Minnesota Administrative Rules
Agency 144 - Health Department
Chapter 4685 - HEALTH MAINTENANCE ORGANIZATIONS
ACCESSIBILITY OF SERVICES
Part 4685.1010 - AVAILABILITY AND ACCESSIBILITY
Universal Citation: MN Rules 4685.1010
Current through Register Vol. 49, No. 13, September 23, 2024
Subpart 1. Definitions.
For the purpose of this part, the terms in items A and B have the meanings given them.
A. "Referral
centers" means medical facilities that provide specialized medical care such as
organ transplants and coronary artery bypass surgery. Examples of criteria the
health maintenance organization may use in designating a facility as a referral
center are volume of services provided annually and the case mix and severity
adjusted mortality and morbidity rates. Referral centers may be located within
or outside the health maintenance organization's service area.
B. "Service area" means the geographic
locations in which the health maintenance organization is approved by the
commissioner to sell its health maintenance organization products. Geographic
locations shall be identified according to recognized political subdivisions
such as cities, counties, and townships.
Subp. 2. Basic services.
The health maintenance organization shall have available, either directly or through arrangements, appropriate and sufficient personnel, physical resources, and equipment to meet the projected needs of its enrollees for covered health care services. The health maintenance organization, in coordination with participating providers, shall develop and implement written standards or guidelines that assess the capacity of each provider network to provide timely access to health care services in accordance with subpart 6.
A. Primary care services.
(1) Primary care physician services shall be
available and accessible 24 hours per day, seven days per week within the
health maintenance organization's service area. The health maintenance
organization shall fulfill this requirement through written standards for:
(a) regularly scheduled appointments during
normal business hours;
(b) after
hours clinics;
(c) use of a 24-hour
answering service with standards for maximum allowable call-back times based on
what is medically appropriate to each situation;
(d) back-up coverage by another participating
primary care physician; and
(e)
referrals to urgent care centers, where available, and to hospital emergency
care.
(2) The health
maintenance organization shall provide or contract with a sufficient number of
primary care physicians to meet the projected needs of its enrollees for
primary care physician services.
(3) The health maintenance organization shall
ensure that there are a number of primary care physicians with hospital
admitting privileges at one or more participating general hospitals within the
health maintenance organization's service area so that necessary admissions are
made on a timely basis consistent with generally accepted practice
parameters.
(4) To the extent that
primary care services are provided through primary care providers other than
physicians, and to the extent permitted under applicable scope of practice in
state licensing laws for a given provider, these services shall be available
and accessible as required by subitems (1) to (3).
B. Specialty physician services.
(1) The health maintenance organization shall
provide directly, contract for, or otherwise arrange for specialty physician
services which are covered benefits and to which enrollees have continued
access in the health maintenance organization's service area. These services
shall be available and accessible 24 hours per day, seven days per week. The
health maintenance organization shall fulfill this requirement through written
standards for:
(a) regularly scheduled
appointments during normal business hours;
(b) after hours clinics;
(c) use of a 24-hour answering service with
standards for maximum allowable call-back times based on what is medically
appropriate to each situation;
(d)
back-up coverage by another participating specialty physician; and
(e) referrals to urgent care centers, where
available, and to hospital emergency care.
(2) Specialty physician services to which
enrollees do not have continued access, for example referrals for consultation
or second opinions, shall be provided by the health maintenance organization
through contracts or other arrangements with specialty physicians.
(3) The health maintenance organization shall
ensure that there are a number of specialty physicians with hospital admitting
privileges so that necessary admissions are made on a timely basis consistent
with generally accepted practice parameters.
C. Services of facilities licensed as general
hospitals under chapter 4640 (general hospital services) shall be provided
through contracts between the health maintenance organization and hospitals.
These services shall be available and accessible, on a timely basis consistent
with generally accepted practice parameters, 24 hours per day, seven days per
week within the health maintenance organization's service area. Services of
facilities licensed as specialized hospitals under chapter 4640 (specialized
hospital services), including chemical dependency and mental health services,
shall be provided through contracts between the health maintenance organization
or its contracted providers and hospitals, either within or outside the health
maintenance organization's service area. These services shall be available
during normal business hours consistent with generally accepted practice
parameters.
