Minnesota Administrative Rules

4685.1010 AVAILABILITY AND ACCESSIBILITY.

Subpart 1.

Definitions.

For the purpose of this part, the terms in items A and B have the meanings given them.

A.

"Referral centers" means medical facilities that provide specialized medical care such as organ transplants and coronary artery bypass surgery. Examples of criteria the health maintenance organization may use in designating a facility as a referral center are volume of services provided annually and the case mix and severity adjusted mortality and morbidity rates. Referral centers may be located within or outside the health maintenance organization's service area.

B.

"Service area" means the geographic locations in which the health maintenance organization is approved by the commissioner to sell its health maintenance organization products. Geographic locations shall be identified according to recognized political subdivisions such as cities, counties, and townships.

Subp. 2.

Basic services.

The health maintenance organization shall have available, either directly or through arrangements, appropriate and sufficient personnel, physical resources, and equipment to meet the projected needs of its enrollees for covered health care services. The health maintenance organization, in coordination with participating providers, shall develop and implement written standards or guidelines that assess the capacity of each provider network to provide timely access to health care services in accordance with subpart 6.

A.

Primary care services.

(1)

Primary care physician services shall be available and accessible 24 hours per day, seven days per week within the health maintenance organization's service area. The health maintenance organization shall fulfill this requirement through written standards for:

(a)

regularly scheduled appointments during normal business hours;

(b)

after hours clinics;

(c)

use of a 24-hour answering service with standards for maximum allowable call-back times based on what is medically appropriate to each situation;

(d)

back-up coverage by another participating primary care physician; and

(e)

referrals to urgent care centers, where available, and to hospital emergency care.

(2)

The health maintenance organization shall provide or contract with a sufficient number of primary care physicians to meet the projected needs of its enrollees for primary care physician services.

(3)

The health maintenance organization shall ensure that there are a number of primary care physicians with hospital admitting privileges at one or more participating general hospitals within the health maintenance organization's service area so that necessary admissions are made on a timely basis consistent with generally accepted practice parameters.

(4)

To the extent that primary care services are provided through primary care providers other than physicians, and to the extent permitted under applicable scope of practice in state licensing laws for a given provider, these services shall be available and accessible as required by subitems (1) to (3).

B.

Specialty physician services.

(1)

The health maintenance organization shall provide directly, contract for, or otherwise arrange for specialty physician services which are covered benefits and to which enrollees have continued access in the health maintenance organization's service area. These services shall be available and accessible 24 hours per day, seven days per week. The health maintenance organization shall fulfill this requirement through written standards for:

(a)

regularly scheduled appointments during normal business hours;

(b)

after hours clinics;

(c)

use of a 24-hour answering service with standards for maximum allowable call-back times based on what is medically appropriate to each situation;

(d)

back-up coverage by another participating specialty physician; and

(e)

referrals to urgent care centers, where available, and to hospital emergency care.

(2)

Specialty physician services to which enrollees do not have continued access, for example referrals for consultation or second opinions, shall be provided by the health maintenance organization through contracts or other arrangements with specialty physicians.

(3)

The health maintenance organization shall ensure that there are a number of specialty physicians with hospital admitting privileges so that necessary admissions are made on a timely basis consistent with generally accepted practice parameters.

C.

Services of facilities licensed as general hospitals under chapter 4640 (general hospital services) shall be provided through contracts between the health maintenance organization and hospitals. These services shall be available and accessible, on a timely basis consistent with generally accepted practice parameters, 24 hours per day, seven days per week within the health maintenance organization's service area. Services of facilities licensed as specialized hospitals under chapter 4640 (specialized hospital services), including chemical dependency and mental health services, shall be provided through contracts between the health maintenance organization or its contracted providers and hospitals, either within or outside the health maintenance organization's service area. These services shall be available during normal business hours consistent with generally accepted practice parameters.

D.

The health maintenance organization shall contract with or employ sufficient numbers of providers of ancillary services to meet the projected needs of its enrollees. The services shall be available during normal daytime business hours consistent with generally accepted practice parameters.

