044-13 Wyo. Code R. §§ 13-7 - Services

The requirements of this section are applicable to the categories of services listed as available under the health care plan. The HMO may wish to provide such services directly or arrange for their provision according to the specific requirement of the plan, provided the commissioner may waive or modify such requirements if inapplicable to a particular HMO's operation.

(a) Emergency service must be provided on a twenty-four (24) hour basis.

(b) Inpatient hospital and medical care which shall mean acute care hospital services, including, but not limited to, a semi-private room with customary furnishings and equipment, meals (including special diets as medically necessary), general nursing care, use of operating room and related facilities, intensive care unit and services, drugs, medications, biologicals, anesthesia and oxygen services, diagnostic laboratory and x-ray services, special duty nursing as medically necessary, physical therapy, respiratory therapy, administration of blood and blood products, and other diagnostic, therapeutic and rehabilitative services as appropriate, and coordinated discharge planning including the planning of such continuing care as may be necessary, both medically and as a means of preventing possible early rehospitalization and which shall be available on a twenty-four (24) hour basis.

(c) Outpatient services:

(i) Ambulatory outpatient services shall be provided, which shall include diagnostic and treatment services, physical therapy, speech therapy, occupational therapy services as appropriate, and those hospital services which can reasonably be provided on an ambulatory basis. Such services may be provided at a hospital, any other appropriate licensed facility, or any appropriate facility which is not required by law to be licensed, if the professionals delivering such services are licensed to practice, are certified, or practice under the authority of the plan, medical group, or individual practice association or other authority authorized by applicable Wyoming law.

(ii) The outpatient services shall, as a minimum, have an ongoing preventive health program which shall include, under a physician's or other appropriate licensed provider's supervision:

(A) Reasonable health appraisal examinations on a periodic basis;

(B) A variety of voluntary family planning services;

(C) Prenatal care;

(D) Vision and hearing testing for persons through age sixteen (16);

(E) Immunizations for children in accordance with the recommendations of the American Academy of Pediatrics and immunizations for adults as recommended by the U.S. Public Health Service;

(F) Venereal disease tests;

(G) Cytology examinations on a reasonable periodic basis; and

(H) Effective health education services, including information regarding personal health behavior and health care, and recommendations regarding the optimal use of health care services provided by the plan or health care organizations affiliated with the plan.

(iii) Diagnostic laboratory services shall be available by either of the following methods:

(A) If provided in house by the HMO, laboratory services shall be under the direction of a qualified physician and shall participate successfully in all proficiency testing programs offered by the Department of Health and Social Services in those specialties in which the HMO laboratory performs examinations; or

(B) If provided by service contract, the laboratory service may be certified as an independent laboratory in the Medicare Program, or it must maintain an acceptable quality control program.

(iv) Diagnostic and therapeutic radiological services must be provided by the HMO as specified in the plan. The services may be offered by contract and shall be under the direction of a qualified physician.

(v) Pharmacy services:

(A) The plan of pharmacy services provided by the HMO shall assure quality and accessibility.

(B) Pharmacy services to enrollees shall be provided either directly by a licensed staff pharmacist or pharmacy through arrangements with qualified pharmacies, pharmacists, or by a qualified service agency.

(C) The plan of pharmacy services provided by a service agency shall be by contract with an agency administrator capable of performing drug utilization review and claims processing, and shall assure quality and accessibility.

(vi) Other services shall be available in accordance with those specified in the plan.

Notes

044-13 Wyo. Code R. §§ 13-7