N.M. Admin. Code § 13.10.23.14 - CONTINUATION AND TRANSITION OF TREATMENT
Each health care insurer shall offer continuation and transition of treatment to covered persons in compliance with the Insurance Code and applicable rules.
A. If a
covered person's health care provider leaves the MHCP's network of providers,
the MHCP shall permit the covered person to continue an ongoing course of
treatment with the provider for a transitional period.
B. For all covered persons except those
addressed Subsection C of
13.10.23.14 NMAC, the transitional
period shall continue for a time that is sufficient to permit coordinated
transition planning consistent with the patient's condition and needs relating
to continuity of case, and, in any event, shall not be not less than thirty
days.
C. If a covered person has
entered the third trimester of pregnancy at the time of the provider's
disaffiliation, and the MHCP offers maternity coverage, the transitional period
shall include the provision of post-partum care directly related to the
delivery.
D. The MHCP will not be
required to permit the covered person to continue treatment with the current
provider if the provider's disaffiliation with the MHCP was for reasons related
to medical competence or professional behavior.
E. For transitional periods exceeding thirty
days, the MHCP shall authorize continued care as provided in this section only
if the health care provider agrees:
(1) to
accept reimbursement from the MHCP at the rates applicable prior to the start
of the transitional period as payment in full;
(2) to adhere to the MHCP's quality assurance
requirements and to provide to the MHCP necessary medical information related
to such care; and
(3) to otherwise
adhere to the MHCP's policies and procedures, including but not limited to
procedures regarding referrals, pre-authorization and treatment planning
approved by the MHCP.
F.
If upon the effective date of enrollment a new covered person's health care
provider is not a member of the MHCP's provider network, the MHCP shall permit
the covered person to continue an ongoing course of treatment with the covered
person's current health care provider for a transitional period of
time.
G. For covered persons in an
ongoing course of treatment, the transitional period shall be sufficient to
permit coordinated transition planning consistent with the patient's condition
and needs relating to continuity of care, and, in any event, shall not be less
than thirty days.
H. If a covered
person has entered the third trimester of pregnancy at the effective date of
enrollment, and the MHCP offers maternity coverage, the transitional period
shall include the provision of post-partum care directly related to the
delivery.
I. While a covered person
is under the care of a provider outside the MHCP's network pursuant to this
section, the covered person may receive care from other providers outside the
network as ordered by the treating health care professional in consultation
with the MHCP. The MHCP shall be obligated to authorize such care and to pay
for such services only if the provider furnishing the care to the covered
person agrees to accept the conditions described in this section.
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.