Out of Area Coverage. The HMO must provide or arrange for out of area covered benefits “in emergency situations and non-emergency situations when travel back to the service area is not possible, is impractical, or when medically necessary services could not be provided elsewhere.” However, the HMO is not responsible for out of state routine care if the enrollee resides out of state for 30 days. Routine Physicals. HMO shall provide for routine physical exams “required for employment, school/camp or other entities/programs that require such examinations as a condition of employment or participation.”
Non-Participating Providers. The HMO must pay for services from a non-participating provider if the enrollee was referred there by his/her PCP, even if the referral was in error. However, an enrollee is responsible for the cost of care by a non-participating provider if the enrollee initiated the care without a referral or authorization.
Second Opinions. Each HMO is to have a Second Opinion program that can be “utilized at the enrollee’s option for diagnosis and treatment of serious medical conditions, such as cancer and for elective surgical procedures.”
Existing Plans of Care. The HMO shall pay for plans of care for new enrollees, including prescriptions, durable medical equipment, medical supplies, prosthetic and orthotic appliances, and any other on-going services initiated prior to enrollment. These services will be continued until the enrollee is evaluated by his/her PCP and a new plan of care is established.
Protection of Enrollee – Provider Communications. “Health care professionals may not be prohibited from advising their patients about their health status or medical care or treatment, regardless of whether this care is covered as a benefit under the contract.”
*The 600+ page, 2-volume contract between the Division of Medical Assistance and Health Services can be found on the Internet at the N.J. Department of Human Services Web site (see link below). The site is searchable.
Last legal review 3/10/05. |
