New Mexico Register / Volume XXIX, Issue 8 / April 24, 2018
TITLE 8 SOCIAL SERVICES
CHAPTER 308 MANAGED CARE PROGRAM
PART 9 BENEFIT PACKAGE
8.308.9.1 ISSUING AGENCY: New Mexico Human Services Department (HSD).
[8.308.9.1 NMAC
- Rp,
8.308.9.1 NMAC, 5/1/2018]
8.308.9.2 SCOPE: This rule applies to the general public.
[8.308.9.2 NMAC
- Rp,
8.308.9.2 NMAC, 5/1/2018]
8.308.9.3 STATUTORY AUTHORITY: The New Mexico medicaid
program and other health care programs are administered pursuant to regulations
promulgated by the federal department of health and human services under Title
XIX of the Social Security Act as amended or by state statute. See Section 27-1-12 et seq., NMSA 1978.
[8.308.9.3 NMAC
- Rp,
8.308.9.3 NMAC, 5/1/2018]
8.308.9.4 DURATION: Permanent.
[8.308.9.4 NMAC
- Rp,
8.308.9.4 NMAC, 5/1/2018]
8.308.9.5 EFFECTIVE DATE: May 1, 2018, unless a later date is cited at
the end of a section.
[8.308.9.5 NMAC
- Rp,
8.308.9.5 NMAC, 5/1/2018]
8.308.9.6 OBJECTIVE: The objective of this rule is to provide
instructions for the service portion of the New Mexico medical assistance
division programs.
[8.308.9.6 NMAC
- Rp,
8.308.9.6 NMAC, 5/1/2018]
8.308.9.7 DEFINITIONS:
A. Alternative benefits plan services with limitations
(ABP): The medical assistance
division (MAD) category of eligibility “other adults” has an alternative
benefit plan (ABP). The HSD contracted
managed care organization (MCO) covers ABP specific services for an ABP
member. Services are made available
through MAD under a benefit plan similar to services provided by commercial
insurance plans. ABP benefits include
preventive services and treatment services.
An ABP member has limitations on specific benefits; and does not have all MCO medicaid benefits
available. All early and periodic screening, diagnosis
and treatment (EPSDT) program services are available to an ABP member under 21
years. ABP services for an ABP member
under the age of 21 years are not subject to the duration, frequency, and
annual or lifetime benefit limitations that are applied to an ABP eligible
recipient 21 years of age and older. A
MCO ABP contracted provider and an ABP member have rights and responsibilities
as described in Title 8 Chapter 308 NMAC, Social Services.
B. Alternative benefits plan
general benefits for ABP exempt member (ABP exempt): An ABP member who self-declares he or she has
a qualifying condition is evaluated by the MCO’s utilization management for
determination if he or she meets the qualifying condition. An ABP exempt member utilizes his or her
benefits described in 8.308.9 NMAC and in 8.308.12 NMAC.
[8.308.9.7 NMAC
- Rp,
8.308.9.7 NMAC, 5/1/2018]
8.308.9.8 [RESERVED]
[8.308.9.8 NMAC
- Rp,
8.308.9.8 NMAC, 5/1/2018]
8.308.9.9 BENEFIT PACKAGE: This part defines the benefit
package for which a MCO shall be paid a fixed per-member-per-month capitated
payment rate. The MCO shall cover the
services specified in 8.308.9 NMAC. The
MCO shall not delete a benefit from the MCO benefit package. A MCO is encouraged to offer value added
services that are not medicaid covered benefits or in
lieu of services or settings. The MCO
may utilize providers licensed in accordance with state and federal requirements
to deliver services. The MCO shall
provide and coordinate comprehensive and integrated health care benefits to
each member enrolled in managed care and shall cover the physical health,
behavioral health and long-term care services per this section, its contract,
and as directed by HSD. If the MCO is
unable to provide covered services to a particular member using one of its
contracted providers, the MCO shall adequately and timely cover these services
for that member using a non-contract provider for as long as the member’s MCO
provider network is unable to provide the service. At such time that the required services
become available within the MCO’s network and the member can be safely
transferred, the MCO may transfer the member to an appropriate contract
provider according to a transition of care plan developed specifically for the
member; see 8.308.11 NMAC.
[8.308.9.9 NMAC
- Rp,
8.308.9.9 NMAC, 5/1/2018]
8.308.9.10 MEDICAL ASSISTANCE DIVISION PROGRAM
RULES:
New Mexico administrative code (NMAC) rules and related
documents contain a detailed description of the services covered by MAD, the
limitations and exclusions to covered services, and non-covered services. The NMAC rules are the official source of
information on covered and non-covered services. Unless otherwise directed, the MCO shall
determine its own utilization management (UM) protocols and shall comply with
state and federal requirements for UM including, but not limited to 42 CFR Part
456, which is based on reasonable medical evidence. The MCO shall comply with the most rigorous
standards or applicable provisions of either NCQA, HSD regulation, the Balanced
Budget Act of 1997, or 42 CFR Part 438 related to timeliness of decisions. The MCO shall ensure that medicaid
covered benefits are furnished in an amount, duration, and scope that is no
less than the amount, duration, and scope for the same services furnished to
beneficiaries pursuant to 42 CFR 440.230.
MAD may review and approve the MCO’s UM protocols. Unless otherwise directed by MAD, a HSD
contracted MCO is not required to follow MAD’s reimbursement methodologies or
MAD’s fee schedules unless otherwise required in a NMAC rule. The MCO shall comply with 42 CFR Parts 438,
440, and 456.
[8.308.9.10
NMAC - Rp,
8.308.9.10 NMAC, 5/1/2018]
8.308.9.11 GENERAL PROGRAM DESCRIPTION:
A. The MCO shall provide medically necessary
services consistent with the following:
(1) a
determination that a health care service is medically necessary does not mean
that the health care service is a covered benefit; benefits are to be
determined by HSD;
(2) in making
the determination of medical necessity of a covered service the MCO shall do so
by:
(a) evaluating the member’s physical and
behavioral health information provided by a qualified professional who has
personally evaluated the member within his or her scope of practice; who has
taken into consideration the member’s clinical history, including the impact of
previous treatment and service interventions and who has consulted with other
qualified health care professionals with applicable specialty training, as
appropriate;
(b) considering the views and choices of
the member or his or her authorized representative regarding the proposed covered service as
provided by the clinician or through independent verification of those views;
and
(c) considering
the services being provided concurrently by other service delivery systems;
(3) not denying physical, behavioral
health and long-term care services solely because the member has a poor
prognosis; medically necessary services may not be arbitrarily denied or
reduced in amount, duration or scope to an otherwise eligible member
solely because of his or her diagnosis,
type of illness or condition;
(4) governing decisions regarding benefit
coverage for a member under 21
years of age by the EPSDT program coverage rule to the extent they are
applicable; and
(5) making
services available 24 hours, seven days a week, when medically necessary and
are a covered benefit.
