Compilation of Rules and Regulations of the State of Georgia
Department 111 - RULES OF DEPARTMENT OF COMMUNITY HEALTH
Chapter 111-8 - HEALTHCARE FACILITY REGULATION
Subject 111-8-29 - RULES AND REGULATIONS FOR HEALTH MAINTENANCE ORGANIZATIONS
Rule 111-8-29-.03 - Basic Health Care Services
Universal Citation: GA Rules and Regs r 111-8-29-.03
Current through Rules and Regulations filed through September 23, 2024
An HMO shall provide or arrange for the provision of basic health care services to its enrollees as needed and without limitations as to time, cost, type of service, or waiting period, e.g. maternity benefits, except as otherwise provided for in these rules and regulations. Provided, however, that such persons or institutions shall not be required to provide or receive services which conflict with their religious belief or moral objection. Exemptions claimed under this provision must be fully disclosed in the health benefits plan. Upon the determination of necessity, the HMO shall be responsible for medically necessary emergency care 24-hours per day, seven days per week, during the time of an existing contract. The HMO is responsible to provide or arrange for the provision of nonemergency care during reasonable and customary working hours and days. An HMO must provide the basic health care services listed herein and may not provide less service, nor may the HMO withhold a basic health care service because of an enrollee's known or unknown health condition. An HMO may provide one or more health benefits plans which exceed the basic health care services by including one or more supplemental health services. The basic health care services are:
(a) Preventive Care Services (including family planning services and services for the detection of asymptomatic diseases). The following services will be provided on a periodic basis, as specified in the plan:
1. The full range of family planning services;
2. Services for infertility;
3. Preventive eye/ear examinations by a physician, optometrist, or other qualified health professional to determine the need for correction, for children through age seventeen (17). The cost of corrective appliances and/or artificial aids shall not be included as a basic service unless otherwise specified in the health benefits plan;
4. Pediatric and adult immunizations in accordance with the Immunization Program of the Georgia Department of Public Health;
5. Periodic health examinations with appropriate protocols for specific age and sex groups, which may include pelvic and breast examinations and pap smears for women and other special diagnostic and screening procedures for enrollees considered to be at risk for specific disease states (e.g., obesity, hypertension, diabetes, glaucoma, cardiovascular disorders, lung diseases, cancer, sickle cell disease, etc.);
6. Well-child care services aimed at preventing problems and promoting the well-being of the child according to an established schedule of examinations and services planned for early detection and treatment of disorders for the promotion of healthy growth and development (e.g., health assessments, nutrition counseling, immunizations, screening, health education, etc.); and
7. Health education activities (including nutritional education and counseling). Health education activities shall state in writing the targeted population, purposes and techniques to be utilized in the program and the evaluation of results.
(b) Emergency Care.
1. Medically necessary emergency care service is medical care rendered by affiliated or non-affiliated providers, whether in or out of the service area, under unforeseen conditions requiring services necessary for the repair of accidental injury, relief of acute pain and/or infection, protection of the person's health, or the amelioration of illness which, if not immediately diagnosed and treated, would result in physical or mental impairment or loss of life. Outpatient and inpatient in-area medically necessary emergency health services shall be available 24-hours a day, seven days a week. Emergency health services shall include in-area ambulance services to the nearest facility designated by the HMO plan. The HMO shall have a plan for coverage of out-of-area emergencies; the plan shall cover ambulance service. An HMO associated physician or other delegated health professional shall authorize the use of nonemergency ambulance services.
2. Medically necessary emergency services shall include psychiatric emergency care provided in an emergency room. Such care shall not be considered among the limited short-term outpatient mental health visits.
3. Emergency care related to alcohol use and abuse shall include:
(i) immediate medical evaluation and care;
(ii) medical management of intoxicated persons until they are no longer incapacitated by the effects of alcohol; and/or
(iii) initiation of other appropriate health services needed for continuity of care.
