Arkansas Administrative Code › Agency 007 - ARKANSAS DEPARTMENT OF HEALTH › Division 05 - Health Facility Services › Rule 007.05.98-002 - Rules and Regulations for Health Maintenance Organizations in Arkansas

Current through Register Vol. 49, No. 6, June, 2024
RULES AND REGULATIONS
FOR
HEALTH MAINTENANCE ORGANIZATIONS
IN ARKANSAS
SECTION I.
AUTHORITY.
The following Rules and Regulations for Health
			 Maintenance Organizations in Arkansas are duly adopted and promulgated by the
			 Arkansas Department of Health pursuant to the authority expressly conferred by
			 the laws of the State of Arkansas in Act 454 of 1975.
SECTION II
L PURPOSE.
These
			 Rules and Regulations have been prepared for the purpose of establishing a
			 criterion for minimum standards for licensure and operation of Health
			 Maintenance Organizations in Arkansas that is consistent with current trends in
			 patient care practices. By necessity they are of a regulatory nature, but are
			 considered to be practical minimum design standards for these
			 entities/facilities. These standards are not static and are subject to periodic
			 revisions in the future as new knowledge and changes in patient care trends
			 become apparent. However, it is expected that Health Maintenance Organizations
			 will exceed these minimum requirements and that they will not be dependent upon
			 future revisions in these standards as a necessary prerequisite for improved
			 services. Health Maintenance Organizations have a strong moral responsibility
			 for providing a progressive preventive health program which assures that
			 adequate medical care is available and acceptable to all Enrollees.
These Rules and Regulations apply to certified Health
				Maintenance Organizations, as well as to applicants for a Health Maintenance
				Organization Certificate of Authority, and are promulgated to carry out Act 454
				and to facilitate the full and uniform implementation, enforcement, and intent
				of the Act.
These Rules and Regulations explain the requirements a Health
				Maintenance Organization applicant must satisfy in order for
the
Arkansas Department of Health to certify to the Arkansas Insurance
				Department that the applicant's proposed plan of operation meets Arkansas
				Department of Health requirements.
These Rules and Regulations are adopted in the best interest of
				the public health, safety, and welfare. Compliance with these Rules and
				Regulations in no way conveys assurance of the quality of patient care, but
				rather provides the basic framework of capabilities required from which quality
				patient care may evolve.
Persons in the process of developing a Health Maintenance
				Organization shall periodically inform the Department of their developmental
				activities and make use of Department technical advice and assistance.
SECTION III. DEFINITIONS. As used
			 in these Rules and Regulations, unless the content otherwise requires, the
			 words and terms defined in Section
			 III inclusive, have the meanings
			 ascribed to them.
A. Act. Arkansas Act 454 of
			 1975, as amended.
B.
Administrator.
The person responsible for the management of the
			 Health Maintenance Organization (HMO).
C. Case
Management.
An activity
			 which assists individuals in gaining and coordinating access to necessary care
			 and services appropriate to the needs of the individual. It is the facilitation
			 of health services including either medical or ancillary health care resources
			 for efficient and medically appropriate ends for enrolled members. The activity
			 is designed to achieve the optimal patient outcome in the most cost-effective
			 manner.
D.
Certificate of
			 Authority.
A document issued by the Commissioner of the Arkansas
			 Insurance Department permitting one to establish, maintain, and operate an
			 HMO.
E.
Commissioner.
The Commissioner of the Arkansas Insurance Department.
F.
Consumer.
Solely for the
			 purpose of the composition of the Governing Body/Oversight Committee, is any
			 person other than a person (i)whose occupation involves, or before retirement
			 involved, the administration of health activities or the providing of Health
			 Care Services, (ii) who is, or ever was, employed by a health care facility as
			 a licensed Health Professional, or (iii) who has, or ever had, a direct,
			 substantial financial or managerial interest in the rendering of Health Care
			 Services other than the payment of a reasonable expense reimbursement or
			 compensation as a member of the board of an HMO.
G.
Credentials.
Certificates,
			 diplomas, licenses, or other written documentation which establish proof of
			 training, education, and experience in a field of expertise.
H.
Department
The Arkansas
			 Department of Health.
I.
Director.
The Director of the Arkansas Department of
			 Health.
J.
Emergency Health
			 Care Services.
Those Health Care Services which shall be available on a
			 twenty-four (24) hours per day, seven (7) days per week basis to evaluate and
			 treat medical conditions of a recent onset and severity, including, but not
			 limited to, severe pain that would lead a prudent lay person, possessing an
			 average knowledge of medicine and health, to believe that his or her condition,
			 sickness, or injury is of such a nature that failure to get immediate medical
			 care could result in (i) placing the patient's health in serious jeopardy;
			 (ii)serious impairment to bodily functions; or (iii) serious dysfunction of any
			 bodily organ or part.
K.
Enrollee.
An individual who is contractually entitled to receive
			 covered Health Care Services from an HMO.
L.
Evidence of Coverage.
Any
			 certificate, agreement, contract, identification card, or document issued to an
			 Enrollee setting out the coverage to which he/she is entitled.
M.