B. The MCO shall
meet all HSD requirements related to the anti-gag requirement. The MCO shall meet all HSD requirements
related to advance directives. This
includes but is not limited to:
(1) providing a member or his
or her authorized representative with written information on advance directives
that include a description of applicable state and federal law and regulation,
the MCO’s policy respecting the implementation of the right to have an advance
directive, and that complaints concerning noncompliance with advance directive
requirements may be filed with HSD; the information must reflect changes in
federal and state statute, regulation or rule as soon as possible, but no later
than 90 calendar days after the effective date of such a change;
(2) honoring advance directives within its UM protocols; and
(3) ensuring
that a member is offered the opportunity to prepare an advance directive and
that, upon request, the MCO provides assistance in the process.
C. The MCO shall allow second opinions: A member or his or her authorized
representative shall have the right to seek a second opinion from a qualified
health care professional within his or her MCO’s network, or the MCO shall
arrange for the member to obtain a second opinion outside the network, at no
cost to the member. A second opinion may
be requested when the member or his or her authorized representative needs
additional information regarding recommended treatment or believes the provider
is not authorizing requested care.
D. The MCO shall
meet all care coordination requirement set forth in 8.308.10 NMAC, Care
Coordination.
E. The MCO shall
meet all behavioral health parity requirements as set forth in CFR 42, Chapter
IV, subchapter C, 438.905 - Parity requirements.
[8.308.9.11 NMAC -
Rp, 8.308.9.11 NMAC, 5/1/2018]
8.308.9.12 GENERAL COVERED SERVICES:
A. Ambulatory
surgical services: The benefit package includes surgical
services rendered in an ambulatory surgical center setting as detailed in
8.324.10 NMAC.
B. Anesthesia
services: The benefit package includes
anesthesia and monitoring services necessary for the performance of surgical or
diagnostic procedures as detailed 8.310.2 NMAC.
C. Audiology
services: The benefit package includes audiology
services as detailed in 8.310.2 and 8.324.5 NMAC with some limitations. For a ABP member 21 years and older,
audiology services are limited to hearing testing or screening when part of a
routine health exam and are not covered as a separate service. Audiologist services, hearing aids and other
aids are not covered.
D. Client transportation: The benefit package covers expenses for
transportation, meals, and lodging it determines are necessary to secure MAD
covered medical or behavioral health examination and treatment for a MCO member
in or out of his or her home community as detailed in 8.301.6, 8.324.7 and 8.310.2
NMAC.
E. Community intervener:
The benefit package includes community
intervener services. The community
intervener works one-on-one with a deaf-blind member who is five-years of age
or older to provide critical connections to other people and his or her
environment. The community intervener
opens channels of communication between the member and others, provides access
to information, and facilitates the development and maintenance of
self-directed independent living.
(1) Member
eligibility: To be eligible for
community intervener services, a member must be five-years of age or older and
meet the clinical definition of deaf-blindness, defined as:
(a) the
member has a central visual acuity of 20/200 or less in the better eye with
corrective lenses, or a field defect such that the peripheral diameter of
visual field subtends an angular distance no greater than 20 degrees, or a
progressive visual loss having a prognosis leading to one or both these
conditions;
(b) the member has a chronic hearing impairment so severe that
most speech cannot be understood with optimum amplification or the progressive
hearing loss having a prognosis leading to this condition; and
(c) the
member for whom the combination of impairments described above cause extreme
difficulty in attaining independence in daily life activities, achieving
psychosocial adjustment, or obtaining a vocation.
(2) Provider
qualifications: The minimum provider
qualifications for a community intervener are as follows:
(a) is at least 18 years of age;
(b) is not the spouse of the member to
whom the intervener is assigned;
(c) holds a high school diploma or a high
school equivalency certificate;
(d) has a minimum of two years of
experience working with individuals with developmental disabilities;
(e) has the ability to proficiently communicate in the
functional language of the deaf-blind member to whom the intervener is
assigned; and
(f) completes an orientation or training course by any person or
agency who provides direct care services to deaf-blind individuals.
F. Dental
services: The benefit package includes dental
services as detailed in 8.310.2 NMAC.
G. Diagnostic
imaging and therapeutic radiology services: The benefit package
includes medically necessary diagnostic imaging and radiology services as
detailed in 8.310.2 NMAC.
H. Dialysis
services: The benefit package includes medically
necessary dialysis services as detailed in 8.310.2 NMAC. Dialysis benefits are limited to the first
three months of dialysis pending the establishment of medicare
eligibility unless the member does not qualify for medicare
benefits as determined by the social security administration. A dialysis provider shall assist a member in
applying for and pursuing final medicare eligibility determination. If the member does not qualify for medicare benefits, the MCO is responsible for covering
dialysis services.
I. Durable
medical equipment and medical supplies: The benefit package
includes covered vision appliances, hearing aids and related services and
durable medical equipment and medical supplies and oxygen as detailed in
8.324.5 NMAC. For an ABP eligible
recipient 21 years of age and older, see 8.309.4 NMAC for service limitations.
J. Emergency
and non-emergency transportation services:
(1) The
benefit package includes transportation service such as ground ambulance and
air ambulance in an emergency and when medically necessary, and taxicab and handivan, commercial bus, commercial air, meal and lodging
services as indicated for medically necessary physical and behavioral health
services, as detailed in 8.324.7 NMAC. MAD
covers the most appropriate and least costly transportation alternatives only
when a member does not have a source of transportation available and the member
does not have access to alternative free sources. The MCO shall coordinate efforts when
providing transportation services for a member requiring physical or behavioral
health services.
(2) The
benefit package also includes non-medical transportation as detailed in 8.314.5
NMAC.
K. Experimental or investigational services: The benefit package includes medically
necessary services which are not considered unproven, investigational or
experimental for the condition for which they are intended or used as determined
by MAD as detailed in 8.310.2 NMAC.
L. Health home services: The benefit package includes CareLink NM (or its successor) health home services as
detailed in 8.310.10 NMAC for qualified beneficiaries in areas these services
are available through by MAD-approved providers.
M. Home health agency
services
and other nursing care: The benefit package includes
home health agency services
as detailed in 8.325.9 and 8.320.2 NMAC.
For an ABP eligible recipient 21 years of age and older, see 8.309.4
NMAC for service limitations.
(1) A
MCO may also cover private duty nursing services and in home rehabilitation
services as needed to provide medically necessary services to members even
though those services are not rendered through a home health agency.
(2) In
addition to home health agency services, a MCO is also required to provide in
home services under the EPSDT program through private duty nursing and EPSDT
personal care (which is not to be confused with the personal care option
services covered as a community benefit).
See 8.308.9.15 NMAC regarding EPSDT services.
(3) Services
in the home are also a benefit under community based services. See 8.308.12. NMAC Community Benefit.
(4) For
an ABP eligible recipient 21 years of age and older, see 8.309.4 NMAC for
service limitations.
N. Hospice
services: The benefit package includes hospice
services as detailed in 8.325.4 NMAC.
