Okla. Admin. Code § 365:40-5-40

Current through Vol. 42, No. 8, January 2, 2025

Section 365:40-5-40 - Services to members

Within the HMO's service area, basic health care services and those supplemental health care services for which enrollees have contracted to be provided by the HMO shall be:

(1) Provided or arranged by the HMO, except as described in Parts 7, 13 and 19 of this Subchapter. Basic health care services shall be provided for HMO members as needed and without limitations as to time and cost.

(2) Available and accessible to each of the HMO's enrollees with reasonable promptness with respect to:

(A) Geographic location, hours of operation, and provisions for after-hours services (medically necessary emergency services shall be available and accessible twenty-four (24) hours a day, seven (7) days a week). An HMO that has a service area located in a non-metropolitan area may make a basic health care service available outside its service area if that basic health care service is not a primary care or emergency care service and if there is an insufficient number of providers of that basic health care service within the service area who will provide that service to enrollees of the HMO.

(B) Staffing patterns within generally accepted norms for meeting the projected enrollment needs.

(C) The type of health professional so that availability of health professionals is adequate to meet the enrollees' needs.

(3) Provided in a manner that assures continuity, except as described in Part 7 of this Subchapter, including but not limited to:

(A) Provision of a health professional who is primarily responsible for coordinating the enrollee's overall health care.

(B) Development of a health (including medical) record keeping system through which pertinent information relating to the health care of the patient is accumulated and is readily available to appropriate professionals.

(C) Coordination of the enrollee's participation in the selection of an alternative type of health care professional.

Okla. Admin. Code § 365:40-5-40

Added at 21 Ok Reg 77, eff 11-1-03 (emergency); Added at 21 Ok Reg 1672, eff 7-14-04