Effective – 28 Aug 1997 354.552. Community-based health maintenance organizations, requirements. — 1. A community-based health maintenance organization shall have available and accessible a sufficient number and type of physicians, specialists, and other providers as needed to: (1) Provide the benefits covered by the plan; (2) Meet the medical needs of the health plan’s enrolled […]
Effective – 28 Aug 1997 354.554. Standing referrals for certain members of community-based health maintenance organizations, when. — Each community-based health maintenance organization shall offer coverage that allows an enrollee who suffers from a life-threatening condition or a degenerative, disabling condition requiring a regimen of specialized medical treatment lasting for six months or more to […]
Effective – 28 Aug 1997 354.556. Trustees, vacancies, elections. — 1. The terms of office of the trustees elected by the enrollees of the community-based health maintenance organization shall begin immediately upon their election. 2. If a vacancy occurs in the office of a trustee, the vacancy shall be filled for the unexpired term in […]
Effective – 28 Aug 1997 354.558. Materials provided to prospective purchasers. — A community-based health maintenance organization shall provide each prospective purchaser of its services with the following marketing materials prior to enrollment: (1) A list of the health care providers who have a contractual agreement to provide services under the plan of coverage. It […]
Effective – 28 Aug 1997 354.559. Disclosure to members, restrictions and prohibitions. — No community-based health maintenance organization shall prohibit or restrict any provider from disclosing to any subscriber, enrollee or member any information that such provider deems appropriate regarding the nature of treatment, risks or alternatives thereto, the availability of other therapy, consultation or […]
Effective – 28 Aug 1997 354.560. Payment arrangements, department to adopt rules — disclosure of financial arrangements — confidentiality. — 1. The director of the department of commerce and insurance shall adopt rules governing the use of payment arrangements by community-based health maintenance organizations which use payment withholding arrangements that place a physician at substantial […]
Effective – 28 Aug 1997 354.562. Grievance procedures, rulemaking authority. — The director of the department of commerce and insurance shall promulgate rules governing grievance procedures for enrollees of a community-based health maintenance organization. Such regulations shall be consistent with and not less or more stringent than federal regulations governing grievance procedures promulgated by the […]
Effective – 28 Aug 1997 354.563. Medicare rules to apply to community-based health maintenance organizations, when. — If the Health Care Financing Administration of the United States Department of Health and Human Services promulgates regulations governing the practice of utilization review in health maintenance organizations serving enrollees in the Medicare program, the director of the […]
Effective – 28 Aug 1997 354.565. Community-based health maintenance organization designation given, when — revocation. — The director of the department of commerce and insurance shall designate those health maintenance organizations which meet the criteria established in subdivision (3) of section 354.400 as community-based health maintenance organizations. After a community-based health maintenance organization has been […]
Effective – 28 Aug 1997 354.567. Community-based health maintenance organizations subject to other laws regarding health maintenance organizations. — Community-based health maintenance organizations shall be subject to the same provisions of law as other health maintenance organizations to the extent they are not inconsistent with the provisions of sections 354.552 to 354.567. ——– (L. 1997 […]
Effective – 28 Aug 1997 354.570. Rulemaking — procedure. — No rule or portion of a rule promulgated pursuant to sections 192.068, 354.603, 376.423, 376.1353, 376.1356, 376.1378, 376.1387, * 354.560, 354.562 and 354.563 shall become effective unless it has been promulgated in accordance with the provisions of chapter 536. ——– (L. 1997 H.B. 335 § […]
Effective – 28 Aug 2007 354.600. Definitions. — For purposes of sections 354.600 to 354.636 the following terms shall mean: (1) “Facility”, an institution providing health care services or a health care setting, including but not limited to hospitals and other licensed inpatient centers, ambulatory surgical or treatment centers, skilled nursing facilities, residential treatment centers, […]
Effective – 28 Aug 2018, 2 histories 354.603. Sufficiency of health carrier network, requirements, criteria — access plan filed with the department, when. — 1. A health carrier shall maintain a network that is sufficient in number and types of providers to assure that all services to enrollees shall be accessible without unreasonable delay. In […]
Effective – 28 Aug 2001 354.606. Providers notified of specific covered services, when — hold harmless provision — cessation of operations procedure — selection standards for health care professionals, filing with the department. — 1. A health carrier shall establish a mechanism by which the participating provider shall be notified on an ongoing basis of […]
Effective – 28 Aug 1997 354.609. Termination of a contract, procedure. — 1. A health carrier and a participating provider shall provide at least sixty days written notice to each other before terminating the contract without cause. The written notice shall include an explanation of why the contract is being terminated. The health carrier shall […]
Effective – 28 Aug 1997 354.612. Continuation of care after provider termination, when. — 1. Contracts between health plans and providers shall include a provision for the continuation of care to enrollees for a period of up to ninety days by a provider who terminates or is terminated from a network where the continuation of […]
Effective – 28 Aug 1997 354.615. Referrals to appropriate providers, when. — 1. If a health carrier determines that it does not have a health care provider with appropriate training and experience in its panel or network to meet the particular health care needs of an enrollee, the health carrier shall make a referral to […]
Effective – 28 Aug 1999 354.618. Open referral health plans offered, when — definitions — obstetrician/ gynecologist services to be offered, when — eye care providers, discrimination against, prohibited — exemptions. — 1. A health carrier shall be required to offer as an additional health plan, an open referral health plan whenever it markets a […]
Effective – 28 Aug 1997 354.621. Intermediary and participating provider requirements. — 1. Intermediaries and participating providers with whom they contract shall comply with all the applicable requirements of sections 354.600 to 354.636. 2. A health carrier’s statutory responsibility to monitor the offering of covered benefits to enrollees shall not be delegated or assigned to […]
Effective – 28 Aug 1997 354.624. Proposed provider contract forms filed with the director — contracts maintained at place of business, available for review, when. — 1. A health carrier shall file with the director all contract forms proposed for use with its participating providers and intermediaries. The forms shall not contain any information on […]