O. Hospital outpatient service: The
benefit package includes hospital outpatient services for preventive,
diagnostic, therapeutic, rehabilitative or palliative medical or behavioral
health services as detailed in 8.311.2 NMAC.
P. Inpatient
hospital services: The benefit package includes hospital
inpatient acute care, procedures and services for the member as detailed in
8.311.2 NMAC. The MCO shall comply with
the maternity length of stay in the Health Insurance Portability and
Accountability Act (HIPAA) of 1996.
Coverage for a hospital stay following a normal, vaginal delivery may
not be limited to less than 48 hours for both the member and her newborn
child. Health coverage for a hospital
stay in connection with childbirth following a caesarean section may not be
limited to less than 96 hours for the member and her newborn child.
Q. Laboratory
services: The benefit package includes
laboratory services provided according to the applicable provisions of Clinical
Laboratory Improvement Act (CLIA) as detailed in 8.310.2 NMAC.
R. Nursing
facility services: The
benefit package includes nursing facility services as detailed in 8.312.2
NMAC. Nursing facility services are not
a benefit for an ABP eligible recipient except as a short term “step-down”
hospital discharge prior to going home.
S. Nutrition services: The
benefit package includes nutritional services based on scientifically validated
nutritional principles and interventions which are generally accepted by the
medical community and consistent with the physical and medical condition of the
member as detailed in 8.310.2 NMAC.
T. Physical health services:
(1) Primary care and
specialty care services are found in the following 8.310.2, 8.310.3, 8.320.2,
and 8.320.6 NMAC. The services are
rendered in a hospital, clinic, center, office, school-based setting, and when facilities
and settings are parent approved, including the home.
(2) The benefits specifically include:
(a) labor and delivery in a hospital;
(b) labor and delivery in an eligible recipient’s home;
(c) labor and delivery in a midwife’s unlicensed birth center;
(d) labor and delivery in a department of health licensed birth
center; and
(e) other
related birthing services performed by a certified nurse midwife or a
direct-entry midwife licensed by the state of New Mexico, who is either validly
contracted with and fully credentialed by the MCO or validly contracted with
HSD and participates in MAD birthing options program as detailed in 8.310.2
NMAC.
(f) The MCO shall
operate a proactive prenatal care program to promote early initiation and
appropriate frequency of prenatal care consistent with the standards of the
American college of obstetrics and gynecology.
(g) The MCO shall
participate in MAD’s birthing options program.
U. Podiatry: The benefit package includes podiatric
services furnished by a provider, as required by the condition of the member as
detailed in 8.310.2 NMAC.
V. Prosthetics and orthotics: The
benefit package includes prosthetic and orthotic services as detailed in
8.324.5 NMAC.
W. Rehabilitation
services: The benefit package includes inpatient
and outpatient hospital, and outpatient physical, occupational and speech
therapy services as detailed in 8.323.5 NMAC. For an ABP eligible recipient 21 years of age
and older, see 8.309.4 NMAC for service limitations
X. Private duty nursing: The benefit package includes private duty
nursing services for a member under 21 years of
age. See Subsection M of 8.308.9.12 NMAC.
Y. Swing bed hospital services: This
benefit package includes services provided in hospital swing beds to a member
expected to reside in such a facility on a long-term or permanent basis as
defined in 8.311.5 NMAC. Swing bed
hospital services are not a benefit for an ABP eligible recipient except as a
short term “step-down” hospital discharge prior to going home.
Z. Tobacco cessation
services: The benefit package
includes cessation services as described in 8.310.2 NMAC and education.
AA. Transplant services: The
following transplants are covered in the benefit package as long as the procedures
are not considered experimental or investigational: heart transplants, lung transplants,
heart-lung transplants, liver transplants, kidney transplants, autologous bone
marrow transplants, allogeneic bone marrow transplants and corneal transplants
as detailed in 8.310.2 NMAC. See 8.325.6
NMAC for guidance whether MAD has determined if a transplant is experimental or
investigational.
BB. Vision
and eye care services: The benefit
package includes specific vision care services that are medically necessary for
the diagnosis of and treatment of eye diseases for a member as detailed in
8.310.2 NMAC. All services must be
furnished within the scope and practice of the medical professional as defined
by state law and in accordance with applicable federal, state and local laws
and rules. For an ABP eligible recipient
21 years and older, the service limitations are listed below:
(1) Routine
vision care is not covered.
(2) MAD
does not cover refraction or eyeglasses other than for aphakia
following removal of the lens.
CC. Other services: When an additional benefit service is
approved by MAD, the MCO shall cover that service as well.
[8.308.9.12
NMAC - Rp, 8.308.9.12 NMAC,
5/1/2018]
8.308.9.13 SPECIFIC CASE MANAGEMENT PROGRAMS: The benefit
package includes case management services necessary to meet an identified
service need of a member. The following
are specific case management programs available when a member meets the
requirements of a specific service.
A. Case
management services for adults with developmental disabilities: Case management services are provided to a
member 21 years of age and older who is developmentally disabled as detailed in
8.326.2 NMAC.
B. Case management services for pregnant women and their
infants:
Case management services are provided to a member who is
pregnant up to 60 calendar days following the end of the month of the delivery
as detailed in 8.326.3 NMAC.
C. Case management services for traumatically brain injured
adults:
Case management services are provided to a member 21 years
of age and older who is traumatically brain injured as detailed in 8.326.5
NMAC.
D. Case management services for children up to the age of
three:
Case management services for a member up to the age of three
years who is medically at-risk due to family conditions and who does not have a
developmental delay as detailed in 8.326.6 NMAC.
E. Case management services for the medically at risk
(EPSDT): Case management services for a member under 21
years of age who is medically at-risk for a physical or behavioral health
condition as detailed in 8.320.2 NMAC.
[8.308.9.13
NMAC - Rp, 8.308.9.13 NMAC,
5/1/2018]
8.308.9.14 PHARMACY SERVICES: The benefit package includes
pharmacy and related services, as detailed in 8.324.4 NMAC.
A. The MCO may
determine its formula for estimating acquisition cost and establishing pharmacy
reimbursement.
B. The MCO shall
include on the MCO’s formulary or PDL all multi-source generic drug items with
the exception of items used for cosmetic purposes, items consisting of more
than one therapeutic ingredient, anti-obesity items, items that are not
medically necessary and as otherwise approved by MAD. Cough, cold and allergy medications must be
covered but all multi-source generic products do not need to be covered. This requirement does not preclude a MCO from
requiring authorization prior to dispensing a multi-source generic item.
C. The MCO is not
required to cover all multi-source generic over-the-counter items. Coverage of over-the-counter items may be
restricted to instances for which a practitioner has written a prescription,
and for which the item is an economical or preferred therapeutic alternative to
the prescribed item.
D. The MCO shall
cover brand name drugs and drug items not generally on the MCO formulary or PDL
when determined to be medically necessary by the MCO or as determined by the
MCO member appeal process or a HSD administrative hearing. See 8.308.15 NMAC.
