Alabama Administrative Code › Title 420 - ALABAMA STATE BOARD OF HEALTH › Chapter 420-5-6 - HEALTH MAINTENANCE ORGANIZATIONS › Section 420-5-6-.04 - Basic Health Care Services

Current through Register Vol. 42, No. 9, June 28, 2024
(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.