Ala. Admin. Code r. 420-5-6-.04

Current through Register Vol. 43, No. 1, October 31, 2024

Section 420-5-6-.04 - Basic Health Care Services

(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

Ala. Admin. Code r. 420-5-6-.04

Filed September 1, 1982. Repealed and New Rule adopted in lieu thereof: Filed March 31, 1987. Amended: Filed January 20, 1999; effective February 24, 1999.

Statutory Authority:Code of Ala. 1975, §§ 22-2-2(6), etseq., 22-21-20, etseq., 27-21A-1, etseq.