E. Unless otherwise
approved by MAD, the MCO shall have an open formulary for all psychotropic
medications. Minor tranquilizers,
sedatives, and hypnotics are not considered psychotropic medications for the
purpose of this rule.
F. MCO shall
ensure that a native American member accessing the
pharmacy benefit at an Indian health service (IHS), tribal, and urban Indian (I/T/U) facility is exempt from the
MCO’s PDL when these pharmacies have their own PDL.
G. The MCO shall
reimburse family planning clinics, school-based health centers (SBHCs) and the
department of health (DOH) public health clinics for oral contraceptive agents
and plan B when dispensed to a member and billed using healthcare common
procedure coding (HCPC) codes and CMS 1500 forms.
H. The MCO shall
meet all federal and state requirements related to pharmacy rebates and submit
all necessary information as directed by HSD.
I. For a member 21 years of age and older not residing
in an institution, the MCO must, at a minimum , cover the over-the-counter
items which are insulin, diabetic
test strips, prenatal vitamins, electrolyte replacement items, ophthalmic
lubricants, pediculosides and scabicides,
certain insect repellants, sodium chloride for inhalations, topical and vaginal
antifungals and topical anti-inflammatories.
Other over-the-counter items may be designated as covered items after
making a specific determination that it is overall more economical to cover an
over-the-counter item as an alternative to prescription items or when an over-the-counter
item is a preferred therapeutic alternative to prescription drug items. Such coverage is subject to the generic-first
coverage provisions. Otherwise, the
eligible recipient 21 years and older, or his or her authorized representative
is responsible for purchasing or otherwise obtaining an over-the-counter item.
(1) The MCO may cover additional over-the
counter items, with or without prior authorization, at its discretion or as
medically necessary when a specific regimen of over-the-counter drugs is
required to treat chronic disease conditions.
(2) For a member under 21 years of age,
the MCO must cover over-the-counter drug items as medically necessary for the
member, with or without prior authorization.
J. The MCO shall
meet all federal and state requirements for identifying drug items purchased
under the 340B drug purchasing provisions codified as Section 340B of the
federal Public Health Service Act.
[8.308.9.14
NMAC - Rp, 8.308.9.14 NMAC,
5/1/2018]
8.308.9.15 EARLY AND PERIODIC SCREENING DIAGNOSIS AND TREATMENT (EPSDT) SERVICES: The
benefit package includes the delivery of the federally mandated EPSDT services (42
CFR Part 441, Subpart B) provided by a primary care provider (PCP) as detailed
in 8.320.2 NMAC. The MCO shall provide
access to early intervention programs and services for a member identified in
an EPSDT screen as being at-risk for developing or having a severe emotional,
behavioral or neurobiological disorder.
Unless otherwise specified in a service rule, EPSDT services are for a
member under 21 years of age. For
detailed description of each service, see 8.320.2 NMAC. EPSDT behavioral health services are included
in 8.308.9.19 NMAC.
A. EPSDT nutritional counseling and services: The benefit package
includes nutritional services furnished to a pregnant member and a member under 21 years of age as detailed in 8.310.2 NMAC.
B. EPSDT
personal care: The benefit package includes personal
care services for a member.
C. EPSDT private duty nursing: The benefit package includes private
duty nursing for a member and the services shall be delivered in either his or
her home or school setting.
D. EPSDT
rehabilitation services: A
member under 21 years of age who is eligible for home and community based
waiver services receives medically necessary rehabilitation services through
the EPSDT program; see 8.320.2 NMAC for a detailed description. The home and community-based waiver program provides
rehabilitation services only for the purpose of community integration.
E. Services
provided in schools: The benefit package includes services
to a member provided in a school, excluding those specified in his or her
individual education plan (IEP) or the individualized family service plan
(IFSP); see 8.320.6 NMAC.
F. Tot-to-teen
health checks:
(1) The MCO shall
adhere to the MAD periodicity schedule and ensure that each eligible member
receives age-appropriate EPSDT screens (tot-to-teen health checks), referrals,
and appropriate services and follow-up care.
See 8.320.2 NMAC for detailed description of the benefits. The services include, but are not limited to:
(a) education of and outreach to a member or the member’s family
regarding the importance of regular screens and health checks;
(b) development of a proactive approach to ensure that the
member receives the services;
(c) facilitation of appropriate coordination with school-based
providers;
(d) development of a systematic communication process with MCO
network providers regarding screens and treatment coordination;
(e) processes to document, measure and assure compliance with MAD’s
periodicity schedule; and
(f) development of a proactive process to insure the appropriate
follow-up evaluation, referral and treatment, including early intervention for developmental
delay, vision and hearing screening, dental examinations and immunizations.
(2) The
MCO will facilitate appropriate referral for possible or identified behavioral
health conditions. See 8.321.2 NMAC for
EPSDT behavioral health services descriptions.
[8.308.9.15
NMAC - Rp, 8.308.9.15 NMAC,
5/1/2018]
8.308.9.16 REPRODUCTIVE HEALTH SERVICES: The
benefit package includes reproductive health services as detailed in 8.310.2
NMAC. The MCO shall implement written
policies and procedures approved by HSD which define how a member is educated
about his or her rights to family planning services, freedom of choice, to
include access to non-contract providers, and methods for accessing family
planning services.
A. The family
planning policy shall ensure that a member of the appropriate age of both sexes
who seeks family planning services shall be provided with counseling pertaining
to the following:
(1) human immunodeficiency virus (HIV) and other sexually transmitted diseases and risk reduction
practices; and
(2) birth control pills and devices including plan B and long
acting reversible contraception.
B. The MCO shall
provide a member with sufficient information to allow him or her to make
informed choices including the following:
(1) types of family planning services available;
(2) the member’s right to access these services in a timely and
confidential manner;
(3) freedom to choose a qualified family planning provider who
participates in the MCO network or from a provider who does not participate in
the member’s MCO network; and
(4) if a member chooses to receive family planning services from
a non-contracted provider, the member shall be encouraged to exchange medical
information between the PCP and the non-contracted provider for better
coordination of care.
C. Pregnancy
termination procedures: The benefit package includes
services for the termination of a pregnancy as detailed in 8.310.2 NMAC. Medically necessary pregnancy terminations
which do not meet the requirements of 42 CFR 441.202 are excluded from the
capitation payment made to the MCO and shall be reimbursed solely from state
funds pursuant to the provisions of 8.310.2 NMAC.
[8.308.9.16
NMAC - Rp, 8.308.9.16 NMAC,
5/1/2018]
8.308.9.17 PREVENTIVE PHYSICAL HEALTH SERVICES: The MCO shall
follow current national standards for preventive health services, including
behavioral health preventive services. Standards
are derived from several sources, including the U.S. preventive services task
force, the centers for disease control and prevention; and the American college
of obstetricians and gynecologists. Any
preventive health guidelines developed by the MCO under these standards shall
be adopted and reviewed at least every two years, updated when appropriate and
disseminated to its practitioners and members.
