N.J. Admin. Code § 11:24-6.3

Current through Register Vol. 56, No. 24, December 18, 2024

Section 11:24-6.3 - Institutional services

(a) The HMO shall maintain contracts or other arrangements acceptable to the Department with institutional providers which have the capability to meet the medical needs of members and are geographically accessible. The network of providers shall include:

1. At least one licensed acute care hospital including at least licensed medical-surgical, pediatric, obstetrical, and critical care services in any county or service area no greater than 20 miles or 30 minutes driving time, whichever is less, from 90 percent of members within the county or service area;

2. Surgical facilities including acute care hospitals, licensed ambulatory surgical facilities, and/or Medicare-certified physicians surgical practices available in each county or service area no greater than 20 miles or 30 minutes driving time, whichever is less, from 90 percent of members within the county or service area;

3. Tertiary and specialized services as follows:

i. The HMO shall have a contract or otherwise agree to cover medically necessary trauma services at a reasonable cost with all Level I or II trauma centers designated by the New Jersey Department of Health and Senior Services pursuant to N.J.A.C. 8:33P. The member may not be balance billed for any covered trauma services provided by such designated trauma centers.

ii. The HMO must have a policy assuring access, as evidenced by contract or other agreement acceptable to the Department, to the following specialized services, as determined to be medically necessary. Such services will be available within 45 miles or 60 minutes average driving time, whichever is less, of 90 percent of members within each county or approved sub-county area:

(1) At least one hospital providing regional perinatal services;

(2) A hospital offering tertiary pediatric services;

(3) In-patient psychiatric services for adults, adolescents and children;

(4) Residential substance abuse treatment center;

(5) Diagnostic cardiac catheterization services in a hospital;

(6) Specialty out-patient centers for HIV/AIDS, sickle cell disease, hemophilia, and cranio facial and congenital anomalies; and

(7) Comprehensive rehabilitation services.

iii. The HMO shall have a policy assuring access, as evidenced by contract or other agreement acceptable to the Department, to the following specialized services, as determined to be medically necessary. Such services will be available within 20 miles or 30 minutes average driving time, whichever is less, of 90 percent of members within each county or approved sub-county area:

(1) A licensed long term care facility with Medicare-certified skilled nursing beds;

(2) Therapeutic radiation provider;

(3) Magnetic resonance imaging center;

(4) Diagnostic radiology provider, including x-ray, ultrasound, and CAT scan;

(5) Emergency mental health service, including a short term care facility for involuntary psychiatric admissions;

(6) Out-patient therapy providers for mental health and substance abuse conditions; and

(7) Licensed renal dialysis provider.

4. At least one home health agency licensed by the Department to serve each county where 1,000 or more members reside; and

5. At least one hospice program certified by Medicare in any county where 1,000 or more members reside.

(b) The HMO may request, and will be granted, relief from the time and mileage requirements in (a) above where it can document to the satisfaction of the Department that appropriate access to alternative sites is available. Such documentation shall address travel accommodations and travel times, financial hardship placed on families and other logistical details as requested by the Department of a specific HMO.

(c) In any county or approved sub-county service area in which 20 percent of an HMO's projected or actual membership must rely upon public transportation to access health care services, as documented by U.S. Census Data, the driving times in the criteria in (a) above shall be based upon average transit time using public transportation. The HMO shall demonstrate how it will meet this requirement in its application.

N.J. Admin. Code § 11:24-6.3