New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 2 - PROVIDER NETWORK › Section 8.308.2.12 - ACCESS TO HEALTH CARE SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
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.