Unless a member refuses and the refusal is documented, the MCO shall
provide the following preventive health services or screens or document that
the services (with the results) were provided by other means. The MCO shall document medical reasons not to
perform these services for an individual member. Member refusal is defined to include refusal
to consent to and refusal to access care.
A. Initial assessment: The MCO shall conduct a health risk
assessment (HRA), per HSD guidelines and processes, for the purpose of
obtaining basic health and demographic information about the member, assisting
the MCO in determining the need for a comprehensive needs assessment (CNA) for
care coordination level assignment.
B. Family planning: The MCO must
have a family planning policy. This
policy must ensure that a member of the appropriate age of both sexes who seeks
family planning services is provided with counseling and treatment, if
indicated, as it relates to the following:
(1) methods of contraception; and
(2) HIV
and other sexually transmitted diseases and risk reduction practices.
C. Guidance: The
MCO shall adopt policies that shall ensure that an applicable asymptomatic
member is provided guidance on the following topics unless the member’s refusal
is documented:
(1) prevention of tobacco use;
(2) benefits of physical activity;
(3) benefits of a healthy diet;
(4) prevention of osteoporosis and heart disease in a menopausal
member citing the advantages and disadvantages of calcium and hormonal
supplementation;
(5) prevention of motor vehicle injuries;
(6) prevention of household and recreational injuries;
(7) prevention of dental and periodontal disease;
(8) prevention of HIV infection and other sexually transmitted
diseases;
(9) prevention of an unintended pregnancy; and
(10) prevention or intervention for obesity or weight issues.
D. Immunizations: The
MCO shall adopt policies that to the extent possible,
ensure that within six months of enrollment, a member is immunized according to
the type and schedule provided by current recommendations of the state
department of health (DOH). The MCO
shall encourage providers to verify and document all administered immunizations
in the New Mexico statewide immunization information system (SIIS).
E. Nurse
advice line: The MCO shall provide a toll-free
clinical telephone nurse advice line function that includes at least the
following services and features:
(1) clinical assessment and triage to evaluate the acuity and
severity of the member’s symptoms and make the clinically appropriate referral;
and
(2) pre-diagnostic and post-treatment health care decision
assistance based on the member’s symptoms.
F. Prenatal care: The MCO shall
operate a proactive prenatal care program to promote early initiation and
appropriate frequency of prenatal care consistent with the standards of the
American college of obstetrics and gynecology.
The program shall include at least the following:
(1) educational outreach to a member of childbearing age;
(2) prompt
and easy access to obstetrical care, including an office visit with a
practitioner within three weeks of having a positive pregnancy test (laboratory
or home) unless earlier care is clinically indicated;
(3) risk
assessment of a pregnant member to identify high-risk cases for special
management;
(4) counseling which strongly advises voluntary testing for HIV;
(5) case management services to address the special needs of a
member who has a high risk pregnancy, especially if risk is due to psychosocial
factors, such as substance abuse or teen pregnancy;
(6) screening for determination of need for a post-partum home
visit; and
(7) coordination with other services in support of good prenatal
care, including transportation, other community services and referral to an
agency that dispenses baby car seats free or at a reduced price.
G. Screens: The MCO shall adopt policies
which will ensure that, to the extent possible, within six months of enrollment
or within six months of a change in screening standards, each asymptomatic
member receives at least the following preventive screening services listed
below.
(1) Screening
for breast cancer: A female member
between the ages of 40-69 years shall be screened every one to two years by
mammography alone or by mammography and annual clinical breast examination.
(2) Blood
pressure measurement: A member 18
years of age or older shall receive a blood pressure measurement at least every
two years.
(3) Screening
for cervical cancer: A female member
with a cervix shall receive cytopathology testing starting at the onset of
sexual activity, but at least by 21 years of age and every three years
thereafter until reaching 65 years of age when prior testing has been
consistently normal and the member has been confirmed not to be at high
risk. If the member is at high risk, the
frequency shall be at least annual.
(4) Screening
for chlamydia: All sexually active
female members 25 years of age and younger shall be screened for
chlamydia. All female members over 25
years of age shall be screened for chlamydia if they inconsistently use barrier
contraception, have more than one sex partner, or have had a sexually transmitted
disease in the past.
(5) Screening
for colorectal cancer: A member 50
years of age and older, who is at normal risk for colorectal cancer shall be
screened with annual fecal occult blood testing or sigmoidoscopy or colonoscopy
or double contrast barium at a periodicity determined by the MCO.
(6) EPSDT
screening for elevated blood lead levels:
A risk assessment for elevated blood lead levels shall be performed
beginning at six months and repeated at nine months of age. A member shall receive a blood lead
measurement at 12 months and 24 months of age.
A member between the ages of three and six years, for whom no previous
test exists, should also be tested, and screenings shall be done in accordance
with the most current recommendations of the American academy of pediatrics.
(7) EPSDT
newborn screening: A newborn member
shall be screened for those disorders specified in the state of New Mexico
metabolic screen and any screenings shall be done in accordance with the most
current recommendations of the American academy of pediatrics.
(8) Screening
for obesity: A member shall receive
body weight, height and length measurements with each physical exam. A member under 21 years of age shall receive
a BMI percentile designation.
(9) Prenatal
screening: All pregnant members shall be screened for preeclampsia, Rh (D)
incompatibility, down syndrome, neural tube defects, hemoglobinopathies, vaginal and rectal group B
streptococcal infection and screened and counseled for HIV in accordance with
the most current recommendations of the American college of obstetricians and
gynecologists.
(10) Screening
for rubella: All female members of childbearing ages shall be screened for
rubella susceptibility by history of vaccination or by serology.
(11) Screening
for tuberculosis: Routine tuberculin
skin testing shall not be required for all members. The following high-risk members shall be
screened or previous screenings noted:
(a) a
member who has immigrated from countries in Asia, Africa, Latin America or the
middle east in the preceding five years;
(b) a member who has substantial contact with immigrants from
those areas; a member who is a migrant farm worker;
(c) a member who is an alcoholic, homeless or is an injecting
drug user. HIV-infected persons shall be
screened annually; and
(d) a member whose screening tuberculin test is positive (>10
mm of induration) must be referred to the local DOH public health office in his
or her community of residence for contact investigation.
(12) Serum
cholesterol measurement: A male
member 35 years and older and a female member 45 years and older who is at
normal risk for coronary heart disease shall receive serum cholesterol and HDL
cholesterol measurement every five years.
A member 20 years and older with risk factors for
heart disease shall have serum cholesterol and HDL cholesterol measurements
annually.
(13) Tot-to-teen
health checks: The MCO shall operate
the tot-to-teen mandated EPSDT program as outlined in 8.320.2 NMAC. Within three months of enrollment lock-in,
the MCO shall ensure that the member is current according to the screening
schedule, unless more stringent requirements are specified in these
standards. The MCO shall encourage its
PCPs to assess and document for age, height, gender appropriate weight, and
body mass index (BMI) percentage during EPSDT screens to detect and treat
evidence of weight or obesity issues in members under
21 years of age.
(14) Screening
for type 2 diabetes: A member with one or more of the following
risk factors for diabetes shall be screened.
