N.M. Admin. Code § 8.308.2.11

Current through Register Vol. 35, No. 21, November 5, 2024

Section 8.308.2.11 - STANDARDS FOR ACCESS

The MCO shall establish and follow protocols to ensure the accessibility, availability and referral to health care providers for each medically necessary service to its members. The MCO shall provide access to the full array of covered services within the benefit package. If a service is unavailable based on the access guidelines, a service equal to or higher than that service shall be offered.

A. Access to urgent and emergency services: Services for emergency conditions provided by physical and behavioral health providers, including emergency transportation, urgent conditions, and post-stabilization care shall be covered by the MCO (only within the United States for both physical and behavioral health). An urgent condition exists when a member manifests acute symptoms and signs that, by reasonable medical judgment, represent a condition of sufficient severity that the absence of medical attention within 24 hours could reasonably result in an emergency condition. Serious impairment of biopsychosocial functioning, imminent out-of-home placement for child and adolescent members or serious jeopardy to the behavioral health of the member are considered urgent conditions. An emergency condition exists when a member manifests acute symptoms and signs that, by reasonable lay person judgment, represent a condition of sufficient severity that the absence of immediate medical attention, including behavioral health treatment, could reasonably result in death, serious impairment of bodily function or major organ or serious jeopardy to the overall health of the member or with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy. Post-stabilization care means covered services related to an emergency medical or behavioral health condition, that are provided after the member is stabilized in order to maintain the stabilized condition and may include improving or resolving the member's condition.

(1) The MCO shall ensure that there is no clinically significant delay caused by the MCO's utilization control measures. Prior authorization is not required for emergency services in or out of the MCO's network, and all emergency services shall be reimbursed at the HSD approved rate. The MCO shall not retroactively deny a claim for an emergency screening examination because the condition, which appeared to be an emergency medical or behavioral health condition under the prudent layperson standard, turned out to be non-emergent in nature.

(2) The MCO shall ensure that the member has the right to use any hospital or other licensed emergency setting for emergency care, regardless of whether the provider is contracted with the MCO.

(3) The MCO shall ensure that the member has access to the nearest appropriately designated trauma center according to established emergency medical standards (EMS) triage and transportation protocols.

B. PCP availability: The MCO shall follow a process that ensures a sufficient number of PCPs are available to allow members a reasonable choice among providers.

(1) The MCO shall have at least one PCP available per 2,000 members and not more than 2,000 members are assigned to a single provider unless approved by HSD.

(2) The MCO must ensure that members have adequate access to specialty providers.

(3) The minimum number of PCPs from which to choose and the distances to those providers shall vary by county based on whether the county is urban, rural or frontier. Urban counties are: Bernalillo, Los Alamos, Santa Fe and Dona Ana. Frontier counties are: Catron, Harding, DeBaca, Union, Guadalupe, Hidalgo, Socorro, Mora, Sierra, Lincoln, Torrance, Colfax, Quay, San Miguel and Cibola. Rural counties are those that are not urban or frontier. The standards are as follows:

(a) ninety percent of urban member residents shall travel no farther than 30 miles;

(b) ninety percent of rural member residents shall travel no farther than 45 miles; and

(c) ninety percent of frontier member residents shall travel no farther than 60 miles.

C. Pharmacy provider availability: The MCO shall ensure that a sufficient number of pharmacy providers are available to its members. The MCO shall ensure that pharmacy services meet geographic access standards based on its member's county of residence. The access standards are as follows:

(1) ninety percent of urban residents shall travel no farther than 30 miles;

(2) ninety percent of rural residents shall travel no farther than 45 miles; and

(3) ninety percent of frontier residents shall travel no farther than 60 miles.

D. For all other provider types, including, but not limited to behavioral health providers, physical health providers, long term care providers, hospitals and transportation providers, as directed by MAD, the following standards shall apply:

(1) ninety percent of urban residents shall travel no farther than 30 miles;

(2) ninety percent of rural residents shall travel no farther than 60 miles, unless this type of provider is not physically present in the prescribed radius or unless otherwise exempted by MAD; and

(3) ninety percent of frontier residents shall travel no farther than 90 miles, unless this type of provider is not physically present in the prescribed radius or unless otherwise exempted by MAD.

E. The MCO must provide transportation as necessary to meet the standards of access.

N.M. Admin. Code § 8.308.2.11

8.308.2.11 NMAC - N, 1-1-14, Adopted by New Mexico Register, Volume XXIX, Issue 08, April 24, 2018, eff. 5/1/2018