Alabama Administrative Code › Title 420 - ALABAMA STATE BOARD OF HEALTH › Chapter 420-5-6 - HEALTH MAINTENANCE ORGANIZATIONS › Section 420-5-6-.01 - General

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Statutory Authority for Adoption of Rules. Under and by
				  virtue of authority vested in it by the Legislature of Alabama,
Code of Ala. 1975
, §§
										22-2-2(6),
et
seq
., §§
										22-21-20,
et
seq
., §§
										27-21A-1,
et
seq
., Health Maintenance
				  Organizations are required to be regulated by the Alabama Department of Public
				  Health. The State Board of Health does hereby adopt and promulgate this
				  Chapter.
(2) Applicability.
(a) These Rules shall be applicable to all persons who
				  propose to establish and operate a health maintenance organization or who
				  currently operate a health maintenance organization under
Code of
				  Ala. 1975
, §§
										22-21-20
et
seq
., and §§
										27-21A-1,
et
seq
.
(3) Definitions.
(a) "Delegation" means a formal process by which a health
				  maintenance organization and an applicant organization gives another entity the
				  authority to perform certain functions on its behalf, such as credentialing,
				  utilization management, and quality improvement. Although the health
				  maintenance organization and applicant organization can delegate the authority
				  to perform a function, it cannot delegate the responsibility for ensuring that
				  the function is performed appropriately.
(b) "Department" means the Alabama Department of Public
				  Health.
(c) "Enrollee" means an individual who is enrolled in a
				  health maintenance organization.
(d) "Governing Body" means a board of directors, or other
				  individuals which have the authority to establish policy for the health
				  maintenance organization and in which ultimate responsibility and authority for
				  the conduct of the health maintenance organization is vested.
(e) "Health Care Services" means 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 for the purpose of
				  preventing, alleviating, curing or healing human illness, injury or physical
				  disability. Nothing in this definition and nothing in these Rules shall be
				  construed to authorize any person employed by, or contracting with, a health
				  maintenance organization to engage in the practice of medicine unless that
				  person is licensed to practice medicine or to perform any act or render any
				  medical service which act or service requires that the individual be licensed
				  by an appropriate licensing agency of the State of Alabama or certified by the
				  Secretary of Health and Human Services for Medicare participation and that
				  person has complied with Alabama Health Planning Laws, §§
										22-21-260,
et
seq
. The fact that an
				  employer purchases health care services from a health maintenance organization
				  does not make the employer responsible for the provision of those
				  services.
(f) "Health Maintenance Organization" means any person that
				  undertakes to provide, or arrange for, basic health care services through an
				  organized system which combines the delivery and financing of health care to
				  enrollees. The organization shall provide physician services directly through
				  physician employees or under contractual arrangements with either individual
				  physicians or a group or groups of physicians. The organization shall provide
				  basic health care services directly or under contractual arrangements. When
				  reasonable and appropriate, the organization may provide physician services and
				  basic health care services through other arrangements. The organization may
				  provide, or arrange for, health care services on a prepayment or other
				  financial basis.
(g) "Physician" means a doctor of medicine or doctor of
				  osteopathy licensed to practice medicine by the Medical Licensure Commission of
				  Alabama or licensed to practice in the locale in which the patient is
				  treated.
(h) "Primary Care Provider" means a physician currently
				  licensed in the state in which he/she practices who supervises, coordinates,
				  provides initial and basic care to enrollees, maintains continuity of care for
				  enrollees and initiates referrals for specialist care. The primary care
				  provider is responsible for the medical management of the health maintenance
				  organization enrollee's health. The care of episodic illness alone does not
				  constitute the role of a primary care provider. A physician's assistant or a
				  certified registered nurse practitioner may perform certain of the above
				  activities with appropriate physician oversight as prescribed by law.
(i) "Provider" means any physician, hospital or other person
				  or organization licensed and practicing within the scope of such a license or
				  otherwise authorized in the state in which he/she practices to furnish health
				  care services.
(j) "State Health Officer" means the executive officer of the
				  Alabama Department of Public Health.
Author:
Department of Public Health
Statutory Authority:
Code of Ala.
				  1975
, §§
										22-2-2(6),
et
seq
., 22-21-20,
et
seq
., 27-21A-1,
et
seq
.