New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 22 - MANAGED HEALTH CARE PLAN COMPLIANCE › Section 13.10.22.8 - ACCESS TO HEALTH CARE SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Provider network adequacy:
Each health care insurer through its
				MHCP shall maintain and have available an adequate network of licensed primary
				care practitioners (PCPs) to provide comprehensive basic health care services
				to its enrolled population at all times. Those MHCPs currently doing business
				in New Mexico shall submit to the superintendent for approval an access plan
				addressing all of the criteria of this section. A MHCP new to this state shall
				submit a preliminary access plan to the division as part of its application for
				licensure. A MHCP new to this state shall file a follow-up access plan with the
				superintendent within six months after it obtains a certificate of authority.
				The superintendent shall approve or reject an access plan submitted by a MHCP
				within 45 days after the access plan is submitted to the division. In
				considering whether to approve or reject an access plan, the superintendent
				shall determine whether the MHCP meets all of the following criteria; however,
				the superintendent may make reasonable exceptions to the criteria on a case by
				case basis when the MHCP demonstrates the need for such exceptions.
(1) Whether, in population areas of 50,000 or
				more residents, two PCPs are available within no more than 20 miles or 20
				minutes average driving time for 90 percent of the enrolled population, or, in
				population areas of less than 50,000, whether two PCPs are available in any
				county or service area within no more than 60 miles or 60 minutes average
				driving time for 90 percent of the enrolled population. For remote rural areas,
				the superintendent shall consider on a case by case basis whether the MHCP has
				made sufficient PCPs available given the number of residents in the county or
				service area and given the community's standard of care.
(2) Whether the MHCP has a sufficient number
				of PCPs to meet the primary care needs of the enrolled population, using, as
				guidelines for calculation, the following criteria:
1) that each covered person will have four
				primary care visits annually, averaging a total of one hour;
2) that each PCP will see an average of four
				patients per hour; and
3) that one
				full-time equivalent PCP will be available for every 1,500 covered
				persons.
(3) Whether the
				MHCP demonstrates that the projected PCP network is sufficient to meet the
				primary care needs of adult, pediatric, and obstetric-gynecological patients.
				Each MHCP should show the adequacy of PCP availability by verifying that the
				PCPs committed to provide sufficient time for new patients so that projected
				clinic hour needs of the projected enrollment by service area are
				met.
(4) Whether the MHCP provides
				reasonable and reliable access for its covered persons to qualified health care
				professionals in those specialties that are covered by the MHCP. In developing
				its access plan, the MHCP should:
1)
				demonstrate that a sufficient number of licensed medical specialists are
				available to covered persons for specialty care when referral to such care is
				determined to be medically necessary by the PCP or other treating health care
				professional in consultation with the MHCP; and
2) attempt to provide at least one licensed
				medical specialist in those specialties that are generally available in the
				geographic area served, taking into consideration the urban or rural nature of
				the service area, the geographic location of each covered person, and the type
				of specialty care needed by the covered person population. A MHCP shall not
				restrict PCPs, in consultation with the MHCP, from referring covered persons to
				providers outside the network, even when geographically distant from the
				covered person's residence, when access to such treatment by such provider is
				medically necessary and no other provider can provide comparable treatment
				in-network or on a more cost-effective basis.
(5) Whether the MHCP has contracts, or other
				arrangements acceptable to the superintendent, with institutional providers -
				so that:
1) the need for services covered by
				the MHCP is satisfied;
2) the
				medical needs of covered persons are met 24 hours per day, seven days per week;
				and
3) the institutional services
				are geographically accessible to covered persons. In its access plan, the MHCP
				should demonstrate that in population areas of 50,000 or more residents, at
				least one licensed acute care hospital providing, at a minimum, licensed
				medical-surgical, emergency medical, pediatric, obstetrical, and critical care
				services is available no greater than 30 miles or 30 minutes average driving
				time for 90 percent of the enrolled population within the service area, and, in
				population areas of less than 50,000, that the acute care hospital is available
				no greater than 60 miles or 60 minutes average driving time for 90 percent of
				the enrolled population within the service area. For remote rural areas, the
				superintendent shall consider on a case by case basis whether the MHCP has made
				at least one licensed acute care hospital available given the number of
				residents in the county or service area and given the community's standard of
				care.
(6) Whether a
				sufficient number of health care professionals, such as registered and licensed
				practical nurses, are available to covered persons to ensure the delivery of
				covered health care services.
(7)
				Whether the MHCP has made surgical facilities including acute care hospitals
				for major surgery, hospitals for minor surgical procedures, licensed ambulatory
				surgical facilities, and medicare eligible surgical practices reasonably
				available, given the population of the service area and the institutional
				facilities available in or around the service area.
(8) Whether the MHCP has a policy assuring
				access to tertiary and specialized services as evidenced by contract or other
				agreement acceptable to the superintendent. In its access plan, the MHCP should
				describe the geographic location of and covered persons' accessibility to the
				following such services:
(a) at least one
				hospital providing regional perinatal services, if maternity coverage is
				offered as a health care service;
(b) a hospital offering tertiary pediatric
				services;
(c) a hospital offering
				diagnostic cardiac catheterization services;
(d) inpatient psychiatric services for adults
				and children, if provided as a covered health care service; and
(e) a residential substance abuse treatment
				center, if provided as a covered health care service.
(9) Whether the MHCP has a policy assuring
				access to the specialized services listed below, as evidenced by contract or
				other agreement acceptable to the superintendent. The MHCP should demonstrate
				in its access plan the geographic location of and covered persons'
				accessibility to the following such services:
(a) a therapeutic radiation
				provider;
(b) magnetic resonance
				imaging center;
(c) diagnostic
				radiology provider, including x-ray, ultrasound, and CAT scan; and
(d) a licensed renal dialysis
				center.
(10) Whether the
				MHCP has at least one licensed home health care professional available to serve
				each service area where 3,000 or more covered persons reside, if home health
				care is provided as a covered health care service.