Current through Register Vol. 42, No. 11, August 30, 2024
(1) A health maintenance organization shall
provide at least basic health care services: basic health care services means
emergency care, inpatient hospital and physician care, and outpatient medical
services.
(a) Emergency. A medical condition
manifesting itself by acute symptoms of sufficient severity (including severe
pain) such that a prudent layperson, who possesses an average knowledge of
health and medicine, could reasonably expect the absence of immediate medical
attention to result in (i) placing the health of the individual (or, with
respect to a pregnant woman, the health of the woman or her unborn child) in
serious jeopardy, (ii) serious impairment to bodily functions, or (iii) serious
dysfunction of any bodily organ or part. Emergency care must be available in
and out of the service area and shall include ambulance services for emergency
care dispatched by 911, if available, or by the local government authority.
Emergency care shall be available 24 hours a day, seven days a week.
(b) Inpatient Hospital Care. Medically
necessary hospital services affording inpatient treatment to enrollees in a
hospital. Inpatient hospital care includes, at a minimum, room and board;
general nursing care; special diets when medically necessary; newborn care; use
of intensive care unit and services; x-ray; laboratory, and other diagnostic
tests; drugs, medications, biologicals, anesthesia, and oxygen services;
special duty nursing when medically necessary; radiation therapy;
administration of whole blood and blood plasma; short term physical medicine
and rehabilitative services. A health maintenance organization which contracts
with the Alabama Medicaid Agency shall provide the maximum medically necessary
inpatient hospital stay required by Medicaid for Medicaid enrollees. A health
maintenance organization which contracts with the Alabama Medicaid Agency shall
implement written protocols and shall make arrangements which may be outside
the health maintenance organization for medically necessary care of Medicaid
enrollees who require care beyond the maximum hospital stay required by
Medicaid for Medicaid enrollees;
(c) Physician Care. Generally accepted and
medically necessary health services performed, prescribed, or supervised for
registered bed patients, including diagnostic and therapeutic care. Medically
necessary and maintenance health services performed, prescribed, or supervised
by physicians for patients who are not confined to bed in an institution or at
home. These services may be provided in a nonhospital-based health care
facility, at a hospital, or in a physician's office. Physician care shall
include consultant and referral services; and
(d) Outpatient Medical Services. Services
shall include, at a minimum, maternity coverage including risk-appropriate
prenatal care, intrapartum and postpartum care, and transportation, including
air transportation, where necessary, for the medically high risk pregnant
woman; pediatric care from birth including pediatric maintenance visits,
treatment visits, and immunizations according to written schedules; adult care
including periodic physical examinations provided with the goal of protection
against and early detection and minimization of the ill effects and causes of
disease or disability and including adult immunizations, and other maintenance
services as appropriate.
(2) Basic health care services shall be
provided according to, at a minimum, standards certified by the State Health
Officer.
(3) A health maintenance
organization shall provide basic health care services and frequently utilized
specialty services and ancillary services to its enrollees as needed and
without unreasonable limitations as to the time and cost. For the purposes of
this rule, "ancillary services" means those covered services customarily
provided by a participating ancillary provider (including for example:
laboratory, durable medical equipment, pharmacy) in his or her office or place
of business, or as applicable, in a physician's office, enrollee home setting
(such as home health), mobile vehicle (diagnostic providers) as well as
services customarily provided by participating ancillary providers to
institutionalized patients.
(a) "Frequently
Utilized Specialty Services" means those covered specialized physician services
that the health maintenance organization has identified as high volume
specialties based on utilization and demographics of the enrollees.
(4) Reasonable exclusions, such as
are customarily found in group health insurance policies, will be permitted.
Examples of reasonable exclusions are cosmetic surgery unless medically
necessary, custodial or domiciliary care, and durable medical equipment for
home use.
(5) A health maintenance
organization may provide, in addition to basic health services, other health
services such as outpatient substance abuse services, residential treatment for
substance abuse or mental health at recommended levels of 30 days for adults
and 60 days for adolescents, cosmetic surgery, prescription drug coverage,
dental coverage, and similar services which an enrolled population may require
to maintain physical and mental health.
Author: Department of Public
Health
Statutory Authority:
Code of Ala.
1975, §§
22-2-2(6),
et
seq., 22-21-20,
et
seq., 27-21A-1,
et
seq.