D. The health
maintenance organization shall contract with or employ sufficient numbers of
providers of ancillary services to meet the projected needs of its enrollees.
The services shall be available during normal daytime business hours consistent
with generally accepted practice parameters.
E. The health maintenance organization shall
contract with or employ sufficient numbers of qualified providers of outpatient
mental health and chemical dependency services to meet the projected needs of
its enrollees consistent with generally accepted practice parameters.
(1) Services for people with alcohol and
other chemical dependency problems shall be provided by outpatient treatment
programs licensed by the Minnesota Department of Human Services under parts
9530.5000 to 9530.6500 or by hospitals licensed under chapter 4640.
(2) Outpatient chemical dependency treatment
programs serving adolescents must meet all of the requirements of the Minnesota
Department of Human Services contained in part 9530.6400.
(3) Outpatient mental health services shall
be provided by licensed psychiatrists, psychologists, social workers, marriage
and family therapists, and psychiatric nurses, as appropriate in each case, and
by mental health centers and mental health clinics licensed by the Minnesota
Department of Human Services under chapter 9520.
(4) The health maintenance organization,
either directly or through its contracted mental health or chemical dependency
provider, shall have available services that are culturally specific or
appropriate to a specific age, gender, or sexual preference, to the extent
reasonably possible. If any of these services cannot be provided by licensed
providers and programs, the health maintenance organization shall file a
request for an exception to the requirements of subitems (1) to (4). A request
for an exception shall be considered a filing under part 4685.3300. The health
maintenance organization shall submit specific data in support of its
request.
F. The health
maintenance organization shall provide directly, contract for, or otherwise
arrange for residential treatment programs licensed by the Department of Human
Services under parts 9530.4100 to 9530.4450 to provide services to people with
alcohol and other chemical dependency problems.
G. The health maintenance organization shall
provide directly, contract for, or otherwise arrange for emergency care and
urgently needed care to be available and accessible within the health
maintenance organization's service area 24 hours per day, seven days per week.
Contracts may be with hospitals, urgent care centers, and after hours clinics.
Emergency care and urgently needed care provided by noncontracted providers
shall be covered in accordance with subpart 7.
H. If a specific health maintenance
organization provider refuses to continue to provide care to a specific health
maintenance organization enrollee, the health maintenance organization shall
furnish the enrollee with the name, address, and telephone number of other
participating providers in the same area of medical specialty. Examples of
reasons for refusal to continue to provide care to an enrollee are: unpaid
bills incurred by that individual before enrollment in the health maintenance
organization; unpaid copayments or coinsurance incurred by the enrollee after
enrollment in the health maintenance organization; an enrollee who is
uncooperative or abusive toward the provider; and the inability of the enrollee
and the provider to agree on a course of treatment.
I. The health maintenance organization is
responsible for implementing a system that, to the greatest possible extent,
assures that routine referrals, either by the health maintenance organization
or by a participating provider, are made to participating providers. An
enrollee cannot be held liable if the health maintenance organization provider,
in error, gives a referral to a nonparticipating provider. This issue may be
addressed in contracts between the health maintenance organization and its
providers.
J. Referral procedures
must be described in an enrollee's evidence of coverage and must be available
to an enrollee upon request for information regarding referral procedures.
Effective July 1, 1999, information regarding referral procedures shall clearly
describe at least the following:
(1) under
what circumstances and for what services a referral is necessary;
(2) how to request a referral;
(3) how to request a standing referral;
and
(4) how to appeal a referral
determination.
Subp. 3. [Repealed, L 1999 c 239 s 43]
Subp. 4. Exceptions for access to care and geographic accessibility.
A request for an exception to the requirements of subparts 2 and 3 shall be considered a filing under part 4685.3300. The health maintenance organization shall submit specific data in support of its request. The commissioner shall consider the factors in items A to C in granting an exception if the health maintenance organization is unable to meet the requirements of subparts 2 and 3 in a particular service area or part of a service area:
A. the utilization
patterns of the existing health care delivery system or the health maintenance
organization's reasonably justified projections of utilization of health care
services in the proposed service area;
B. the financial ability of the health
maintenance organization to pay charges for health care services that are not
provided under contract or by employees of the health maintenance organization.
