Current through Register Vol. 35, No. 6, March 26, 2024
A.
Provider network adequacy:
Each health care insurer through its MHCP shall maintain and have available an
adequate network of licensed primary care practitioners (PCPs) to provide
comprehensive basic health care services to its enrolled population at all
times. Those MHCPs currently doing business in New Mexico shall submit to the
superintendent for approval an access plan addressing all of the criteria of
this section. A MHCP new to this state shall submit a preliminary access plan
to the division as part of its application for licensure. A MHCP new to this
state shall file a follow-up access plan with the superintendent within six
months after it obtains a certificate of authority. The superintendent shall
approve or reject an access plan submitted by a MHCP within 45 days after the
access plan is submitted to the division. In considering whether to approve or
reject an access plan, the superintendent shall determine whether the MHCP
meets all of the following criteria; however, the superintendent may make
reasonable exceptions to the criteria on a case by case basis when the MHCP
demonstrates the need for such exceptions.
(1) Whether, in population areas of 50,000 or
more residents, two PCPs are available within no more than 20 miles or 20
minutes average driving time for 90 percent of the enrolled population, or, in
population areas of less than 50,000, whether two PCPs are available in any
county or service area within no more than 60 miles or 60 minutes average
driving time for 90 percent of the enrolled population. For remote rural areas,
the superintendent shall consider on a case by case basis whether the MHCP has
made sufficient PCPs available given the number of residents in the county or
service area and given the community's standard of care.
(2) Whether the MHCP has a sufficient number
of PCPs to meet the primary care needs of the enrolled population, using, as
guidelines for calculation, the following criteria:
1) that each covered person will have four
primary care visits annually, averaging a total of one hour;
2) that each PCP will see an average of four
patients per hour; and
3) that one
full-time equivalent PCP will be available for every 1,500 covered
persons.
(3) Whether the
MHCP demonstrates that the projected PCP network is sufficient to meet the
primary care needs of adult, pediatric, and obstetric-gynecological patients.
Each MHCP should show the adequacy of PCP availability by verifying that the
PCPs committed to provide sufficient time for new patients so that projected
clinic hour needs of the projected enrollment by service area are
met.
(4) Whether the MHCP provides
reasonable and reliable access for its covered persons to qualified health care
professionals in those specialties that are covered by the MHCP. In developing
its access plan, the MHCP should:
1)
demonstrate that a sufficient number of licensed medical specialists are
available to covered persons for specialty care when referral to such care is
determined to be medically necessary by the PCP or other treating health care
professional in consultation with the MHCP; and
2) attempt to provide at least one licensed
medical specialist in those specialties that are generally available in the
geographic area served, taking into consideration the urban or rural nature of
the service area, the geographic location of each covered person, and the type
of specialty care needed by the covered person population. A MHCP shall not
restrict PCPs, in consultation with the MHCP, from referring covered persons to
providers outside the network, even when geographically distant from the
covered person's residence, when access to such treatment by such provider is
medically necessary and no other provider can provide comparable treatment
in-network or on a more cost-effective basis.
(5) Whether the MHCP has contracts, or other
arrangements acceptable to the superintendent, with institutional providers -
so that:
1) the need for services covered by
the MHCP is satisfied;
2) the
medical needs of covered persons are met 24 hours per day, seven days per week;
and
3) the institutional services
are geographically accessible to covered persons. In its access plan, the MHCP
should demonstrate that in population areas of 50,000 or more residents, at
least one licensed acute care hospital providing, at a minimum, licensed
medical-surgical, emergency medical, pediatric, obstetrical, and critical care
services is available no greater than 30 miles or 30 minutes average driving
time for 90 percent of the enrolled population within the service area, and, in
population areas of less than 50,000, that the acute care hospital is available
no greater than 60 miles or 60 minutes average driving time for 90 percent of
the enrolled population within the service area. For remote rural areas, the
superintendent shall consider on a case by case basis whether the MHCP has made
at least one licensed acute care hospital available given the number of
residents in the county or service area and given the community's standard of
care.
(6) Whether a
sufficient number of health care professionals, such as registered and licensed
practical nurses, are available to covered persons to ensure the delivery of
covered health care services.
(7)
Whether the MHCP has made surgical facilities including acute care hospitals
for major surgery, hospitals for minor surgical procedures, licensed ambulatory
surgical facilities, and medicare eligible surgical practices reasonably
available, given the population of the service area and the institutional
facilities available in or around the service area.
