Current through Supplement No. 394, October, 2024
1.
Access to care.
a. A health maintenance organization shall
establish and maintain adequate arrangements to provide health services for its
enrollees, including:
(1) Reasonable
proximity to the business or personal residences of the enrollees so as not to
result in unreasonable barriers to accessibility;
(2) Reasonable hours of operation and
after-hours services;
(3)
Emergency care services available and accessible within the service area
twenty-four hours a day, seven days a week; and
(4) Sufficient providers, personnel,
administrators, and support staff to assure that all services contracted for
will be accessible to enrollees on an appropriate basis without delays
detrimental to the health of enrollees.
b. A health maintenance organization shall
make available to each enrollee a primary care physician and provide
accessibility to medically necessary specialists through staffing, contracting,
or referral. A health maintenance organization shall provide for continuity of
care for enrollees referred to specialists.
c. A health maintenance organization shall
have written procedures governing the availability of services utilized by
enrollees, including at least the following:
(1) Well-patient examinations and
immunizations;
(2) Emergency
telephone consultation on a twenty-four hours per day, seven days per week
basis;
(3) Treatment of
emergencies;
(4) Treatment of
minor illness; and
(5) Treatment
of chronic illnesses.
2.
Basic health care services. A
health maintenance organization shall provide, or arrange for the provision of,
as a minimum, basic health care services that must include the following:
a. Emergency care services, as defined in
subsection 5 of section 45-06-06-03.
b. Inpatient hospital services, meaning
medically necessary hospital services including room and board; general nursing
care; special diets when medically necessary; use of operating room and related
facilities; use of intensive care units and services; x-ray, laboratory, and
other diagnostic tests; drugs, medications, biologicals, anesthesia, and oxygen
services; special nursing when medically necessary; physical therapy, radiation
therapy, and inhalation therapy; administration of whole blood and blood
plasma; and short-term rehabilitation services.
c. Inpatient physician care services, meaning
medically necessary health care services performed, prescribed, or supervised
by physicians or other providers including diagnostic, therapeutic, medical,
surgical, preventive, referral, and consultative health care services.
d. Outpatient medical services,
meaning preventive and medically necessary health care services provided in a
physician's office, a nonhospital-based health care facility, or at a hospital.
Outpatient medical services must include diagnostic services; treatment
services; laboratory services; x-ray services; referral services; and physical
therapy, radiation therapy, and inhalation therapy. Outpatient services must
also include preventive health services that must include at least a broad
range of voluntary family planning services, well-child care from birth,
periodic health evaluations for adults, screening to determine the need for
vision and hearing correction, and pediatric and adult immunizations in
accordance with accepted medical practice.
3.
Out-of-area services and
benefits.
a. Out-of-area services are
subject to the same copayment requirements set forth in subsection 6 of section
45-06-07-04.
b. When an enrollee is traveling or
temporarily residing out of a health maintenance organization's service area, a
health maintenance organization shall provide benefits for reimbursement for
emergency care services and transportation which is medically necessary and
appropriate under the circumstances to return the enrollee to a health
maintenance organization provider, subject to the following conditions:
(1) The condition could not reasonably have
been foreseen;
(2) The enrollee
could not reasonably arrange to return to the service area to receive treatment
from the health maintenance organization's provider;
(3) The travel or temporary residence must be
for some purpose other than the receipt of medical treatments; and
(4) The health maintenance organization is
notified by telephone within twenty-four hours of the commencement of such care
unless it is shown that it was not reasonably possible to communicate with the
health maintenance organization in such time limits.
c. Services received by an enrollee outside
of the health maintenance organization's service area will be covered only so
long as it is unreasonable to return the enrollee to the service area.
4.
Supplemental
health care services. In addition to the basic health care services
required to be provided in subsection 2, a health maintenance organization may
offer to its enrollees any supplemental health care services it chooses to
provide. Limitations as to time and cost may vary from those applicable to
basic health care services.
5.
Nonbasic health care services. A health maintenance organization
may offer nonbasic health care services to any group or individual on a prepaid
basis, subject to the same conditions as for supplemental health care services,
as described in subsection 4, except that the health maintenance organization
need not provide basic health care services as a condition to providing
nonbasic health care services.