The commissioner shall determine what information must be submitted by the
health maintenance organization in order to demonstrate its financial ability
to pay charges and may require an analysis of the impact on minimum loss ratio
requirements; and
C. the health
maintenance organization's system of documentation of authorized referrals to
nonparticipating providers. This system of documentation of authorized
referrals shall explain how, under certain circumstances, enrollees will be
given referrals to nonparticipating providers, either by the health maintenance
organization or by a provider acting on behalf of the health maintenance
organization.
Subp. 5. Coordination of care.
A. The
health maintenance organization shall arrange for the services of primary care
providers to provide initial and basic care to enrollees.
(1) An enrollee who is dissatisfied with the
assigned or selected primary care provider shall be allowed to change primary
care providers in accordance with the health maintenance organization's
procedures and policies.
(2) If
requested by an enrollee, or if determined necessary because of a pattern of
inappropriate utilization of services, an enrollee's health care may be
supervised and coordinated by the primary care provider.
B. In plans in which referrals to specialty
providers and ancillary services are required:
(1) the primary care or other authorized
provider or the health maintenance organization shall initiate the referrals;
and
(2) the health maintenance
organization shall inform its primary care and other authorized providers of
their responsibility to provide written referrals and any specific procedures
that must be followed in providing referrals.
C. The health maintenance organization shall
provide for the coordination of care for enrollees given a referral or standing
referral. When possible, the health maintenance organization shall provide this
coordination of care through the enrollee's primary care or other authorized
provider.
Subp. 6. Timely access to health care services.
A. The health maintenance organization,
either directly or through its provider contracts, shall arrange for covered
health care services, including referrals to participating and nonparticipating
providers, to be accessible to enrollees on a timely basis in accordance with
medically appropriate guidelines consistent with generally accepted practice
parameters.
B. The health
maintenance organization, in coordination with its participating providers,
shall develop and implement written appointment scheduling guidelines based on
type of health care service. Examples of types of health care services include
well baby and well child examinations, prenatal care appointments, routine
physicals, follow up appointments for chronic conditions such as high blood
pressure, and diagnosis of acute pain or injury.
Subp. 7. Access to emergency care.
A. In accordance with the
requirements of Minnesota Statutes, section
62D.07,
the health maintenance organization shall inform its enrollees, through the
evidence of coverage or contract, as well as through other forms of
communication, how to obtain emergency care.
B. The health maintenance organization may
require enrollees to notify it of nonreferred emergency care, including mental
health and chemical dependency care, as soon as possible after emergency care
is initially provided, and no later than 48 hours after becoming physically or
mentally able to give notice. However, the health maintenance organization
shall make exceptions in situations in which:
(1) the enrollee is physically or mentally
unable to give notice within 48 hours; and
(2) emergency care would have been covered
under the contract had notice been provided within the 48-hour time
period.
C. Emergency
care shall be covered whether provided by participating or nonparticipating
providers.
D. Emergency care shall
be covered whether provided within or outside the health maintenance
organization's service area.
E. In
determining whether care is reimbursable as emergency care, the health
maintenance organization shall take the following factors into consideration:
(1) a reasonable person's belief that the
circumstances required immediate medical care that could not wait until the
next working day or next available clinic appointment;
(2) the time of day and day of week the care
was provided;
(3) the presenting
symptoms, to ensure that the decision to reimburse as emergency care shall not
be made solely on the basis of the actual diagnosis;
(4) the enrollee's efforts to follow the
health maintenance organization's established procedures for obtaining
emergency care; and
(5) any
circumstances which precluded use of the health maintenance organization's
established procedures for obtaining emergency care.
In processing the claim, the health maintenance organization shall obtain sufficient information from the provider of emergency care, including the presenting symptoms, to enable the health maintenance organization to make an informed determination as to whether reimbursement as emergency care is appropriate.
Subp. 8. [Repealed, 28 SR 1249]
Statutory Authority: MS s 62D.20
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