(8) Whether the MHCP has a policy assuring
access to tertiary and specialized services as evidenced by contract or other
agreement acceptable to the superintendent. In its access plan, the MHCP should
describe the geographic location of and covered persons' accessibility to the
following such services:
(a) at least one
hospital providing regional perinatal services, if maternity coverage is
offered as a health care service;
(b) a hospital offering tertiary pediatric
services;
(c) a hospital offering
diagnostic cardiac catheterization services;
(d) inpatient psychiatric services for adults
and children, if provided as a covered health care service; and
(e) a residential substance abuse treatment
center, if provided as a covered health care service.
(9) Whether the MHCP has a policy assuring
access to the specialized services listed below, as evidenced by contract or
other agreement acceptable to the superintendent. The MHCP should demonstrate
in its access plan the geographic location of and covered persons'
accessibility to the following such services:
(a) a therapeutic radiation
provider;
(b) magnetic resonance
imaging center;
(c) diagnostic
radiology provider, including x-ray, ultrasound, and CAT scan; and
(d) a licensed renal dialysis
center.
(10) Whether the
MHCP has at least one licensed home health care professional available to serve
each service area where 3,000 or more covered persons reside, if home health
care is provided as a covered health care service.
B.
Appointment waiting times:
Each MHCP shall demonstrate that the network will meet the following criteria:
(1) emergencies shall be triaged through the
PCP or by a hospital emergency room through medical screening or
evaluation;
(2) urgent care shall
be available within 48 hours of notification to the PCP or MHCP, or sooner as
required by the medical exigencies of the case;
(3) for both emergent and urgent care, the
MHCP shall ensure 7 day, 24 hour access to triage services, and that each PCP
will have back-up coverage by another provider;
(4) the MHCP shall have an adequate number of
PCPs with admitting privileges at one or more participating hospitals within
the MHCP's service area so that necessary hospital admissions are made on a
timely basis consistent with generally accepted practice parameters;
(5) routine appointments shall be scheduled
as soon as is practicable given the medical needs of the covered person and the
nature of the health care professional's medical practice;
(6) routine physical exams shall be scheduled
within 4 months;
(7) in all
instances of scheduling, the MHCP or its participating health care
professionals shall have guidelines to assess when an appointment should be
scheduled based on the type of health care service to be provided; upon
request, the MHCP shall make such guidelines available to covered
persons;
(8) all appointments shall
be scheduled either during normal business hours or after hours (if
applicable), depending upon the individual patient's needs and in accordance
with the individual physician's scheduling practice.
C.
Referrals: The MHCP shall
implement a system that ensures routine referrals are made to other
participating health care professionals.
(1)
A covered person shall not be held liable for payment of services if the MHCP
health care professional mistakenly makes a referral to a non-participating
health care professional, unless the MHCP has notified the covered person in
writing concerning the use of non-participating health care professionals and
informed the covered person that the MHCP will not be responsible for future
payment to the non-participating health care professionals.
(2) The MHCP shall bear the burden of showing
that the covered person has been adequately informed by specific written notice
of the MHCP's future refusal to pay for future care provided by the identified
non-participating health care professional.
(3) The MHCP shall ensure that a covered
person is not precluded from obtaining a referral from the covered person's PCP
to a specialist or other health care professional that is within the MHCP's
network, if the referral is reasonable.
D.
Provider lists: A MHCP must
provide a list of all providers to subscribers, enrollees, covered persons or
prospective enrollees upon request.
(1) The
list shall include specialty health care professionals and other health care
professionals providing health care services, and shall specify the locations,
including addresses, of such providers.
(2) The list shall identify those health care
professionals who are not currently accepting new patients.
(3) The information shall be made available
and upon request be provided to enrollees in the evidence of
coverage.
(4) Information should be
provided through toll-free phones and electronic means, as specified in
13.10.23.7 NMAC.
(5) MHCPS are
encouraged to facilitate a covered person's ability to obtain a second opinion
from a participating health care professional regarding the covered person's
request for a second opinion from, or referral to, a non-participating health
care professional.
E.
Out-of-network services: In the event medically necessary covered
services are not reasonably available through participating health care
professionals, the MHCP shall provide in the contract terms that the MHCP and
the PCP or other participating health care professional shall refer a covered
person to a non-participating health care professional and shall fully
reimburse the non-participating health care professional at the usual,
customary, and reasonable rate or at an agreed upon rate. The contract must
further state that before a MHCP may deny such a referral to a
non-participating physician or health care professional, the request must be
reviewed by a specialist similar to the type of specialist to whom a referral
is requested.
F.
