(1) A health maintenance organization shall establish and maintain adequate arrangements to provide the health services contracted for by its subscribers including:
(a) reasonable proximity to the business or personal residences of the enrollees so as not to result in unreasonable barriers to accessibility;
(b) reasonable hours of operation and after-hours services;
(c) emergency care services available and accessible within the service area 24 hours a day, seven days a week; and
(d) sufficient providers and personnel, including health professionals, 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.
(2) 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.
(3) A health maintenance organization shall have written procedures governing the availability of frequently utilized services contracted for by subscribers, including at least the following:
(a) well-patient examinations and immunizations;
(b) emergency telephone consultation on a 24 hours per day, seven days per week basis;
(c) treatment of emergencies;
(d) treatment of minor illnesses; and
(e) treatment of chronic illnesses.
(4) A health maintenance organization shall provide or arrange for the provision of emergency care and basic health care services, including the following:
(a) emergency care services, as defined in ARM 6.6.2503;
(b) inpatient hospital care, meaning medically necessary hospital care services including, but not limited to, 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; psychotherapy; administration of whole blood and blood the plasma; and short-term rehabilitation services;
(c) inpatient provider care, meaning medically necessary health care services performed, prescribed, or supervised by providers or other health professionals 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, providers office, a non-hospital-based health care facility, or a hospital. Outpatient medical services include but are not limited to diagnostic services; treatment services; laboratory services; x-ray services; referral services; and physical therapy, radiation therapy, psychotherapy, and inhalation therapy. Outpatient services also include preventive health services which include at least a broad range of voluntary family planning services, services for infertility, 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.
(5) Out-of-area services are subject to the same copayment requirements set forth in ARM 6.6.2509.
(6) When an enrollee is traveling or temporarily residing out of a health maintenance organization’s service area, the health maintenance organization must provide benefits for reimbursement for emergency care services, without regard to whether the health care provider furnishing the emergency care services is a participating network provider with respect to the emergency care services.
(7) In addition to the basic health care services required to be provided in (4), a health maintenance organization may offer to its enrollee 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.
History: 33-31-103 MCA; IMP, 33-31-202, 33-31-301, MCA; NEW, 1987 MAR p. 1770, Eff. 10/16/87; AMD, 2018 MAR p. 1102, Eff. 6/9/18.