E.

The health maintenance organization shall contract with or employ sufficient numbers of qualified providers of outpatient mental health and chemical dependency services to meet the projected needs of its enrollees consistent with generally accepted practice parameters.

(1)

Services for people with alcohol and other chemical dependency problems shall be provided by outpatient treatment programs licensed by the Minnesota Department of Human Services under Minnesota Statutes, sections 245G.01 to 245G.20 and 245G.22, or by hospitals licensed under chapter 4640.

(2)

Outpatient chemical dependency treatment programs serving adolescents must meet all of the requirements of the Minnesota Department of Human Services contained in part 9530.6400.

(3)

Outpatient mental health services shall be provided by licensed psychiatrists, psychologists, social workers, marriage and family therapists, and psychiatric nurses, as appropriate in each case, and by mental health centers and mental health clinics licensed by the Minnesota Department of Human Services under chapter 9520.

(4)

The health maintenance organization, either directly or through its contracted mental health or chemical dependency provider, shall have available services that are culturally specific or appropriate to a specific age, gender, or sexual preference, to the extent reasonably possible. If any of these services cannot be provided by licensed providers and programs, the health maintenance organization shall file a request for an exception to the requirements of subitems (1) to (4). A request for an exception shall be considered a filing under part 4685.3300. The health maintenance organization shall submit specific data in support of its request.

F.

The health maintenance organization shall provide directly, contract for, or otherwise arrange for residential treatment programs licensed by the Department of Human Services under parts 9530.4100 to 9530.4450 to provide services to people with alcohol and other chemical dependency problems.

G.

The health maintenance organization shall provide directly, contract for, or otherwise arrange for emergency care and urgently needed care to be available and accessible within the health maintenance organization's service area 24 hours per day, seven days per week. Contracts may be with hospitals, urgent care centers, and after hours clinics. Emergency care and urgently needed care provided by noncontracted providers shall be covered in accordance with subpart 7.

H.

If a specific health maintenance organization provider refuses to continue to provide care to a specific health maintenance organization enrollee, the health maintenance organization shall furnish the enrollee with the name, address, and telephone number of other participating providers in the same area of medical specialty. Examples of reasons for refusal to continue to provide care to an enrollee are: unpaid bills incurred by that individual before enrollment in the health maintenance organization; unpaid copayments or coinsurance incurred by the enrollee after enrollment in the health maintenance organization; an enrollee who is uncooperative or abusive toward the provider; and the inability of the enrollee and the provider to agree on a course of treatment.

I.

The health maintenance organization is responsible for implementing a system that, to the greatest possible extent, assures that routine referrals, either by the health maintenance organization or by a participating provider, are made to participating providers. An enrollee cannot be held liable if the health maintenance organization provider, in error, gives a referral to a nonparticipating provider. This issue may be addressed in contracts between the health maintenance organization and its providers.

J.

Referral procedures must be described in an enrollee's evidence of coverage and must be available to an enrollee upon request for information regarding referral procedures. Effective July 1, 1999, information regarding referral procedures shall clearly describe at least the following:

(1)

under what circumstances and for what services a referral is necessary;

(2)

how to request a referral;

(3)

how to request a standing referral; and

(4)

how to appeal a referral determination.

Subp. 3.

[Repealed, L 1999 c 239 s 43]

Subp. 4.

Exceptions for access to care and geographic accessibility.

A request for an exception to the requirements of subparts 2 and 3 shall be considered a filing under part 4685.3300. The health maintenance organization shall submit specific data in support of its request. The commissioner shall consider the factors in items A to C in granting an exception if the health maintenance organization is unable to meet the requirements of subparts 2 and 3 in a particular service area or part of a service area:

A.

the utilization patterns of the existing health care delivery system or the health maintenance organization's reasonably justified projections of utilization of health care services in the proposed service area;

B.

the financial ability of the health maintenance organization to pay charges for health care services that are not provided under contract or by employees of the health maintenance organization. The commissioner shall determine what information must be submitted by the health maintenance organization in order to demonstrate its financial ability to pay charges and may require an analysis of the impact on minimum loss ratio requirements; and

C.

the health maintenance organization's system of documentation of authorized referrals to nonparticipating providers. This system of documentation of authorized referrals shall explain how, under certain circumstances, enrollees will be given referrals to nonparticipating providers, either by the health maintenance organization or by a provider acting on behalf of the health maintenance organization.

