Wyoming Administrative Code › Agency 044 - Insurance Dept › Sub-Agency 0002 - General Agency, Board or Commission Rules › Chapter 13 - HEALTH MAINTENANCE ORGANIZATIONS › Section 13-7 - Services

Current through July 13, 2024
The requirements of this section are applicable to the
				  categories of services listed as available under the health care plan. The HMO
				  may wish to provide such services directly or arrange for their provision
				  according to the specific requirement of the plan, provided the commissioner
				  may waive or modify such requirements if inapplicable to a particular HMO's
				  operation.
(a) Emergency service must
				be provided on a twenty-four (24) hour basis.
(b) Inpatient hospital and medical care which
				shall mean acute care hospital services, including, but not limited to, a
				semi-private room with customary furnishings and equipment, meals (including
				special diets as medically necessary), general nursing care, use of operating
				room and related facilities, intensive care unit and services, drugs,
				medications, biologicals, anesthesia and oxygen services, diagnostic laboratory
				and x-ray services, special duty nursing as medically necessary, physical
				therapy, respiratory therapy, administration of blood and blood products, and
				other diagnostic, therapeutic and rehabilitative services as appropriate, and
				coordinated discharge planning including the planning of such continuing care
				as may be necessary, both medically and as a means of preventing possible early
				rehospitalization and which shall be available on a twenty-four (24) hour
				basis.
(c) Outpatient services:
(i) Ambulatory outpatient services shall be
				provided, which shall include diagnostic and treatment services, physical
				therapy, speech therapy, occupational therapy services as appropriate, and
				those hospital services which can reasonably be provided on an ambulatory
				basis. Such services may be provided at a hospital, any other appropriate
				licensed facility, or any appropriate facility which is not required by law to
				be licensed, if the professionals delivering such services are licensed to
				practice, are certified, or practice under the authority of the plan, medical
				group, or individual practice association or other authority authorized by
				applicable Wyoming law.
(ii) The
				outpatient services shall, as a minimum, have an ongoing preventive health
				program which shall include, under a physician's or other appropriate licensed
				provider's supervision:
(A) Reasonable health
				appraisal examinations on a periodic basis;
(B) A variety of voluntary family planning
				services;
(C) Prenatal
				care;
(D) Vision and hearing
				testing for persons through age sixteen (16);
(E) Immunizations for children in accordance
				with the recommendations of the American Academy of Pediatrics and
				immunizations for adults as recommended by the U.S. Public Health
				Service;
(F) Venereal disease
				tests;
(G) Cytology examinations on
				a reasonable periodic basis; and
(H) Effective health education services,
				including information regarding personal health behavior and health care, and
				recommendations regarding the optimal use of health care services provided by
				the plan or health care organizations affiliated with the plan.
(iii) Diagnostic laboratory
				services shall be available by either of the following methods:
(A) If provided in house by the HMO,
				laboratory services shall be under the direction of a qualified physician and
				shall participate successfully in all proficiency testing programs offered by
				the Department of Health and Social Services in those specialties in which the
				HMO laboratory performs examinations; or
(B) If provided by service contract, the
				laboratory service may be certified as an independent laboratory in the
				Medicare Program, or it must maintain an acceptable quality control
				program.
(iv) Diagnostic
				and therapeutic radiological services must be provided by the HMO as specified
				in the plan. The services may be offered by contract and shall be under the
				direction of a qualified physician.
(v) Pharmacy services:
(A) The plan of pharmacy services provided by
				the HMO shall assure quality and accessibility.
(B) Pharmacy services to enrollees shall be
				provided either directly by a licensed staff pharmacist or pharmacy through
				arrangements with qualified pharmacies, pharmacists, or by a qualified service
				agency.
(C) The plan of pharmacy
				services provided by a service agency shall be by contract with an agency
				administrator capable of performing drug utilization review and claims
				processing, and shall assure quality and accessibility.
(vi) Other services shall be available in
				accordance with those specified in the plan.