Risk factors include:
(a) a family history of diabetes (parent or sibling with
diabetes); obesity (>twenty percent over desired body weight or BMI
>27kg/m2);
(b) race or ethnicity (e.g. hispanic,
native American, African American, Asian-Pacific islander);
(c) previously identified impaired fasting glucose or impaired
glucose tolerance; hypertension (>140/90 mmHg); HDL cholesterol level <35
mg/dl and triglyceride level >250 mg/dl; history of gestational diabetes
mellitus (GDM); and
(d) a delivery of newborn over nine pounds.
(15) A
member 21 years of age and older must be screened to detect high risk for
behavioral health conditions at his or her first encounter with a PCP after
enrollment.
(16) The
MCO shall require its PCPs to refer a member, whenever clinically appropriate,
to behavioral health provider, see 8.321.2 NMAC. The MCO shall assist the member with an
appropriate behavioral health referral.
(17) Screens
and preventative screens shall be updated as recommended by the United States
preventative services task force.
[8.308.9.17
NMAC - Rp, 8.308.9.17 NMAC,
5/1/2018]
8.308.9.18 TELEMEDICINE SERVICES: The benefit
package includes telemedicine services as detailed in 8.310.2 NMAC.
A. The
MCO must:
(1) promote and employ broad-based utilization
of statewide access to Health Insurance
Portability and Accountability Act (HIPAA)-compliant telemedicine service systems including, but not limited
to, access to text telephones or teletype (TTYs) and 711 telecommunication
relay services;
(2) follow state guidelines for telemedicine
equipment or connectivity;
(3) follow accepted HIPAA and 42 CFR part two
regulations that affect telemedicine transmission, including but not limited to staff and contract provider
training, room setup, security of transmission lines, etc;
the MCO shall have and implement policies and procedures that follow all
federal and state security and procedure guidelines;
(4) identify, develop, and implement training for
accepted telemedicine
practices;
(5) participate in the needs assessment of the
organizational, developmental, and programmatic requirements of telemedicine programs;
(6) report to HSD on the telemedicine outcomes of telemedicine projects and submit the telemedicine report; and
(7) ensure that telemedicine services meet the following shared values,
which are ensuring: competent care with
regard to culture and language needs; work sites are distributed across the
state, including native American sites for both clinical and educational
purposes; and coordination of telemedicine and technical functions at either end of network connection.
B. The
MCO shall participate in project extension for community healthcare outcomes
(ECHO), in accordance with state prescribed requirements and standards, and
shall:
(1) work collaboratively with HSD, the university of
New Mexico, and providers on project ECHO;
(2) identify high needs, high cost members who
may benefit from project ECHO participation;
(3) identify its PCPs who serve high needs, high
cost members to participate in project ECHO;
(4) assist project ECHO with engaging its MCO PCPs in
project ECHO’s center for medicare and medicaid innovation (CMMI) grant project;
(5) reimburse primary care clinics for participating in
the project ECHO model;
(6) reimburse “intensivist” teams;
(7) provide claims data to HSD to support the
evaluation of project ECHO;
(8) appoint a centralized liaison to obtain prior
authorization approvals related to project ECHO; and
(9) track quality of care and outcome measures
related to project ECHO.
[8.308.9.18
NMAC - Rp, 8.308.9.18 NMAC,
5/1/2018]
8.308.9.19 BEHAVIORAL HEALTH SERVICES:
A. The MCO shall
cover the following behavioral health services listed below. When an additional behavioral health service
is approved by MAD, the MCO shall cover that service as well. See 8.321.2 NMAC for detailed descriptions of
each service. MAD makes available on its
website its behavioral health service
definitions and crosswalk, along with other information.
(1) Applied behavior analysis: The benefit package includes applied behavior
analysis (ABA) services for a member 12 months of age up to 21 years of age who
has a well-documented medical diagnosis of autism spectrum disorder (ASD), and
for a member 12 months to three years of age who has a well-documented risk for
the development of ASD. The need for ABA
services must be identified in the member’s tot to teen healthcheck
screen or another diagnostic evaluation furnished through a healthcheck
referral.
(2) Assertive community treatment
services (ACT): The benefit
package includes assertive community treatment services for a member 18 years
of age and older.
(3) Behavioral health respite: Behavioral health respite care is provided to
a member under 21 years of age to support the member’s
family and strengthen their resiliency during the respite while the member is
in a supportive environment. Respite
care is provided to a member with a severe emotional disturbance who resides
with his or her family and displays challenging behaviors that may periodically
overwhelm the member’s family’s ability to provide ongoing supportive
care. See the New Mexico interagency
behavioral health purchasing collaborative service requirements and utilization
guidelines-respite services-for a detailed description. Behavioral health respite is not a benefit
for ABP eligible recipients.
(4) Comprehensive
community support services: The benefit package includes
comprehensive community support services for a member.
(5) Crisis
Services: The benefit package
includes three types of crisis services:
(a) 24-hour crisis telephone support; and
(b) mobile crisis team; and
(c) crisis triage centers.
(6) Family support services: The benefit package includes family support
services to a member whose focus is on the member and his or her family and the
interactive effect through a variety of informational and supportive activities
that assists the member and his or her family develop patterns of interaction
that promote wellness and recovery over time.
The positive interactive effect between the member and his or her family
strengthens the effectiveness of other treatment and recovery initiatives. See the New Mexico interagency behavioral
health purchasing collaborative service requirements and utilization guidelines
-family support services-for a detailed description. Family support services are not a benefit for
ABP eligible recipients.
(7) Hospital outpatient services: The
benefit package includes outpatient psychiatric and partial hospitalization
services provided in PPS-exempt unit of a general hospital for a member.
(8) Inpatient hospital services: The
benefit package includes inpatient hospital psychiatric services provided in
general hospital units and prospective payment system (PPS)-exempt units in a
general hospital as detailed in 8.311.2 NMAC.
(9) Intensive
outpatient (IOP) services: The benefit package includes intensive
outpatient services for a member 13 years of age.
(10) Medication
assisted treatment (MAT) and Opioid Treatment Programs: The
benefit package includes opioid treatment services for opioid addiction to a
member through an opioid treatment center as defined in 42 CFR Part 8,
Certification of Opioid Treatment; and buprenorphine and related
pharmaceuticals. Medication assisted
treatments include use of buprenorphine and similarly acting products.
(11) Outpatient therapy services: The
benefit package includes outpatient therapy services (individual, family, and
group) for a member.
(12) Psychological rehabilitation services: The benefit package includes adult
psychosocial rehabilitation services for a member 18 years and older.
(13) Recovery services: The
MCO benefit package includes recovery services for a member. Recovery services are peer-to-peer support
within a group setting to develop and enhance wellness and healthcare
practices. The service enables a member
to identify additional needs and goals and link him or herself to additional
support as a result. See the New Mexico
interagency behavioral health purchasing collaborative service requirements and
utilization guidelines -recovery services-for a detailed description. Recovery services are not a benefit for ABP
eligible recipients.
