Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 40 - Health Maintenance Organization (HMO) › Subchapter 5 - Life, Accident & Health Division and Consumer Assistance and Claims Division Rules › Part 5 - BASIC AND SUPPLEMENTAL HEALTH CARE SERVICES › Section 365:40-5-20 - Basic health care services

Current through Vol. 41, No. 20,
				  July 1, 2024
Basic health care services shall include:
(1) Physician services including consultant
				  and referral services by a physician, and other health professional services as
				  necessary to provide allopathic, osteopathic, chiropractic, podiatric,
				  optometric, and psychological services. If a service of a physician may also be
				  provided under applicable State law by another type of health professional, an
				  HMO may provide the service through these other health professionals.
(2) Outpatient services including diagnostic
				  services, treatment services and x-ray services, for patients who are
				  ambulatory and may be provided in a non-hospital based health care facility or
				  at a hospital.
(3) Inpatient
				  hospital services including room and board, general nursing care, meals and
				  special diets when medically necessary, use of operating room and related
				  facilities, use of intensive care unit and services, x-ray services,
				  laboratory, and other diagnostic tests, drugs, medications, biologicals,
				  anesthesia and oxygen services, special duty nursing when medically necessary,
				  radiation therapy, inhalation therapy, perfusion, and administration of whole
				  blood and blood plasma.
(4)
				  Outpatient services and inpatient hospital services including short-term
				  rehabilitation services and physical therapy which the HMO expects can result
				  in the significant improvement of an enrollee's condition within two
				  months,
(5) Medically necessary
				  emergency health services, which shall include instructions to enrollees on how
				  to get medically necessary emergency health services both in and out of the
				  service area.
(6) Twenty outpatient
				  visits per enrollee per year, as may be necessary and appropriate for
				  short-term evaluative or crisis intervention mental health services, or
				  both.
(7) Diagnosis, medical
				  treatment and referral services (including referral services to appropriate
				  ancillary services) for the abuse of or addiction to alcohol and drugs,
				  including
(A) Diagnosis and medical treatment
				  for the abuse of or addiction to alcohol and drugs including detoxification for
				  alcoholism or drug abuse on either an outpatient or inpatient basis, whichever
				  is medically determined to be appropriate, in addition to the other required
				  basic health care services for the treatment of other medical
				  conditions.
(B) Referral services
				  for either medical or for nonmedical ancillary services. Medical ancillary
				  services shall be a part of basic health care services; nonmedical ancillary
				  services (such as vocational rehabilitation and employment counseling) and
				  prolonged rehabilitation services in a specialized inpatient or residential
				  facility need not be a part of basic health care services.