902 KAR 20:054. Health maintenance organizations; operations and services.


      RELATES TO: KRS 216B.010-216B.130, 216B.990(1), (2)

      STATUTORY AUTHORITY: KRS 216B.042, 216B.105

      NECESSITY, FUNCTION, AND CONFORMITY: KRS 216B.042 and 216B.105 mandate that the Kentucky Cabinet for Human Resources regulate health facilities and health services. This administrative regulation provides licensure requirements for the operations of and services provided by health maintenance organizations.


      Section 1. Definitions. (1) "Board" means the Commission for Health Economics Control in Kentucky.

      (2) "Commissioner" means the Commissioner of the Department of Insurance.

      (3) "Enrollee" means a person who is enrolled in a health maintenance organization.

      (4) "Health care services" means any services included in the furnishing to any individual of medical, optometric, 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 and goods for the preventing, alleviating, curing, or healing of human illness, physical disability or injury.

      (5) "Provider" means a licensed individual physician or group of physicians, licensed health facilities or services, and other licensed health professionals who have entered into an agreement with a health maintenance organization for the purpose of providing health services to enrollees.


      Section 2. Scope of Operation and Services. A health maintenance organization provides, directly or through arrangements with others, health care services to individuals voluntarily enrolled with such an organization on a per capita or a predetermined, fixed prepayment rate. These services shall include outpatient services including physician services, inpatient services, diagnostic laboratory and radiology services, health education, and emergency medical services.


      Section 3. Administration and Operation. (1) Licensee.

      (a) The licensee shall be legally responsible for compliance with federal, state and local laws and regulations pertaining to the operation of health maintenance organizations.

      (b) All services covered by the benefit plans of the health maintenance organizations shall be provided in accordance with applicable laws and administrative regulations relating thereto. When the health maintenance organization provides health services directly through its own health facilities or clinics, such facilities or clinics shall comply with applicable requirements of the Certificate of Need and Licensure Law. Any service which the health maintenance organization includes in the covered benefits plan shall be provided by duly licensed institutions, services, or practitioners where such licensure is required by law.

      (2) Administrator. The health maintenance organization shall have an administrator who shall be responsible for the operation of the health maintenance organization and shall delegate such responsibility in his or her absence.

      (3) Certificate of authority. The health maintenance organization shall have evidence that a certificate of authority has been issued and that the coverage of their benefits plan and rate schedules have received approval from the commissioner prior to licensing and relicensing of the organization by the board. The board may revoke the license or take other appropriate action if a health maintenance organization has its certificate of authority revoked or suspended by the commissioner.

      (4) Administrative policies and procedures. The health maintenance organization shall have written policies to include:

      (a) A current description of its operational and organizational structure.

      (b) Procedures for hearing and resolving grievances between the organization (including the staff of the health maintenance organization and providers) and the enrollees of the organization. Such procedures shall assure that grievances and complaints are kept in a separate file and transmitted in a timely manner to appropriate decision making levels within the organization which has authority to take corrective action; and

      (c) A written description provided to enrollees of services covered in the benefits plan of the health maintenance organization which also indicates how, where, and from whom services may be obtained. This description shall include instructions and procedures to enrollees on obtaining medically necessary emergency services other than through health maintenance organization providers (e.g., physicians or services outside the area served by the health maintenance organization) when the enrollee's health would be jeopardized before services could be obtained through such providers.

      (d) Written policies and procedures to carry out utilization studies with reference to the quality assurances of such services.

      (5) Enrollee policies. The health maintenance organization shall have written policies regarding the rights and responsibilities of enrollees to assure that each enrollee:

      (a) Is fully informed of these rights and of all rules governing enrollee conduct and responsibilities;

      (b) Is fully informed of services made available by the health maintenance organization and of the payments applicable for basic and supplemental services;

      (c) Is encouraged and assisted to understand and exercise his enrollee rights and to this end may voice grievances and recommend changes in policies and services;

      (d) Is assured confidential treatment of his records and disclosures, and is afforded the opportunity to approve or refuse their release to any individual not involved in his care except as required by law or third party payment contract; and

      (e) Is treated with consideration, respect, and with full recognition of his dignity and individuality, including privacy in treatment and in care for his personal needs.

      (6) Enrollee records. The health maintenance organization shall maintain a medical record of all services provided to enrollees including diagnosis, treatment and recommended follow-up.

      (7) Medical records. When the health maintenance organization provides services directly, medical records shall be maintained as required by the applicable licensure administrative regulation (e.g., primary care, ambulatory care, etc.).


      Section 4. Provisions of Service. The health maintenance organization shall provide services directly or through contract with appropriately licensed providers.

      (1) A health maintenance organization shall provide as a minimum the following basic services in the covered benefits plan:

      (a) Outpatient services including physician services;

      (b) Inpatient services;

      (c) Diagnostic laboratory and radiology services;

      (d) Health education and education in the appropriate use of health services and in the contribution each person can make to the maintenance of their own health; and

      (e) Emergency medical services.

      (2) The health maintenance organization shall have procedures through which enrollees can obtain medically necessary emergency services for which its members have contracted through physicians or services that do not have contracts with the health maintenance organization (e.g., physicians or services outside the geographic area served by the health maintenance organization) when the enrollees condition would be jeopardized before he could obtain such services through a health maintenance organization provider.

      (3) Within the area served by the health maintenance organization basic health care services for which the enrollees have contracted shall:

      (a) Be available and accessible to each of the health maintenance organization's enrollees promptly as appropriate with respect to its geographic location, hours or operation, and provisions for after-hours services (medically necessary emergency services must be available and accessible twenty-four (24) hours a day, seven (7) days a week).

      (b) Be provided in a manner which assures continuity. (8 Ky.R. 604; Am. 906; eff. 4-7-82; 16 Ky.R. 980; eff. 1-12-90.)