B. Behavioral health EPSDT services: The
benefit package includes the delivery of the federally mandated EPSDT services (42
CFR Section 441.57) provided by a behavioral health practitioner for a member under 21 years of age.
See 8.321.2 NMAC for a detailed description of each service. The MCO shall provide access to EPSDT for a
member identified in his or her EPSDT tot to teen health check screen or
another diagnostic evaluation as being at-risk for developing or having a
severe emotional, behavioral or neurobiological disorder.
(1) Accredited residential treatment center
(ARTC): The benefit package includes
services furnished in an ARTC furnished as part of the EPSDT program. ARTC services are provided to a member who
needs the LOC furnished in an out-of-home residential setting. The need for ARTC services must be identified
in the member’s tot to teen health check screen or another diagnostic
evaluation furnished through a health check referral.
(2) Behavior management skills development
services (BMS): The benefit package
includes BMS services furnished as part of the EPSDT program. BMS services are provided to a member who has
an identified need for such services and meets the required LOC. The need for BMS services must be identified
in the member’s tot to teen health check screen or another diagnostic
evaluation furnished through a health check referral.
(3) Day treatment services: The
benefit package includes day treatment services furnished as part of the EPSDT
program. Day treatment services are
provided to a member who has an identified need for such services and meets the
required LOC. The need for day treatment
services must be identified in the member’s tot to teen health check screen or
another diagnostic evaluation furnished through a health check referral.
(4) Inpatient hospitalization services provided
in freestanding psychiatric hospitals: The benefit package
includes inpatient psychiatric care furnished in a freestanding psychiatric
hospital furnished as part of the EPSDT program. Inpatient hospitalization
services are provided in a freestanding psychiatric hospital are provided to a
member who has an identified need for such services and meet the required
LOC. The need for such services must be
identified in the member’s tot to teen health check screen or another
diagnostic evaluation furnished through a health check referral.
(5) Multi-systemic therapy (MST): The
benefit package includes MST services furnished as part of the EPSDT
program. MST services are provided to a
member who has an identified need for such services and meets the required LOC. The need for MST services must be identified
in the member’s tot to teen health check screen or another diagnostic
evaluation furnished through a health check referral.
(6) Psychosocial rehabilitation services (PSR): The benefit package includes PSR services
furnished as part of the EPSDT program.
PSR is provided to a member who has an identified need for such services
and meets the required LOC. The need for
PSR services must be identified in the member’s tot to teen health check screen
or another diagnostic evaluation furnished through a health check referral.
(7) Treatment foster care I (TFC I): The benefit package includes TFC I furnished
as part of the EPSDT program. TFC I
services are provided to a member who has an identified need for such services
and meets the required LOC. The need for
TFC I services must be identified in the member’s tot to teen health check or
another diagnostic evaluation furnished through a health check referral.
(8) Treatment foster care II (TFC II): The benefit package includes TFC II services
furnished as part of the EPSDT program.
TFC II is provided to a member who has an identified need for such
services and meets the required LOC. The
need for TFC II services must be identified in the member’s tot to teen health check
or another diagnostic evaluation furnished through a health check referral.
(9) Residential
non-accredited treatment center (RTC) and group home: The
benefit package includes services furnished in a RTC center or group home as
part of the EPSDT program. RTC or group
home services are provided to a member who needs the LOC furnished in an
out-of-home residential setting. The
need for RTC and group home services must be identified in the member’s tot to
teen health check screen or another diagnostic evaluation furnished through a
health check referral.
[8.308.9.19
NMAC - Rp, 8.308.9.19 NMAC,
5/1/2018]
8.308.9.20 COMMUNITY BENEFIT SERVICES: The
MCO shall cover community benefit services for a member who meets the specific
eligibility requirements for each MCO community benefit service as detailed in
8.308.12 NMAC. When an additional
community benefit service is approved by MAD, the MCO shall cover that service
as well.
[8.308.9.20
NMAC - Rp, 8.308.9.20 NMAC,
5/1/2018]
8.308.9.21 ALTERNATIVE BENEFITS PLAN (ABP)
BENEFITS FOR ABP MCO MEMBERS: The MAD category of eligibility “other
adults” has an alternative benefit plan (ABP).
The MCO shall cover the ABP specific services for an ABP member. Services are made available through a MCO
under a benefit plan similar to services provided by commercial insurance
plans. ABP benefits include preventive
services and treatment services. An ABP
member:
A. has limitations on specific
benefits;
B. does not have all standard medicaid state plan benefits available; and
C. has some benefits, primarily preventive
services that are available only to an ABP member. The ABP benefits and services are detailed in
Sections 12 through 18 of 8.309.4 NMAC.
All EPSDT services are available to an ABP member under 21 years. Services for an ABP member under the age of
21 years not subject to the duration, frequency, and annual or lifetime benefit
limitations that are applied to an ABP eligible recipient 21 years of age and
older. The MCO shall comply with all HSD
contractual provisions and with all NMAC rules that pertain to the MCO’s
responsibilities to its members as listed below:
(1) provider networks found in 8.308.2 NMAC;
(2) managed care eligibility found in 8.308.6 NMAC;
(3) enrollment and disenrollment from managed care found in
8.308.7 NMAC;
(4) managed care member education - rights and responsibilities
found in 8.308.8 NMAC;
(5) care
coordination found in 8.308.10 NMAC;
(6) transition of care found in 8.308.11 NMAC;
(7) managed care cost sharing found in 8.308.14 NMAC;
(8) managed
care grievance and appeals found in 8.308.15 NMAC;
(9) managed care reimbursement found in 8.308.20 NMAC;
(10) quality management found in 8.308.21 NMAC; and
(11) managed care fraud, waste and abuse found in 8.308.22 NMAC.
[8.308.9.21
NMAC - Rp, 8.308.9.21 NMAC,
5/1/2018]
8.308.9.22 MAD ALTERNATIVE BENEFITS PLAN
GENERAL BENEFITS FOR ABP EXEMPT MEMBERS (ABP exempt): An ABP member who self-declares he or she has
a qualifying condition is evaluated by his or her MCO for determination if he
or she meets an ABP qualifying condition.
An ABP exempt member may select to no longer utilize his or her ABP
benefits package. Instead, the ABP
exempt member will utilize his or her MCO’s medicaid
benefits package. See 8.308.9.11-20 NMAC
for detailed description of the MCO medicaid benefit
services. All services, services limitations and co-payments
that apply to full benefit medicaid recipients apply
to APB-exempt recipients. An ABP-exempt
recipient does not have access to the benefits that only apply to ABP
recipients. The ABP co-payments do not
apply to an ABP-exempt recipient. The
limitations on services that apply only to ABP-recipients do not apply to
ABP-exempt recipients. The
MCO shall comply with all HSD contractual provisions and with all NMAC rules
that pertain to the MCO’s responsibilities to its members as listed below:
A. provider networks found in 8.308.2
NMAC;
B. managed care eligibility found in
8.308.6 NMAC;
C. enrollment and disenrollment from
managed care found in 8.308.7 NMAC;
D. managed care member education -
rights and responsibilities found in 8.308.8 NMAC;
E. care coordination found in 8.308.10
NMAC;
F. transition of care found in
8.308.11 NMAC;
G. community benefits found in 8.308.12
NMAC;
H. managed care member rewards found in
8.308.13 NMAC
I. managed care cost sharing found in
8.308.14 NMAC;
J. managed care grievance and appeals
found in 8.308.15 NMAC;
K. managed care reimbursement found in
8.308.20 NMAC;
L. quality management found in 8.308.21
NMAC; and
M. managed care fraud, waste and abuse
found in 8.308.22 NMAC.