Subp. 5.

Coordination of care.

A.

The health maintenance organization shall arrange for the services of primary care providers to provide initial and basic care to enrollees.

(1)

An enrollee who is dissatisfied with the assigned or selected primary care provider shall be allowed to change primary care providers in accordance with the health maintenance organization's procedures and policies.

(2)

If requested by an enrollee, or if determined necessary because of a pattern of inappropriate utilization of services, an enrollee's health care may be supervised and coordinated by the primary care provider.

B.

In plans in which referrals to specialty providers and ancillary services are required:

(1)

the primary care or other authorized provider or the health maintenance organization shall initiate the referrals; and

(2)

the health maintenance organization shall inform its primary care and other authorized providers of their responsibility to provide written referrals and any specific procedures that must be followed in providing referrals.

C.

The health maintenance organization shall provide for the coordination of care for enrollees given a referral or standing referral. When possible, the health maintenance organization shall provide this coordination of care through the enrollee's primary care or other authorized provider.

Subp. 6.

Timely access to health care services.

A.

The health maintenance organization, either directly or through its provider contracts, shall arrange for covered health care services, including referrals to participating and nonparticipating providers, to be accessible to enrollees on a timely basis in accordance with medically appropriate guidelines consistent with generally accepted practice parameters.

B.

The health maintenance organization, in coordination with its participating providers, shall develop and implement written appointment scheduling guidelines based on type of health care service. Examples of types of health care services include well baby and well child examinations, prenatal care appointments, routine physicals, follow up appointments for chronic conditions such as high blood pressure, and diagnosis of acute pain or injury.

Subp. 7.

Access to emergency care.

A.

In accordance with the requirements of Minnesota Statutes, section 62D.07, the health maintenance organization shall inform its enrollees, through the evidence of coverage or contract, as well as through other forms of communication, how to obtain emergency care.

B.

The health maintenance organization may require enrollees to notify it of nonreferred emergency care, including mental health and chemical dependency care, as soon as possible after emergency care is initially provided, and no later than 48 hours after becoming physically or mentally able to give notice. However, the health maintenance organization shall make exceptions in situations in which:

(1)

the enrollee is physically or mentally unable to give notice within 48 hours; and

(2)

emergency care would have been covered under the contract had notice been provided within the 48-hour time period.

C.

Emergency care shall be covered whether provided by participating or nonparticipating providers.

D.

Emergency care shall be covered whether provided within or outside the health maintenance organization's service area.

E.

In determining whether care is reimbursable as emergency care, the health maintenance organization shall take the following factors into consideration:

(1)

a reasonable person's belief that the circumstances required immediate medical care that could not wait until the next working day or next available clinic appointment;

(2)

the time of day and day of week the care was provided;

(3)

the presenting symptoms, to ensure that the decision to reimburse as emergency care shall not be made solely on the basis of the actual diagnosis;

(4)

the enrollee's efforts to follow the health maintenance organization's established procedures for obtaining emergency care; and

(5)

any circumstances which precluded use of the health maintenance organization's established procedures for obtaining emergency care.

In processing the claim, the health maintenance organization shall obtain sufficient information from the provider of emergency care, including the presenting symptoms, to enable the health maintenance organization to make an informed determination as to whether reimbursement as emergency care is appropriate.

Subp. 8.

[Repealed, 28 SR 1249]

Statutory Authority:

MS s 62D.20

History:

17 SR 2858; 23 SR 1238; L 1999 c 239 s 43; 28 SR 1249

Published Electronically:

January 3, 2018