New Mexico Administrative Code
Title 13 - INSURANCE
Chapter 10 - HEALTH INSURANCE
Part 23 - MANAGED HEALTH CARE PLAN CONTRACTING
Section 13.10.23.14 - CONTINUATION AND TRANSITION OF TREATMENT

Universal Citation: 13 NM Admin Code 13.10.23.14

Current through Register Vol. 35, No. 6, March 26, 2024

Each health care insurer shall offer continuation and transition of treatment to covered persons in compliance with the Insurance Code and applicable rules.

A. If a covered person's health care provider leaves the MHCP's network of providers, the MHCP shall permit the covered person to continue an ongoing course of treatment with the provider for a transitional period.

B. For all covered persons except those addressed Subsection C of 13.10.23.14 NMAC, the transitional period shall continue for a time that is sufficient to permit coordinated transition planning consistent with the patient's condition and needs relating to continuity of case, and, in any event, shall not be not less than thirty days.

C. If a covered person has entered the third trimester of pregnancy at the time of the provider's disaffiliation, and the MHCP offers maternity coverage, the transitional period shall include the provision of post-partum care directly related to the delivery.

D. The MHCP will not be required to permit the covered person to continue treatment with the current provider if the provider's disaffiliation with the MHCP was for reasons related to medical competence or professional behavior.

E. For transitional periods exceeding thirty days, the MHCP shall authorize continued care as provided in this section only if the health care provider agrees:

(1) to accept reimbursement from the MHCP at the rates applicable prior to the start of the transitional period as payment in full;

(2) to adhere to the MHCP's quality assurance requirements and to provide to the MHCP necessary medical information related to such care; and

(3) to otherwise adhere to the MHCP's policies and procedures, including but not limited to procedures regarding referrals, pre-authorization and treatment planning approved by the MHCP.

F. If upon the effective date of enrollment a new covered person's health care provider is not a member of the MHCP's provider network, the MHCP shall permit the covered person to continue an ongoing course of treatment with the covered person's current health care provider for a transitional period of time.

G. For covered persons in an ongoing course of treatment, the transitional period shall be sufficient to permit coordinated transition planning consistent with the patient's condition and needs relating to continuity of care, and, in any event, shall not be less than thirty days.

H. If a covered person has entered the third trimester of pregnancy at the effective date of enrollment, and the MHCP offers maternity coverage, the transitional period shall include the provision of post-partum care directly related to the delivery.

I. While a covered person is under the care of a provider outside the MHCP's network pursuant to this section, the covered person may receive care from other providers outside the network as ordered by the treating health care professional in consultation with the MHCP. The MHCP shall be obligated to authorize such care and to pay for such services only if the provider furnishing the care to the covered person agrees to accept the conditions described in this section.

Disclaimer: These regulations may not be the most recent version. New Mexico may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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