[8.308.9.22
NMAC - Rp, 8.308.9.22 NMAC,
5/1/2018]
8.308.9.23 SERVICES EXCLUDED FROM THE MCO
BENEFIT PACKAGE:
MAD does not cover some services. For the following services that are covered
in another MAP category of eligibility, reimbursement shall be made by MAD or
its contractor. However, the MCO is
expected to coordinate these services, when applicable, and ensure continuity
of care by overseeing PCP consultations, medical record updates and general
coordination.
A. Medicaid in the schools: Services are covered under 8.320.6 NMAC. Reimbursement for services is made by MAD or
its contractor.
B. Special rehabilitation services-family
infant toddler (FIT): Early
intervention services provided for a member birth to three years of age who has
or is at risk for a developmental delay.
Reimbursement for services is made by MAD or its contractor.
[8.308.9.23
NMAC - Rp, 8.308.9.23 NMAC,
5/1/2018]
8.308.9.24 Emergency and post stabilization
services.
A. In this section, emergency medical
condition means a medical condition manifesting itself by acute symptoms of
sufficient severity (including severe pain) that a prudent layperson, who
possesses an average knowledge of health and medicine, could reasonably expect
the absence of immediate medical attention to result in the following:
(1) Placing the health of the individual
(or, for a pregnant woman, the health of the woman or her unborn child) in
serious jeopardy.
(2) Serious impairment to bodily functions.
(3) Serious dysfunction of any bodily
organ or part.
B. In this section, emergency services
means covered inpatient and outpatient services as follows.
(1) Furnished by a provider that is
qualified to furnish these services under the federal rules. See 42 CFR 438.114.
(2) Needed to evaluate or stabilize an
emergency medical condition.
C. Post-stabilization care services
means covered services, related to an emergency medical condition that are
provided after a member is stabilized to maintain the stabilized condition, or,
under the circumstances described 42 CFR 438.114 (e), to improve or resolve the
member’s condition.
D. The MCO is responsible for coverage
and payment of emergency services and post-stabilization care services. The MCO must cover and pay for emergency
services regardless of whether the provider that furnishes the services has a
contract with the MCO. The MCO may not
deny payment for treatment obtained under either of the following
circumstances.
(1) A member had an emergency medical
condition, including cases in which the absence of immediate medical attention
would not have had the outcomes specified in the definition of emergency
medical condition in Subsection A of 8.308.9.24 NMAC.
(2) A representative of the MCO instructs
the member to seek emergency services.
E. The MCO may
not:
(1) limit what
constitutes an emergency medical condition with reference to Subsection A of 8.308.9.24
NMAC on the basis of lists of diagnoses or symptoms; or
(2) refuse to cover
emergency services based on the emergency room provider or hospital not
notifying the member’s PCP or the MCO.
F. A member who has an emergency
medical condition may not be held liable for payment of subsequent screening
and treatment needed to diagnose the specific condition or stabilize the member.
G. The attending emergency physician,
or the provider actually treating the member, is responsible for determining
when the member is sufficiently stabilized for transfer or discharge, and that
determination is binding on the MCO that is responsible for coverage and
payment.
[8.308.9.24 NMAC - Rp, 8.308.9.24 NMAC, 5/1/2018]
8.308.9.25 Additional coverage requirements:
A. The MCO may not arbitrarily deny or
reduce the amount, duration, or scope of a required service solely because of
diagnosis, type of illness, or condition of the member.
B. The services supporting members with
ongoing or chronic conditions or who require long-term services and supports
must be authorized in a manner that reflects the member's ongoing need for such
services and supports.
C. Family planning services are
provided in a manner that protects and enables the member's freedom to choose
the method of family planning to be used consistent with 42 CFR 441.20, family
planning services.
D. The MCO must specify what
constitutes “medically necessary services” in a manner that:
(1) is no more
restrictive than that used in the New Mexico administrative code (NMAC) MAD
rules, including quantitative and non-quantitative treatment limits, as
indicated in state statutes and rules. The
state plan, and other state policy and procedures; and
(2) addresses
the extent to which the MCO is responsible for covering services that address:
(a) the
prevention, diagnosis, and treatment of a member's disease, condition, or
disorder that results in health impairments or disability;
(b) the ability
for a member to achieve age-appropriate growth and development;
(c) the ability
for a member to attain, maintain, or regain functional capacity; and
(d) The opportunity for a member receiving
long-term services and supports to have access to the benefits of community
living, to achieve person-centered goals, and live and work in the setting of his
or her choice.
E. Authorization of services: For the processing of requests for initial and
continuing authorizations of services, the MCO must:
(1) have in
place, and follow, written policies and procedures;
(2) have in effect mechanisms to ensure
consistent application of review criteria for authorization decisions;
(3) consult with the requesting provider
for medical services when appropriate;
(4) authorize
long term services and supports (LTSS) based on an enrollee's current needs
assessment and consistent with the person-centered service plan;
(5) assure that any decision to deny a
service authorization request or to authorize a service in an amount, duration,
or scope that is less than requested, be made by an individual who has
appropriate expertise in addressing the member's medical, behavioral health, or
LTSS needs;
(6) notify the requesting provider, and
give the member written notice of any decision by the MCO to deny a service
authorization request, or to authorize a service in an amount, duration, or
scope that is less than requested and the notice must meet the requirements of
42 CFR 438.404, timely and adequate notice of adverse benefit determination;
and
(7) for drug
items that require prior authorization and drug items that are not on the MCO
preferred drug list:
(a) provide a
response by telephone or other telecommunication device within 24 hours of a
request for prior authorization;
(b) provide for
the dispensing of at least a 72-hour supply of a covered outpatient
prescription drug in an emergency situation;
(c) consider in the review process any
medically accepted indications for the drug item consistent with the American hospital
formulary service drug information; United States pharmacopeia-drug information
(or its successor publications); the DRUGDEX information system; and
peer-reviewed medical literature as described in section 1927(d)(5)(A) of the
Social Security Act.
[8.308.9.25 NMAC - Rp, 8.308.9.25 NMAC, 5/1/2018]
HISTORY OF
8.308.9 NMAC: [RESERVED]
History of
Repealed Material:
8.308.9 NMAC - Managed Care Program, Benefit
Package, filed 12/17/2013 Repealed effective 5/1/2018.