Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 40 - Health Maintenance Organizations › Rule 191-40.5 - Quality of Care

Current through Register Vol. 47, No. 3, July 24, 2024
Each HMO shall:
(1)
				Provide primary care physicians' services commensurate with the need of the
				enrollees, but at a level of not less than that established in the
				commimity.
(2) Advise the insurance
				division annually pursuant to Iowa Code section
				514B12. of the
				ratio of full-time equivalent physicians, paramedical and ancillary health
				personnel to enrollees and fee-for-service patients. Changes in the physician
				ratios shall be immediately reported together with action taken to correct any
				deficiencies in the ratios.
(3)
				Provide assurance that all physicians, paramedical and ancillary health
				personnel engaged in the provisions of health services to enrollees and
				fee-for-service patients are currently licensed or certified by the appropriate
				state agency where they are located to practice their respective profession.
				These personnel shall be no less qualified in their respective profession than
				the current level of qualification, which is maintained in their
				community.
(4) When health care
				facilities are utilized by the health maintenance organization, these
				facilities shall be licensed by the appropriate state agency where they are
				located. These facilities shall be either accredited by the Joint Commission on
				Accreditation of Hospitals or the American Osteopathic Association; or they
				shall be certified as a provider for Medicare or Medicaid.
(5) Have a qualified administrator designated
				by the governing body who shall be responsible for the management of the
				HMO.
(6) Have a formally organized
				medical staff.
(7) Have a chief of
				the medical staff designated by the governing body who shall be responsible for
				the development of medical staff bylaws, rules which shall include assurance to
				enrollees that a continuum of health care services will be provided without
				imreasonable periods of delay.
(8)
				Provide for an ongoing internal peer review program.
(9) Each HMO shall provide a continuous
				program of general health education for disease prevention and identification
				without additional cost to the enrollee. Such a program may include
				publications, media presentations, and classroom instruction. Programs of
				wellness education including stress management, smoking cessation, nutritional
				education, physical fitness programs, and other such programs as approved by
				the division of insurance shall be open to all enrollees on a voluntary basis
				and may be subject to a copayment requirement. These programs shall be
				conducted by qualified personnel.
The HMO must periodically remind and encourage the enrollees
				  of an HMO to utilize benefits including physical examinations which are
				  available and designed to prevent illness. The HMO must also offer periodic
				  screening programs which in the opinion of the medical staff would effectively
				  identify conditions indicative of a health problem. These periodic screening
				  programs shall not carry a copayment. Each HMO shall keep a record of all
				  activities it has conducted to satisfy this requirement and the cost
				  thereof
(10) Maintain a
				medical records system which includes at a minimum the following information:
a. Documentation of utilization rates for
				every enrollee.
b. Patient's name,
				identification number, age, sex, and place of residence and
				employment.
c. Services provided,
				when provided, where provided, and by whom.
d. Medical diagnosis, treatment prescribed,
				therapy prescribed and drugs administered.
e. Statement in regard to the status of the
				patient's health.