N.M. Code R. § 8.308.2.12 - ACCESS TO HEALTH CARE SERVICES
The MCO shall ensure that there are a sufficient number of PCPs and dentists available to members to allow members a reasonable choice, and ensure that there are a sufficient number of behavioral health providers, based on the least restrictive, medically necessary needs of its members, available statewide to members to allow members a reasonable choice.
A. The MCO shall report to HSD all provider
groups, health centers and individual physician practices and sites in its
network that are not accepting new MCO members.
B. For routine, asymptomatic,
member-initiated, outpatient appointments for primary medical care, the
request-to-appointment time shall be no more than 30 calendar days, unless the
member requests a later time.
C.
For routine asymptomatic member-initiated dental appointments the
request-to-appointment time shall be no more than 60 calendar days unless the
member requests a later date.
D.
For routine, symptomatic, member-initiated, outpatient appointments for
non-urgent primary medical and dental care, the request-to-appointment time
shall be no more than 14 calendar days, unless the member requests a later
time.
E. For non-urgent behavioral
health care, the request-to-appointment time shall be no more than 14 calendar
days, unless the member requests a later time.
F. Primary medical, dental and behavioral
health care outpatient appointments for urgent conditions shall be available
within 24 hours.
G. For specialty
outpatient referral and consultation appointments, excluding behavioral health,
which is addressed in Subsection E of this Section, the request-to-appointment
time shall generally be consistent with the clinical urgency, but no more than
21 calendar days, unless the member requests a later time.
H. For routine outpatient diagnostic
laboratory, diagnostic imaging and other testing appointments, the
request-to-appointment time shall be consistent with the clinical urgency, but
no more than 14 calendar days, unless the member requests a later
time.
I. For outpatient diagnostic
laboratory, diagnostic imaging and other testing, if a "walk-in" rather than an
appointment system is used, the member wait time shall be consistent with
severity of the clinical need.
J.
For urgent outpatient diagnostic laboratory, diagnostic imaging and other
testing, appointment availability shall be consistent with the clinical
urgency, but no longer than 48 hours.
K. The timing of scheduled follow-up
outpatient visits with practitioners shall be consistent with the clinical
need.
L. The in-person prescription
fill time (ready for pickup) shall be no longer than 40 minutes. A prescription
phoned in by a practitioner shall be filled within 90 minutes.
M. The MCO's preferred drug list (PDL) shall
follow HSD guidelines for services and items included in the managed care
benefit package, pharmacy services.
N. Access to durable medical equipment: The
MCO shall approve or deny a request for new durable medical equipment (DME) or
for repairs to existing DME owned or rented by the member within seven working
days of the request date.
(1) All new
customized or made-to-measure DME or customized modifications to existing DME
owned or rented by the member shall be delivered to the member within 150
calendar days of the request date.
(2) All standard DME shall be delivered
within 24 hours of the request, if needed on an urgent basis.
(3) All standard DME not needed on an urgent
basis shall be delivered within a time frame consistent with clinical
need.
(4) All DME repairs or
non-customized modifications shall be delivered within 60 calendar days of the
request date.
(5) The MCO shall
have an emergency response plan for non-customized DME needed on an emergent
basis.
(6) The MCO shall ensure
that its member and his or her family or caretaker receive proper instruction
on the use of DME provided by the MCO or its subcontractor.
O. Access to prescribed medical
supplies: The MCO shall approve or deny a request for prescribed medical
supplies within seven working days of the request date. The MCO shall ensure
that:
(1) a member can access prescribed
medical supplies within 24 hours when needed on an urgent basis;
(2) a member can access routine medical
supplies within a time frame consistent with the clinical need;
(3) subject to any requirements to procure a
PCP order to provide supplies to its members, members utilizing medical
supplies on an ongoing basis shall submit to the MCO lists of needed supplies
monthly; and the MCO or its subcontractor shall contact the member if the
requested supplies cannot be delivered in the time frame expected and make
other delivery arrangements consistent with clinical need; and
(4) the MCO shall ensure that its member and
his or her family receive proper instruction on the use of medical supplies
provided by the MCO or its subcontractors.
P. Access to transportation services: The MCO
shall provide the transportation benefit for medically necessary physical and
behavioral health. The MCO shall have sufficient transportation providers
available to meet the needs of its members, including an appropriate number of
handivans available for members who are wheelchair or ventilator dependent or
have other equipment needs. The MCO shall develop and implement policies and
procedures to ensure that:
(1) transportation
arranged is appropriate for the member's clinical condition;
(2) the history of services is available at
the time services are requested to expedite appropriate arrangements;
(3) CPR-certified drivers are available to
transport members consistent with clinical need;
(4) the transportation type is clinically
appropriate, including access to non-emergency ground ambulance
carriers;
(5) members can access
and receive authorization for medically necessary transportation services under
certain unusual circumstances without advance notification; and
(6) minor aged members are accompanied by a
parent or legal guardian as indicated to provide safe transportation. See
8.301.6 NMAC for a detailed description of attendant coverage for a member 18
years of age and older.
Q. Use of technology: The MCO is encouraged
to use technology, such as telemedicine, to ensure access and availability of
services statewide.
R. For
behavioral health crisis services, face-to-face appointments shall be available
within two hours.
Notes
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No prior version found.