Section 26-A3509. SERVICES

 

3509.1An HMO shall establish and maintain adequate arrangements to provide health services for its enrollees, including:

 

(a)Reasonable proximity to the business or personal residences of the enrollees so as not to result in unreasonable barriers to accessibility;

 

(b)Reasonable hours of operation;

 

(c)Emergency care services available and accessible within the service area twenty-four (24) hours a day, seven (7) days a week; and

 

(d)Sufficient providers, personnel, administrators and support staff to assure that all services contracted for will be accessible to enrollees on an appropriate basis without delays detrimental to the health of enrollees.

 

3509.2An HMO shall make available to each enrollee a primary care provider and provide accessibility to medically necessary specialists through staffing, contracting or referral. An HMO shall provide for continuity of care for enrollees referred to specialists.

 

3509.3An HMO shall have written procedures governing the availability of services utilized by enrollees, including at least the following:

 

(a)Well-patient examinations and immunizations;

 

(b)Emergency telephone consultation on a twenty-four (24) hours per day, seven (7) days per week basis;

 

(c)Treatment of emergencies;

 

(d)Treatment of minor illnesses; and

 

(e)Treatment of chronic illnesses.

 

3509.4An HMO shall provide, or arrange for basic health care services, which shall include preventive care, emergency care, inpatient and outpatient hospital and physician care, diagnostic laboratory and diagnostic and therapeutic radiological services, and services mandated under the:

 

(a)Drug Abuse, Alcohol Abuse, and Mental Illness Insurance Coverage Act of 1986, D.C. Law 6-195, D.C. Code § 35-2301 et seq.;

 

(b)Newborn Health Insurance Act of 1979, D.C. Law 3-33, D.C. Code § 35-1101 et seq.; and

 

(c)District of Columbia Cancer Prevention Act of 1990, D.C. Law 8-225, D.C. Code § 35-1101 et seq.

 

3509.5Out-of-area services shall be subject to the copayment requirements set forth in the group and individual contract and evidence of coverage.

 

3509.6When an enrollee is temporarily out of an HMO's service area, the HMO shall provide benefits for reimbursement for emergency care services and emergency transportation which is medically necessary and appropriate under the circumstances, and in the event that emergency care services are provided and further inpatient care is medically necessary, once the enrollee is stabilized, the HMO shall provide benefits for reimbursement for transportation to return the enrollee to an HMO provider, subject to the following conditions:

 

(a)The condition could not reasonably have been foreseen;

 

(b)The enrollee could not reasonably arrange to return to the service area to receive treatment from the HMO's provider;

 

(c)The travel or temporary departure outside of the service area must be for some purpose other than the receipt of unapproved medical treatments; and

 

(d)The HMO is notified by telephone within twenty-four (24) hours of the commencement of such care unless it is shown that it was not reasonably possible to communicate with the HMO within such time limits, if the HMO requires such notification.

 

source

Final Rulemaking published at 46 DCR 7291(September 17, 1999).