-48 NMSA 1978;
(5) immunizations for all adults, as
recommended by the CDC advisory committee for immunization practice;
(6) for all persons 20 years of age or older
and as deemed medically necessary by a primary care practitioner, an annual
consultation with a health professional to discuss lifestyle behaviors that
promote health and well-being including, but not limited to, smoking control,
nutrition and diet recommendations, exercise plans, lower back protection,
immunization practices, breast self-examination, testicular self-examination,
use of seat-belts in motor vehicles, and other preventative health care
practices;
(7) other preventative
health services shall include, under a covered person's primary care
practitioner's supervision:
(a) reasonable
physical and behavioral health appraisal examinations and laboratory and
radiological tests on a periodic basis when medically necessary;
(b) voluntary family planning services;
and
(c) diagnosis and medically
indicated treatments for physical conditions causing infertility except as
required to reverse prior voluntary sterilization surgery.
