TITLE 8 SOCIAL
SERVICES
CHAPTER 308 MANAGED
CARE PROGRAM
PART 8 MEMBER RIGHTS, RESPONSIBILITIES
AND EDUCATION
8.308.8.1 ISSUING
AGENCY: New Mexico Health Care Authority.
[8.308.8.1 NMAC -
Rp, 8.308.8.1 NMAC, 5/1/2018; A, 7/1/2024]
8.308.8.2 SCOPE: This rule applies to the general
public.
[8.308.8.2 NMAC -
Rp, 8.308.8.2 NMAC, 5/1/2018]
8.308.8.3 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. Section 9-8-1 et seq. NMSA 1978 establishes the health care
authority (HCA) as a single, unified department to administer laws and exercise
functions relating to health care facility licensure and health care purchasing
and regulation.
[8.308.8.3 NMAC -
Rp, 8.308.8.3 NMAC, 5/1/2018; A, 7/1/2024]
8.308.8.4 DURATION: Permanent.
[8.308.8.4 NMAC -
Rp, 8.308.8.4 NMAC, 5/1/2018]
8.308.8.5 EFFECTIVE
DATE: May 1, 2018, unless a later date is cited at
the end of a section.
[8.308.8.5 NMAC -
Rp, 8.308.8.5 NMAC, 5/1/2018]
8.308.8.6 OBJECTIVE: The objective of this rule is to provide
instructions for the service portion of the New Mexico medical assistance
programs (MAP).
[8.308.8.6 NMAC -
Rp, 8.308.8.6 NMAC, 5/1/2018]
8.308.8.7 DEFINITIONS: [RESERVED]
8.308.8.8 [RESERVED]
[8.308.8.8 NMAC -
Rp, 8.308.8.8 NMAC, 5/1/2018]
8.308.8.9 [RESERVED]
[8.308.8.9 NMAC -
Rp, 8.308.8.9 NMAC, 5/1/2018]
8.308.8.10 WRITTEN
MEMBER MATERIALS:
A. All written
materials will be available in English and all languages spoken by approximately
five percent or more of the MCO’s membership, as determined by the HSD
contracted managed care organization (MCO) or HSD. Upon consent from the appropriate native
American tribal leadership, the MCO shall make every effort when a written form
is not in the member’s native language to translate the form in the member’s
native language.
B. The MCO is
responsible for providing a member or potential member with its member handbook
and provider directory, as requested by a member.
(1) The
MCO shall send such information to the member within 30 calendar days of receipt
of notification of enrollment in the MCO.
(2) Thereafter,
upon the request from a member, the MCO shall send such information within 10
calendar days. The MCO shall provide the
requestor the option to receive the material in a written or electronic form or
by citation to be found on the member’s MCO’s website.
(3) On
an annual basis, the MCO shall notify the member of the availability of updated
materials and how to obtain such materials.
C. All written
member materials must comply with provisions set forth in 42 CFR 438.10.
[8.308.8.10 NMAC -
Rp, 8.308.8.10 NMAC, 5/1/2018]
8.308.8.11 MEMBER
RIGHTS AND RESPONSIBILITIES: The MCO shall
provide each member or the member's authorized representative with written
information concerning his or her rights and responsibilities.
A. These include the
right:
(1) to
be treated with respect and with due consideration for his or her dignity and
privacy;
(2) to
receive information on available treatment options and alternatives, presented
in a manner appropriate to his or her condition and ability to understand such
information;
(3) to
make and have honored his or her advance directive that is consistent with
state and federal laws;
(4) to
receive covered services in a nondiscriminatory manner;
(5) to
participate in decisions regarding his or her health care, including the right
to refuse treatment;
(6) to
be free from any form of restraint or seclusion used as a means of coercion,
discipline, convenience or retaliation, as specified in federal regulations on
the use of restraints and seclusion;
(7) to
request and receive a copy of his or her medical records and to request that
they be amended or corrected as specified in 45 CFR 164.524 and 526;
(8) to
choose an authorized representative to be involved, as appropriate, in making his
or her health care decisions;
(9) to
provide informed consent;
(10) to
voice grievances concerning the care provided by the MCO;
(11) to
appeal any action regarding medicaid services that
the member or his or her authorized representative or authorized provider
believes is erroneous;
(12) to
protect the member, his or her authorized representative or authorized provider
who uses the grievance, appeal, and HSD administrative hearing processes from
fear of retaliation;
(13) to
choose from among contracted providers in accordance with his or her MCO’s
prior authorization requirements;
(14) to
receive information about covered services and how to access these covered
services, and providers;
(15) to
be free from harassment by the MCO or its contracted providers in regard to contractual disputes between the MCO and the
provider;
(16) to
participate in understanding physical and behavioral health problems and developing
mutually agreed-upon treatment goals; and
(17) to
be assured that the MCO complies with any other applicable federal and state
laws including: Title VI of the Civil
Rights Act of 1964 as implemented by regulations in 45 CFR part 80; the Age
Discrimination Act of 1975 as implemented by regulations 45 CFR part 91; the
Rehabilitation Act of 1973; Title IX of the Education Amendments of 1972
(regarding education programs and activities); Titles II and III of the Americans
with Disabilities Act; and section 1557 of the Patient Protection and
Affordable Care Act.