Specialty
care: Referrals to participating or non-participating specialty health
care professionals must be accessible to covered persons on a timely and
appropriate basis in accordance with generally accepted medical guidelines.
(1) If the MHCP requires covered persons to
obtain prior authorization before referral to specialty care, the MHCP must
provide covered persons the following information in the evidence of coverage:
(a) procedures a covered person must follow
to obtain prior authorization for specialty referrals, including whether a
covered person's PCP, the MHCP's medical director, or a committee must first
authorize the specialty referral;
(b) the necessity, if any, of repeating prior
authorization if the specialist care is to be ongoing; and
(c) procedures to obtain a second medical
opinion.
(d) if a PCP referral is
required under the MHCP, the MHCP must inform PCPs of their responsibility to
provide written referrals; of any specific procedures that must be followed in
providing such referrals; and that the PCP must refer patients to those
participating health care professionals who are qualified to address the
covered person's health care needs as determined by the PCP in consultation
with the MHCP.
(2) The
MHCP shall make determinations on requests for referrals in accordance with
Subsection D of 13.10.13.19 NMAC.
(3) Covered persons denied referral to
specialty care may initiate a grievance through the MHCP's grievance procedures
pursuant to 13.10.17 NMAC.
G.
Ongoing specialty care: If,
in the best medical judgment of the covered person's PCP, the covered person's
health condition requires ongoing specialty care, such as for chronic illnesses
requiring medical supervision beyond the capability or training of the PCP, the
PCP may, after consultation with the specialist and the MHCP, refer the covered
person to the appropriate specialist for ongoing care as the severity of the
condition warrants.
(1) The ultimate
determination, however, of whether the covered person should have ongoing care
from the specialist shall remain with the PCP.
(2) In such cases, neither the PCP nor the
covered person will be required to obtain a prior authorization from the MHCP
for subsequent specialist visits.
(3) The MHCP may review such referrals to
specialist care on an annual basis to determine whether ongoing specialist care
continues to be medically necessary. In conducting such a review, the MHCP
shall consult with the covered person's primary care physician and the
specialist to whom the covered person has been referred.
(4) Nothing in Subsection G of 13.10.22.8
NMAC prohibits a MHCP from requiring that covered persons receive ongoing
specialist care from those specialists who are considered "participating health
care professionals" by the MHCP, unless there are no participating specialists
of the type required to manage the patient's condition. In such instances, the
MHCP shall make indemnity or other payment arrangements for the patient's care,
and covered persons will not be assessed higher or additional co-payments as a
result of such arrangements.
(5) A
MHCP must allow qualified health care professionals who are specialists to act
as PCPs for patients with chronic medical conditions of sufficient severity to
require primary coordination of care by a specialist as determined by the
covered person, the covered person's current treating health care professional,
the covered person's PCP if different than the treating health care
professional, and the MHCP, provided that:
(a) the specialist offers all basic health
care services that are required of them by the MHCP; and
(b) the specialist meets the MHCP's
eligibility criteria for health care professionals who provide primary
care.
H.
Out of state providers: A MHCP is encouraged to enter into
contracts or other arrangements with out of state providers in order to meet
the access requirements of this rule.
I.
Access to non-allopathic health
care services: In order to maximize covered persons' access to all types
of health care services, the division affirmatively encourages each health care
insurer or MHCP to enter into appropriate contracts with qualified health care
professionals, including but not limited to, doctors of oriental medicine,
chiropractic physicians, nurse practitioners, physician assistants, or
certified nurse midwives to provide both allopathic and non-allopathic health
care services.
J.
Reliance
on nationally recognized accreditation standards to meet access
standards: If the MHCP utilizes an open network pursuant to NMSA 1978,
Section 59A-22A-5, then in lieu of the provisions of 13.10.22.8 NMAC,
Subsections A-I, the MHCP shall present to the superintendent written
verification either that the National Committee for Quality Assurance (NCQA) or
American Accreditation Healthcare Commission/URAC (URAC) determined that the
MHCP has achieved one of the two highest ratings for all factors regarding
availability of health care professionals and accessibility of services, under
contemporaneous NCQA or URAC standards.
(1)
In lieu of the above, the plan shall present evidence to the superintendent
that it would achieve these ratings if evaluated by the NCQA or URAC, in
addition to member survey results.
(2) Plans shall also take into account that
the division will utilize the standards described in Subsections D, H and I of
13.10.22.8 NMAC, and the "medical necessity" and "usual, customary, and
reasonable rate" standards found in Subsection E of 13.10.22.8 NMAC.
