Current through Register Vol. 35, No. 18, September 24, 2024
A. The MCO shall provide medically necessary
services consistent with the following:
(1) a
determination that a health care service is medically necessary does not mean
that the health care service is a covered benefit; benefits are to be
determined by HSD;
(2) in making
the determination of medical necessity of a covered service the MCO shall do so
by:
(a) evaluating the member's physical and
behavioral health information provided by a qualified professional who has
personally evaluated the member within their scope of practice; who has taken
into consideration the member's clinical history, including the impact of
previous treatment and service interventions and who has consulted with other
qualified health care professionals with applicable specialty training, as
appropriate;
(b) considering the
views and choices of the member or their authorized representative regarding
the proposed covered service as provided by the clinician or through
independent verification of those views; and
(c) considering the services being provided
concurrently by other service delivery systems;
(3) not denying physical, behavioral health
and long-term care services solely because the member has a poor prognosis;
medically necessary services may not be arbitrarily denied or reduced in
amount, duration or scope to an otherwise eligible member solely because of his
or her diagnosis, type of illness or condition;
(4) governing decisions regarding benefit
coverage for a member under 21 years of age by the EPSDT program coverage rule
to the extent they are applicable; and
(5) making services available 24 hours, seven
days a week, when medically necessary and are a covered benefit.
B. The MCO shall meet all HSD
requirements related to the anti-gag requirement. The MCO shall meet all HSD
requirements related to advance directives. This includes but is not limited
to:
(1) providing a member or his or her
authorized representative with written information on advance directives that
include a description of applicable state and federal law and regulation, the
MCO's policy respecting the implementation of the right to have an advance
directive, and that complaints concerning noncompliance with advance directive
requirements may be filed with HSD; the information must reflect changes in
federal and state statute, regulation or rule as soon as possible, but no later
than 90 calendar days after the effective date of such a change;
(2) honoring advance directives within its UM
protocols; and
(3) ensuring that a
member is offered the opportunity to prepare an advance directive and that,
upon request, the MCO provides assistance in the process.
C. The MCO shall allow second opinions: A
member or their authorized representative shall have the right to seek a second
opinion from a qualified health care professional within their MCO's network,
or the MCO shall arrange for the member to obtain a second opinion outside the
network, at no cost to the member. A second opinion may be requested when the
member or his or her authorized representative needs additional information
regarding recommended treatment or believes the provider is not authorizing
requested care.
D. The MCO shall
meet all care coordination requirement set forth in 8.308.10 NMAC, Care
Coordination.
E. The MCO shall meet
all behavioral health parity requirements as set forth in CFR 42, Chapter IV,
subchapter C, 438.905 - Parity requirements.