4. Emergency care related to drug abuse and addiction shall include treatment for overdose and adverse reactions to psychotropic substances such as barbiturates, amphetamines, hallucinogens (including marijuana), tranquilizers and narcotics.
(c) Outpatient Medical Services and Inpatient Hospital Services.
1. Outpatient medical services shall include diagnostic or treatment services or both for patients who are ambulatory and may be provided in a non-hospital-based health care facility or in a hospital.
2. Inpatient hospital services shall include, but not be limited to room (private, if determined medically necessary by the physician) and board, general nursing care, meals and special diets when medically necessary, use of operating room and related facilities, 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, physical therapy, respiratory therapy, radiation therapy, administration of whole blood and blood products (or components) and derivatives, other diagnostic therapeutic and rehabilitative services as needed, and coordinated discharge planning including the planning of such continuing care as may be necessary both medically and as a means of preventing possible early rehospitalization.
3. Outpatient medical services and inpatient hospital services shall include appropriate short-term rehabilitative services. The HMO must clearly define and make known its policy to enrollees.
4. Prenatal, intrapartum and postnatal maternity care shall be covered. This shall include complications of pregnancy of the mother and care with respect to the newborn child from the moment of birth; and necessary care and treatment of illness, injury, and congenital defects of the infant.
5. Medically necessary plastic surgery shall be provided as needed for the purpose of improving function by anatomic alterations. The HMO has flexibility to determine a policy for elective plastic surgery and must clearly define and make known its policy to enrollees.
6. Prescribed drug(s) and/or injection(s) may be provided to an enrollee at the time of outpatient care as a basic healthcare service. The HMO must clearly define and make known its policy to enrollees.
7. Experimental procedures or biomedical clinical research investigations undertaken by the HMO or by health professionals associated with the HMO which involve HMO enrollees must comply with all current Federal and State regulations, especially with regard to informed patient consent, peer review, and the rights of human subjects.
8. The HMO shall provide outpatient evaluative and crisis intervention mental health services. These basic mental health services may be provided through lesser or longer time periods if enrollees are equitably assured the equivalency of twenty full 50-55 minute session visits per enrollee per year. Modifications of the standard therapeutic full session shall be fully and fairly disclosed to enrollees of the HMO.
9. Diagnosis and medical treatment for the abuse of or addiction to alcohol and drugs includes detoxification on either an outpatient or inpatient basis, whichever is medically determined to be appropriate, in addition to treatment for other medical conditions.
10. Alcohol and drug referral services may be for either medical or for nonmedical ancillary services. Medical services shall be a part of basic health services; nonmedical ancillary services need not be a part of basic health services.
11. Diagnostic laboratory and diagnostic and therapeutic radiology services shall include, but are not to be limited to clinical and anatomic pathology, and diagnostic radiology, including special procedures, therapeutic radiology, nuclear medicine, electrocardiography, electroencephalography, and other generally accepted diagnostic and therapeutic technology. Laboratory and diagnostic radiology services necessary for the care and management of a condition of an enrollee shall be readily accessible.
12. Home health services are services which are provided at an enrollee's home by health care personnel, as prescribed or directed by the primary care physician. Home health services may include such rehabilitative therapy as medical social services and home health aide services. Homemaker services are not a required basic health service.
(d) Physician Care. Physician services (including consultant and referral services by a physician) shall be provided by or at the direction of a currently licensed physician.
1. Consultant services are defined as those services requiring the skills of a physician or other licensed health professional who by training and experience has acquired or demonstrated proficiency in specialized clinical areas. Coordination of patient care shall continue to be the responsibility of the primary care physician associated with the HMO.
2. Referral services are defined as those health and medical services provided directly to an enrollee by another health professional or health agency. Referrals shall be authorized and coordinated through the enrollee's primary care physician.
Ga. L. 1964, pp. 499, 507, 523; Ga. L. 1979, p. 1148 et seq.; O.C.G.A. § 33-21-1et seq.
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