Illinois Administrative Code › Title 50 - INSURANCE › Part 4521 - HEALTH MAINTENANCE ORGANIZATION › Section 4521.130 - Basic Health Care Services

Current through Register Vol. 48, No. 28, July 12, 2024
The provision of Basic Health Care Services shall not
				discriminate against any class of physician. The following minimum standards
				shall meet the requirements for Basic Health Care Services, provided that
				services are medically necessary as determined by the enrollee's primary care
				physician and, if required by the HMO, are authorized on a prospective and
				timely basis by the HMO's Medical Director:
a) Physician services, including primary
			 care, consultation, referral, surgical, anesthesia or other as needed by the
			 enrollee in any level of service delivery. Physician services need not include
			 organ transplants unless specifically authorized by a primary care physician
			 and approved by the HMO's Medical Director;
b) Outpatient diagnostic imaging, pathology
			 services and radiation therapy;
c)
			 Non-mental health inpatient services, including all professional services,
			 medications, surgically implanted devices and supplies used by the enrollee
			 while an inpatient;
d) Emergency
			 services for accidental injury or emergency illness 24 hours per day, and 7
			 days per week. Emergency services are covered benefits inside and out of the
			 plan's service area. Emergency treatment shall include outpatient visits and
			 referrals for emergency mental health problems;
e) Maternity care, including prenatal and
			 post-natal care and care for complication of pregnancy of mother and care with
			 respect to a newborn child from the moment of birth, which shall include the
			 care and treatment of illness, injury, congenital defects, birth abnormalities
			 and premature birth;
f) Blood
			 transfusion services, processing and the administration of whole blood and
			 blood components and derivatives;
g) Preventive health services as appropriate
			 for the patient population, including a health evaluation program and
			 immunizations to prevent or arrest the further manifestation of human illness
			 or injury including but not limited to allergy injections and allergy serum. A
			 health evaluation program shall include at least periodic physical examinations
			 and medical history, hearing and vision testing or screening, routine
			 laboratory testing or screening, blood pressure testing, and uterine cervical
			 cytological testing, and low dose mammography testing as required by Section
			 4-6.1 of the Act;
h) 45 days
			 inpatient mental health care per year. Care in a day hospital, residential
			 non-hospital or intensive outpatient mode may be substituted on a two-to-one
			 basis for inpatient hospital services as deemed appropriate by the primary care
			 physician. 60 individual outpatient mental health care visits per enrollee per
			 year, as appropriate for evaluation, short-term treatment and crisis
			 intervention services. Group outpatient mental health care visits may be
			 substituted on a two-to-one basis for individual mental health care visits as
			 deemed appropriate by the primary care physician;
i) Alcoholism and Drug Abuse
1) Diagnosis, detoxification and treatment of
			 the medical complications of the abuse of or addiction to alcohol or drugs on
			 either an inpatient or outpatient basis.
2) Rehabilitation services on an inpatient
			 basis, for up to 45 days inpatient care per year. Care in a day hospital,
			 residential non-hospital or intensive outpatient treatment mode may be
			 substituted on a two-to-one basis for inpatient hospital services as deemed
			 appropriate by the primary care physician. 60 individual outpatient care visits
			 per enrollee per year as appropriate for evaluation, short-term treatment, and
			 crisis intervention services. Group outpatient care visits may be substituted
			 on a two-to-one basis for individual outpatient visits as deemed appropriate by
			 the primary care physician. Prolonged rehabilitation services in a specialized
			 inpatient or residential facility need not be a part of Basic Health Care
			 Services;