Compilation of Rules and Regulations of the State of Georgia › Department 111 - RULES OF DEPARTMENT OF COMMUNITY HEALTH › Chapter 111-8 - HEALTHCARE FACILITY REGULATION › Subject 111-8-29 - RULES AND REGULATIONS FOR HEALTH MAINTENANCE ORGANIZATIONS › Rule 111-8-29-.03 - Basic Health Care Services

Current through Rules and Regulations filed through June 27, 2024
An HMO shall provide or arrange for the provision of basic
				  health care services to its enrollees as needed and without limitations as to
				  time, cost, type of service, or waiting period, e.g. maternity benefits, except
				  as otherwise provided for in these rules and regulations. Provided, however,
				  that such persons or institutions shall not be required to provide or receive
				  services which conflict with their religious belief or moral objection.
				  Exemptions claimed under this provision must be fully disclosed in the health
				  benefits plan. Upon the determination of necessity, the HMO shall be
				  responsible for medically necessary emergency care 24-hours per day, seven days
				  per week, during the time of an existing contract. The HMO is responsible to
				  provide or arrange for the provision of nonemergency care during reasonable and
				  customary working hours and days. An HMO must provide the basic health care
				  services listed herein and may not provide less service, nor may the HMO
				  withhold a basic health care service because of an enrollee's known or unknown
				  health condition. An HMO may provide one or more health benefits plans which
				  exceed the basic health care services by including one or more supplemental
				  health services. The basic health care services are:
(a) Preventive Care Services (including
				family planning services and services for the detection of asymptomatic
				diseases). The following services will be provided on a periodic basis, as
				specified in the plan:
1. The full range of
				family planning services;
2.
				Services for infertility;
3.
				Preventive eye/ear examinations by a physician, optometrist, or other qualified
				health professional to determine the need for correction, for children through
				age seventeen (17). The cost of corrective appliances and/or artificial aids
				shall not be included as a basic service unless otherwise specified in the
				health benefits plan;
4. Pediatric
				and adult immunizations in accordance with the Immunization Program of the
				Georgia Department of Public Health;
5. Periodic health examinations with
				appropriate protocols for specific age and sex groups, which may include pelvic
				and breast examinations and pap smears for women and other special diagnostic
				and screening procedures for enrollees considered to be at risk for specific
				disease states (e.g., obesity, hypertension, diabetes, glaucoma, cardiovascular
				disorders, lung diseases, cancer, sickle cell disease, etc.);
6. Well-child care services aimed at
				preventing problems and promoting the well-being of the child according to an
				established schedule of examinations and services planned for early detection
				and treatment of disorders for the promotion of healthy growth and development
				(e.g., health assessments, nutrition counseling, immunizations, screening,
				health education, etc.); and
7.
				Health education activities (including nutritional education and counseling).
				Health education activities shall state in writing the targeted population,
				purposes and techniques to be utilized in the program and the evaluation of
				results.