
Primary, specialty and ancillary providers
(a) The HMO shall maintain an adequate network of primary care providers, specialists, and other ancillary health care personnel to serve the enrolled population at all times. For certificate of authority applications to initiate operations within a service area, this adequacy shall be evaluated based on enrollment projections at the end of 12 months of operation. At a minimum, the network of providers shall include:
(3) Endocrinologist;
(6) Neurologist;
(7) Obstetrician/gynecologist;
(8) Oncologist;
(9) Ophthalmologist;
(10) Orthopedist;
(11) Oral surgeon;
(12) Psychiatrist; and
(13) Urologist;
iii. For specialists not identified in (a)1ii above, the HMO shall have a policy assuring access to such specialists within 45 miles or one hour driving time, whichever is less, of 90 percent of members within each county or approved sub-county service area;
iv. There shall be a sufficient number of other health professional staff including but not limited to licensed nurses and other professionals available to HMO members to provide basic health care services;
v. There shall be sufficient licensed optometrists associated with or available to the HMO to assure that, unless referral to an ophthalmologist is determined by the PCP to be medically required and outside the scope of practice of an optometrist, the member can choose to have vision care services provided by a licensed optometrist. The HMO shall have a policy assuring access to these providers, as set forth above in N.J.A.C. 11:24-6.2(a)1 ii.
vi. If the HMO provides pharmacy services, prescription drugs, or a prescription drug plan, no registered pharmacy or pharmacist shall be denied the right to participate as a preferred provider pursuant to the terms of N.J.S.A. 26:2J-4.7.
(b) Physicians qualified to function as primary care providers include the following categories:
3. At the discretion of the HMO, exceptions may be made for appropriate licensed medical specialists to be designated as primary care provider for specified individual members or patient groups who, due to health status or chronic illness, would benefit from medical care management by such a medical specialist.
(c) Health care professionals qualified as primary care providers include the following categories:
3. Certified nurse midwives registered by the New Jersey Board of Medical Examiners.
(d) Geographic access and availability standards for primary care providers (PCPs) shall be as follows:
3. In order to demonstrate PCP availability, an HMO shall verify that the PCP has committed to provide a specific number of hours for new patients that cumulatively add up to projected clinic hour needs of projected enrollment by county or service area.
4. The HMO shall demonstrate that the network of PCPs is sufficient to assure that the following criteria will be met:
iii. In both emergent and urgent care, PCPs shall be required to provide seven day, 24 hour access to triage services;
iv. Routine appointments shall be scheduled within two weeks; and
v. Routine physical exams shall be scheduled within four months.
SeeĀ https://regulations.justia.com/states/new-jersey/title-11/chapter-24/subchapter-6/