Ala. Admin. Code r. 420-5-6-.05

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

Section 420-5-6-.05 - Organization

(1) The health maintenance organization shall be organized in a manner which allows the accomplishment of its stated mission which shall include, as a minimum, delivery of basic health care services, as well as covered frequently utilized specialty services and ancillary services.

(2) The plan shall possess organizational and administrative capacity to provide services and the ability to monitor provision of such services.

(3) The plan shall demonstrate separation of medical services from fiscal management sufficient to assure that medical decisions will not be inappropriately influenced by fiscal management.

(4) The governing body of the health maintenance organization shall be responsible for establishment and oversight of the health maintenance organization's health delivery system. The responsibilities of the governing body of the health maintenance organization shall include, but not be limited to, the following:

(a) Adoption and enforcement of all policies governing the health maintenance organization's management of health care services delivery, quality improvement and utilization review programs including annual meetings for the purpose of evaluation and improvement of the health services of the health maintenance organization and to react to recommendations and findings of the quality improvement committee;

1. The governing body shall keep minutes of meetings and other records to document the fact that the governing body is effectively discharging the obligations of its office regarding health services.

(b) Authority to hire and terminate the administrator and medical director;

(c) Adoption of the health maintenance organization's procedures for maintenance and control of all books, records, and audits which are related to the health services system;

(d) Assurance that the health maintenance organization's medical director is performing the duties of that position and in a manner that results in the operation of a quality improvement program that is effective and otherwise in compliance with the standards of 420-5-6-.07;

(e) Assurance that the health maintenance organization's administrator is performing the duties of that position;

(f) Independent adoption of policies affecting the delivery of health care services;

(g) Assurance that the health maintenance organization complies with applicable laws and regulations;

(h) Provision of reasonable access to the Board for input by the Medical Director at the request of the Medical Director.

(5) Health maintenance organizations operating or contracting with hospitals, independent clinical laboratories, rehabilitation centers, ambulatory surgical treatment facilities, end stage renal disease treatment and transplant centers, abortion or reproductive health centers, skilled nursing facilities, domiciliaries, and other related health care institutions when such institution is primarily engaged in offering to the public generally, facilities and services for the diagnosis, treatment, or both, of injury, deformity, disease, surgical or obstetrical care, shall ensure compliance with Code of Ala. 1975, §§ 22-21-20, etseq.

Author: Department of Public Health

Ala. Admin. Code r. 420-5-6-.05

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.