Current through Register Vol. 35, No. 18, September 24, 2024
The MCO shall follow current national standards for
preventive health services, including behavioral health preventive services.
Standards are derived from several sources, including the U.S. preventive
services task force, the centers for disease control and prevention; and the
American college of obstetricians and gynecologists. Any preventive health
guidelines developed by the MCO under these standards shall be adopted and
reviewed at least every two years, updated when appropriate and disseminated to
its practitioners and members. Unless a member refuses and the refusal is
documented, the MCO shall provide the following preventive health services or
screens or document that the services (with the results) were provided by other
means. The MCO shall document medical reasons not to perform these services for
an individual member. Member refusal is defined to include refusal to consent
to and refusal to access care.
A.
Initial assessment: The MCO shall conduct a health risk assessment
(HRA), per HSD guidelines and processes, for the purpose of obtaining basic
health and demographic information about the member, assisting the MCO in
determining the need for a comprehensive needs assessment (CNA) for care
coordination level assignment.
B.
Family planning: The MCO must have a family planning policy. This
policy must ensure that a member of the appropriate age of both sexes who seeks
family planning services is provided with counseling and treatment, if
indicated, as it relates to the following:
(1)
methods of contraception; and
(2)
HIV and other sexually transmitted diseases and risk reduction
practices.
C.
Guidance: The MCO shall adopt policies that shall ensure that an
applicable asymptomatic member is provided guidance on the following topics
unless the member's refusal is documented:
(1)
prevention of tobacco use;
(2)
benefits of physical activity;
(3)
benefits of a healthy diet;
(4)
prevention of osteoporosis and heart disease in a menopausal member citing the
advantages and disadvantages of calcium and hormonal supplementation;
(5) prevention of motor vehicle
injuries;
(6) prevention of
household and recreational injuries;
(7) prevention of dental and periodontal
disease;
(8) prevention of HIV
infection and other sexually transmitted diseases;
(9) prevention of an unintended pregnancy;
and
(10) prevention or intervention
for obesity or weight issues.
D.
Immunizations: The MCO shall
adopt policies that to the extent possible, ensure that within six months of
enrollment, a member is immunized according to the type and schedule provided
by current recommendations of the state department of health (DOH). The MCO
shall encourage providers to verify and document all administered immunizations
in the New Mexico statewide immunization information system (SIIS).
E.
Nurse advice line: The MCO
shall provide a toll-free clinical telephone nurse advice line function that
includes at least the following services and features:
(1) clinical assessment and triage to
evaluate the acuity and severity of the member's symptoms and make the
clinically appropriate referral; and
(2) pre-diagnostic and post-treatment health
care decision assistance based on the member's symptoms.
F.
Prenatal care: The MCO shall
operate a proactive prenatal care program to promote early initiation and
appropriate frequency of prenatal care consistent with the standards of the
American college of obstetrics and gynecology. The program shall include at
least the following:
(1) educational outreach
to a member of childbearing age;
(2) prompt and easy access to obstetrical
care, including an office visit with a practitioner within three weeks of
having a positive pregnancy test (laboratory or home) unless earlier care is
clinically indicated;
(3) risk
assessment of a pregnant member to identify high-risk cases for special
management;
(4) counseling which
strongly advises voluntary testing for HIV;
(5) case management services to address the
special needs of a member who has a high risk pregnancy, especially if risk is
due to psychosocial factors, such as substance abuse or teen
pregnancy;
(6) screening for
determination of need for a post-partum home visit;
(7) coordination with other services in
support of good prenatal care, including transportation, other community
services and referral to an agency that dispenses baby car seats free or at a
reduced price; and
(8) referral to
a home visiting pilot program for eligible pregnant individuals and children
residing in the HSD-designated counties for services as outlined at
8.308.9.23
NMAC.
G.
Screens: The MCO shall adopt policies which will ensure that, to
the extent possible, within six months of enrollment or within six months of a
change in screening standards, each asymptomatic member receives at least the
following preventive screening services listed below.
(1)
Screening for breast
cancer: A female member between the ages of 40-69 years shall be
screened every one to two years by mammography alone or by mammography and
annual clinical breast examination.
(2)
Blood pressure
measurement: A member 18 years of age or older shall receive a blood
pressure measurement at least every two years.
(3)
Screening for cervical
cancer: A female member with a cervix shall receive cytopathology
testing starting at the onset of sexual activity, but at least by 21 years of
age and every three years thereafter until reaching 65 years of age when prior
testing has been consistently normal and the member has been confirmed not to
be at high risk. If the member is at high risk, the frequency shall be at least
annual.
