Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 240 - HEALTH MAINTENANCE ORGANIZATIONS CODE › Subpart B - APPLICATION FOR HMO CERTIFICATE OF AUTHORITY › Section 240.40 - Personnel, Organization and Provider Requirements

Current through Register Vol. 48, No. 28, July 12, 2024
The application for an HMO Certificate of Authority shall
				  contain the following information about the applicant's personnel, organization
				  and providers:
a) Organization charts
				which include descriptions of the administrative structure of the HMO and the
				HMO's relationship with the medical group, individual practice associations, or
				other provider arrangements, such as home health agencies, durable medical
				suppliers, nursing homes and laboratories.
b) A flow of care chart or narrative which
				illustrates the movement and contacts of the enrollees through the primary and
				specialty care physicians of the HMO care system.
c) A legible map or maps of the plan service
				areas by Zip Code to be served by the HMO showing the location of its offices
				and ambulatory health care facilities.
d) A general description of any facilities to
				be used. An HMO that utilizes the services of physicians in their individual
				offices or contracts with groups of five or less participating physicians shall
				submit a map or maps of the locations of all such individual offices for such
				practitioners. All other HMOs shall submit a floor plan identifying the square
				footage available and a projection of the number of enrollees to be served in
				each ambulatory care facility.
e)
				In addition to the Biographical Affidavit required by the Department of
				Insurance, the name, medical license number, resume and address of the medical
				director of the HMO.
f) The name,
				resume and address of the chief administrative officer of the HMO.
g) Job descriptions for the chief
				administrative officer and medical director positions.
h) The name, medical license number and any
				Drug Enforcement Administration number issued to each physician with whom the
				HMO has agreements.
i)
				Certification that each contract with providers requires the providers to
				assure that all nurses and other ancillary and paramedic personnel are
				licensed, certified or registered, as required to perform their
				duties.
j) A list of each
				participating physician's name, medical license number, hospitals where the
				physician has admitting or staff privileges, each physician's specialty, and
				office address. The HMO shall provide evidence that the variety and composition
				of specialty participating plan physicians reflects the medical needs and
				characteristics of the enrollees in the plan service area. Such evidence may
				include historical data on the service needs experienced by the projected HMO
				population, survey data, or any other data concerning an assessment of the
				needs and characteristics of the projected HMO population.
k) An explanation of how the HMO will make
				medically necessary services available twenty-four hours a day, seven days a
				week.
l) The standards and
				procedures the HMO has developed for the selection of providers.
m) Projections by the HMO for a two-year
				period that include projected enrollment levels, primary care physician to
				enrollee ratios, and plans for providing specialty care, laboratory, X-ray and
				hospital services. The HMO must provide evidence that the ratio and the
				projected ratios are consistent with its assessment and projection of enrollee
				needs and insure the availability and accessibility of health care
				services.