Health Care Plan.
Any
			 arrangement whereby any person undertakes to provide, arrange for, pay for, or
			 reimburse any part of the cost of any Health Care Services, and at least part
			 of such arrangement consists of arranging for or the provision of Health Care
			 Services, as distinguished from mere indemnification against the cost of such
			 services, .on a prepaid basis through insurance or otherwise.
N.
Health Care Services.
Any
			 services included in the furnishing to any individual of medical or dental
			 care, or hospitalization or incident to the furnishing of such care or
			 hospitalization, as well as the furnishing to any person of any and all other
			 services or goods for the purpose of preventing, alleviating, curing, or
			 healing human illness or injury.
O.
Health Maintenance Organization (HMO).
Any person who undertakes
			 to provide or arrange for one or more Health Care Plans under the
			 Act.
P.
Health Professional.
Individuals engaged in the delivery of Health Care Services as are or
			 may be designated under U. S. Public Law 93-222, same being the Health
			 Maintenance Organization Act of 1973 or any amendment thereto or regulation
			 adopted thereunder.
Q.
Hospital.
As defined in the currently certified
Rules
			 and Regulations for Hospitals and Related Institutions in Arkansas
as promulgated by the Arkansas Department of Health.
R.
Inpatient Medical Care,
Shall
			 include, but not be limited to medical and surgical care received in a hospital
			 or skilled nursing environment.
S.
Limited Benefit HMO.
An HMO that elects to provide or arrange for
			 the provision of one (1) Health Care Service (e.g. dental, mental health,
			 vision, etc.) to its Enrollees. The limited benefit shall be the only type of
			 benefit offered to Enrollees under its Health Care Plan. An HMO certified in
			 this category shall comply with all applicable provisions of these Rules and
			 Regulations.
T.
Medical
			 Director.
A physician (M.D. or D.O.) licensed to practice in the State
			 of Arkansas. The Medical Director shall provide medical direction of the HMO's
			 health care activities and consultation for and medical supervision of the
			 medical staff of a Staff Model HMO.
U.
Outpatient Services.
Those
			 covered services which may be rendered in, but are not limited to, clinics,
			 home health services, hospices, kidney dialysis centers, private offices,
			 pharmacies, and hospital-based outpatient services, as a minimum, and may also
			 include, but are not limited to outpatient surgery centers and radiation
			 therapy centers.
V.
Peer
			 Review.
A review of the decisions and actions by one's peers within the
			 organizational structure of the HMO.
W.
Person.
Any natural or
			 artificial person including, but not limited to individuals, partnerships,
			 associations, trusts, or corporations.
X.
Pharmacy.
A facility which
			 possesses the appropriate permit from the Arkansas State Board of
			 Pharmacy.
Y.
Physical Plant.
The physical building, equipment, and fixtures of a Staff Model HMO. It
			 shall include, but not be limited to environment, electrical services, plumbing
			 services, water supply and disposal, infection control, and waste
			 disposal.
Z.
Preventive
			 Health Services.
Services designed to maintain an individual in optimum
			 health and to prevent unnecessary injury, illness, or disability.
AA
Primary Care Physician.
A
			 physician who supervises, coordinates, and provides initial and basic care to
			 Enrollees; initiates their referral for specialty care; and maintains the
			 continuity of patient care. The care of episodic illness alone does not
			 constitute the role of a Primary Care Physician.
BB. Private Review Agency. Any entity
			 certified by the Department under Act 537 of 1989 performing utilization review
			 that is either affiliated with, under contract with, or acting on behalf of an
			 Arkansas business entity or a third party that provides or administers .
			 hospital and medical benefits to citizens of Arkansas including an HMO or any
			 entity offering health insurance policies, contracts, or benefits in this State
			 including a health insurer, non-profit health service plan, health insurance
			 organization, preferred Provider organization, or managed care
			 organization.
CC. Provider. Any
			 person who is licensed in this State to furnish Health Care Services as a
			 Health Professional.
DD.
Quality
Assurance Systems. The planned and systematic management
			 actions which assure the consistent rendering of high quality Health Care
			 Services through the use of monitoring techniques.
EE. Retrospective Review. A mechanism to
			 review medical necessity and appropriateness of medical services through
			 compilation and analysis of data after medical care is rendered which includes,
			 but is not limited to the comparison of Provider practice patterns with
			 parameters established by the utilization review committee, recommendations of
			 changes in Provider practice patterns based on analysis and review, and
			 analyzation of care to Enrollees.
FF. Service Area. The geographic area as
			 defined by county boundaries authorized by the Certificate of
			 Authority.
GG.
Staff Model
			 HMO.
An HMO that provides any of its Health Care Services through
			 physicians and other Health Professionals who work in centralized health
			 centers as salaried or paid employees (staff) of the HMO and where the Health
			 Care Service is provided at a health center owned or leased by the HMO. It
			 shall include a described Physical Plant.
HH.
Utilization
Review
Plan.
A system for the formal assessment of medical necessity,
			 efficiency, and/or appropriateness of Health Care Services and treatment plans
			 on a prospective, concurrent, or retrospective basis.