(4)
Screening for
chlamydia: All sexually active female members 25 years of age and
younger shall be screened for chlamydia. All female members over 25 years of
age shall be screened for chlamydia if they inconsistently use barrier
contraception, have more than one sex partner, or have had a sexually
transmitted disease in the past.
(5)
Screening for colorectal
cancer: A member 50 years of age and older, who is at normal risk for
colorectal cancer shall be screened with annual fecal occult blood testing or
sigmoidoscopy or colonoscopy or double contrast barium at a periodicity
determined by the MCO.
(6)
EPSDT screening for elevated blood lead levels: A risk
assessment for elevated blood lead levels shall be performed beginning at six
months and repeated at nine months of age. A member shall receive a blood lead
measurement at 12 months and 24 months of age. A member between the ages of
three and six years, for whom no previous test exists, should also be tested,
and screenings shall be done in accordance with the most current
recommendations of the American academy of pediatrics.
(7)
EPSDT newborn screening:
A newborn member shall be screened for those disorders specified in the state
of New Mexico metabolic screen and any screenings shall be done in accordance
with the most current recommendations of the American academy of
pediatrics.
(8)
Screening
for obesity: A member shall receive body weight, height and length
measurements with each physical exam. A member under 21 years of age shall
receive a BMI percentile designation.
(9)
Prenatal screening: All
pregnant members shall be screened for preeclampsia, Rh (D) incompatibility,
down syndrome, neural tube defects, hemoglobinopathies, vaginal and rectal
group B streptococcal infection and screened and counseled for HIV in
accordance with the most current recommendations of the American college of
obstetricians and gynecologists.
(10)
Screening for rubella:
All female members of childbearing ages shall be screened for rubella
susceptibility by history of vaccination or by serology.
(11)
Screening for
tuberculosis: Routine tuberculin skin testing shall not be required
for all members. The following high-risk members shall be screened or previous
screenings noted:
(a) a member who has
immigrated from countries in Asia, Africa, Latin America or the middle east in
the preceding five years;
(b) a
member who has substantial contact with immigrants from those areas; a member
who is a migrant farm worker;
(c) a
member who is an alcoholic, homeless or is an injecting drug user. HIV-infected
persons shall be screened annually; and
(d) a member whose screening tuberculin test
is positive (>10 mm of induration) must be referred to the local DOH public
health office in his or her community of residence for contact
investigation.
(12)
Serum cholesterol measurement: A male member 35 years and
older and a female member 45 years and older who is at normal risk for coronary
heart disease shall receive serum cholesterol and HDL cholesterol measurement
every five years. A member 20 years and older with risk factors for heart
disease shall have serum cholesterol and HDL cholesterol measurements
annually.
(13)
Tot-to-teen
health checks: The MCO shall operate the tot-to-teen mandated EPSDT
program as outlined in 8.320.2 NMAC. Within three months of enrollment lock-in,
the MCO shall ensure that the member is current according to the screening
schedule, unless more stringent requirements are specified in these standards.
The MCO shall encourage its PCPs to assess and document for age, height, gender
appropriate weight, and body mass index (BMI) percentage during EPSDT screens
to detect and treat evidence of weight or obesity issues in members under 21
years of age.
(14)
Screening for type 2 diabetes: A member with one or more of
the following risk factors for diabetes shall be screened. Risk factors
include:
(a) a family history of diabetes
(parent or sibling with diabetes); obesity (>twenty percent over desired
body weight or BMI >27kg/m2);
(b) race or ethnicity (e.g. hispanic, native
American, African American, Asian-Pacific islander);
(c) previously identified impaired fasting
glucose or impaired glucose tolerance; hypertension (>140/90 mmHg); HDL
cholesterol level <35 mg/dl and triglyceride level >250 mg/dl; history of
gestational diabetes mellitus (GDM); and
(d) a delivery of newborn over nine
pounds.
(15) A member 21
years of age and older must be screened to detect high risk for behavioral
health conditions at his or her first encounter with a PCP after
enrollment.
(16) The MCO shall
require its PCPs to refer a member, whenever clinically appropriate, to
behavioral health provider, see 8.321.2 NMAC. The MCO shall assist the member
with an appropriate behavioral health referral.
(17) Screens and preventative screens shall
be updated as recommended by the United States preventative services task
force.
