Ill. Admin. Code tit. 77 § 240.40

Current through Register Vol. 48, No. 43, October 25, 2024

Section 240.40 - Personnel, Organization and Provider Requirements

The application for an HMO Certificate of Authority shall contain the following information about the applicant's personnel, organization and providers:

a) Organization charts which include descriptions of the administrative structure of the HMO and the HMO's relationship with the medical group, individual practice associations, or other provider arrangements, such as home health agencies, durable medical suppliers, nursing homes and laboratories.

b) A flow of care chart or narrative which illustrates the movement and contacts of the enrollees through the primary and specialty care physicians of the HMO care system.

c) A legible map or maps of the plan service areas by Zip Code to be served by the HMO showing the location of its offices and ambulatory health care facilities.

d) A general description of any facilities to be used. An HMO that utilizes the services of physicians in their individual offices or contracts with groups of five or less participating physicians shall submit a map or maps of the locations of all such individual offices for such practitioners. All other HMOs shall submit a floor plan identifying the square footage available and a projection of the number of enrollees to be served in each ambulatory care facility.

e) In addition to the Biographical Affidavit required by the Department of Insurance, the name, medical license number, resume and address of the medical director of the HMO.

f) The name, resume and address of the chief administrative officer of the HMO.

g) Job descriptions for the chief administrative officer and medical director positions.

h) The name, medical license number and any Drug Enforcement Administration number issued to each physician with whom the HMO has agreements.

i) Certification that each contract with providers requires the providers to assure that all nurses and other ancillary and paramedic personnel are licensed, certified or registered, as required to perform their duties.

j) A list of each participating physician's name, medical license number, hospitals where the physician has admitting or staff privileges, each physician's specialty, and office address. The HMO shall provide evidence that the variety and composition of specialty participating plan physicians reflects the medical needs and characteristics of the enrollees in the plan service area. Such evidence may include historical data on the service needs experienced by the projected HMO population, survey data, or any other data concerning an assessment of the needs and characteristics of the projected HMO population.

k) An explanation of how the HMO will make medically necessary services available twenty-four hours a day, seven days a week.

l) The standards and procedures the HMO has developed for the selection of providers.

m) Projections by the HMO for a two-year period that include projected enrollment levels, primary care physician to enrollee ratios, and plans for providing specialty care, laboratory, X-ray and hospital services. The HMO must provide evidence that the ratio and the projected ratios are consistent with its assessment and projection of enrollee needs and insure the availability and accessibility of health care services.

Ill. Admin. Code tit. 77, § 240.40