B. The MCO shall
ensure that each member or the member's authorized representative or authorized
provider is free to exercise his or her rights, and the exercise of those
rights does not adversely affect the way that the MCO or provider treats the
member or member's authorized representative or authorized provider.
C. The member or his
or her authorized representative or authorized provider, to the extent
possible, has a responsibility:
(1) to
provide information that the MCO and providers need in order
to care for the member, such information includes, but is not limited to
the member’s:
(a) most
current mailing address;
(b) most
current email address, if one is available;
(c) most
current phone number, including any land line and cell phone, if available; and
(d) most
current emergency contact information;
(2) to
follow the care plans and instructions from his or her provider that have been
agreed upon;
(3) to
keep a scheduled appointment; and
(4) to
reschedule or cancel a scheduled appointment rather than simply fail to keep
it.
[8.308.8.11 NMAC -
Rp, 8.308.8.11 NMAC, 5/1/2018]
8.308.8.12 MEMBER
HEALTH RECORDS: The MCO shall provide a member with access to
electronic or hard copy versions of his or her personal health records.
[8.308.8.12 NMAC -
Rp, 8.308.8.12 NMAC, 5/1/2018]
8.308.8.13 MEMBER
HEALTH EDUCATION: The MCO shall
provide health education to its members.
Health education is intended to advise or inform the MCO members about
issues related to healthy lifestyles, situations that affect or influence
health status, behaviors that affect or influence health status or methods of
medical treatment.
A. The MCO shall
develop a member health education plan that uses classes, individual or group
sessions, videotapes, written materials, media campaigns and modern
technologies (e.g. mobile applications and tools).
(1) All
educational materials shall be provided in a manner and format that is easily
understood by a member.
(2) The
MCO shall notify its members of the schedule of educational events and shall
post such information on its website.
B. The MCO shall
distribute a quarterly newsletter that is intended to educate members about the
managed care system, the proper utilization of services, and to encourage
utilization of preventative care services.
[8.308.8.13 NMAC -
Rp, 8.308.8.13 NMAC, 5/1/2018]
8.308.8.14 MEMBER
WEBSITE: The MCO shall have a member portal on its
website that is available to all members and potential members, and contains
accurate, up-to-date information about the MCO to include, services provided, the
preferred drug list, the provider directory, member handbook, frequently asked
questions (FAQs), contact phone numbers and email addresses as set forth in 42
CFR 438.10. A member or potential member
shall have access to the member handbook and provider directory via the website
without having to log-in.
[8.308.8.14 NMAC -
Rp, 8.308.8.14 NMAC, 5/1/2018]
8.308.8.15 MEMBER
TOLL-FREE LINE: The MCO shall operate a call center with a
toll-free phone line to respond to member questions, concerns, inquiries and
complaints from a member and his or her provider. The line shall be equipped to handle calls
from an individual with limited English proficiency, as well as calls from a member
who is hearing impaired. It should be
staffed 24 hours a day, seven days a week, with qualified nurses to triage
urgent care and emergency calls from a member, and when necessary, to
facilitate the transfer of such calls to a care coordinator.
[8.308.8.15 NMAC -
Rp, 8.308.8.15 NMAC, 5/1/2018]
8.308.8.16 MEMBER
ADVISORY BOARD: The MCO shall convene advisory boards that
meet quarterly and are representative of its membership. The advisory board shall advise the MCO on
issues concerning service delivery, quality of its covered services, and other member
issues as needed or as directed by HSD.
[8.308.8.16 NMAC -
Rp, 8.308.8.16 NMAC, 5/1/2018]
HISTORY OF 8.308.8 NMAC: [RESERVED]
History of
Repealed Material:
8.308.8 NMAC - Managed Care Program, Member Education, filed
12/17/2013 Repealed effective 5/1/2018.