Standards for Access. A. The CONTRACTOR shall ensure the Salud! member caseload of any PCP does not exceed fifteen hundred (1,500) enrollees.
B. The CONTRACTOR shall provide to members and providers clear instructions on how to access services, including those that require prior approval or referral.
C. The CONTRACTOR shall meet time and distance standards for PCPs and pharmacies as determined by HSD or as described in MAD Policy 606.
Standards for Access. 1. The SE shall ensure the accessibility and availability of behavioral health providers for each medically, clinically or psychosocially necessary service.
2. The SE shall comply with NMAC 8.305.8.18.
3. The SE shall submit documentation to the Collaborative, as requested, giving assurances that it has the capacity to serve the expected number of consumers in accordance with the Collaborative’s access standards. This documentation shall be in a format acceptable to the State.
4. The SE shall provide access to the full array of covered services. If a service is unavailable based on the access guidelines, a service equal to or higher than that service shall be offered.
5. The SE shall maintain and update as necessary its Service Access Plan, which shall describe the SE’s system for consumer access to services. The plan will be reviewed during regular quarterly meetings that include the SE and the Collaborative, and shall be revised as required by the Collaborative.
6. The SE shall ensure that in each region of the State there is an array of covered services that allow consumers to be served within the least restrictive setting and in close proximity to their places of residence, with preference given to in-state providers.
a. The SE can include out-of-state providers for those consumers who require services not available from in-state providers.
b. For each child residing in an out-of-state residential facility, the SE shall develop a plan, approved by the Collaborative, to provide medically or clinically necessary and appropriate services in-state.
7. The SE shall report to the Collaborative any high-volume network providers (as defined by the SE) that are not accepting new consumers.
8. For non-Medicaid consumers and non-Medicaid services to Medicaid consumers, the SE shall use diagnostic criteria and risk factors (see Article 3.5) to prioritize access to covered services.
9. The SE shall ensure that the following appointment standards are met:
a. For non-urgent, non-emergent behavioral health care, the request- to-appointment time shall be no more than fourteen (14) days, unless the consumer requests a later time.
b. For urgent behavioral health care, appointments shall be available within twenty-four (24) hours.
c. For crisis services, face-to-face appointments shall be available within two (2) hours.
10. The SE shall report to the Collaborative on the compliance of providers in meeting the appointment standards in section 9 above. The methodology and t...
Standards for Access i. The CONTRACTOR shall ensure the Salud! member caseload of any PCP does not exceed fifteen hundred (1,500) enrollees of the CONTRACTOR. Exceptions to this limit may be made with the consent of HSD/MAD. Reasons for exceeding the limit may include continuing established care, assigning of a family unit or the availability of mid-level clinicians in the practice, which expands the capacity of the PCP.
ii. The CONTRACTOR shall provide to members and providers clear instructions on how to access services, including those that require prior approval or referral.
iii. The CONTRACTOR shall meet time and distance standards for PCPs and pharmacies as determined by HSD/MAD or as described in MAD Policy 8.305.
