Iowa Admin. Code r. 441-86.15 - Participating health and dental plans
(1)
Licensure. The
participating health or dental plan must:
a.
Be licensed by the division of insurance of the department of commerce to
provide health or dental care coverage in Iowa; or
b. Be an organized delivery system licensed
by the director of public health to provide health or dental care
coverage.
(2)
Services. The participating health or dental plan shall
provide coverage for the services specified in rule
441-86.14 (5141) to all children
determined eligible.
a. The participating
health or dental plan shall make services it provides to hawki enrollees at
least as accessible to the enrollees (in terms of timeliness, duration and
scope) as those services are accessible to other commercial enrollees in the
area served by the health or dental plan.
b. Participating health plans shall ensure
that emergency services (inpatient and outpatient) are available for treatment
of an emergency medical condition 24 hours a day, seven days a week, either
through the health plan's own providers or through arrangements with other
providers.
c. If a participating
health or dental plan does not provide statewide coverage, the health or dental
plan shall participate in every county in which it is licensed and in which a
provider network has been established.
(3)
Premium tax. Premiums
paid to participating health and dental plans by the department are exempt from
premium tax.
(4)
Provider
network. The participating health or dental plan shall establish a
network of providers. Providers contracting with the participating health or
dental plan shall comply with hawki requirements, which shall include
collecting copayments, if applicable.
(5)
Identification cards.
Identification cards shall be issued by the participating health or dental plan
to the enrollees for use in securing covered services .
(6)
Marketing.
a. Participating health and dental plans may
not distribute directly or through an agent or independent contractor any
marketing materials.
b. All
marketing materials require prior approval from the department .
c. At a minimum, participating health and
dental plans must provide the following material in writing or electronically:
(1) A current member handbook that fully
explains the services available, how and when to obtain them, and special
factors applicable to the hawki enrollees. At a minimum the handbook shall
include covered services , network providers, exclusions, emergency services
procedures, 24-hour toll-free number for certification of services, daytime
number to call for assistance, appeal procedures, enrollee rights and
responsibilities, and definitions of terms.
(2) All health and dental plan literature and
brochures shall be available in English and any other language when enrollment
in the health or dental plan by enrollees who speak the same non-English
language equals or exceeds 10 percent of all enrollees in the health or dental
plan.
d. All health and
dental plan literature and brochures shall be approved by the
department .
e. The participating
health and dental plans shall not, directly or indirectly, conduct
door-to-door, telephonic, or other "cold-call" marketing.
f. The participating health or dental plan
may make marketing presentations at the discretion of the department .
(7)
Appeal
process. The participating health or dental plan shall have a written
procedure by which enrollees may appeal issues concerning the health or dental
care services provided through providers contracted with the health or dental
plan and which:
a. Is approved by the
department prior to use.
b.
Acknowledges receipt of the appeal to the enrollee .
c. Establishes time frames which ensure that
appeals be resolved within 45 days, except for appeals which involve emergency
medical conditions, which shall be resolved within time frames appropriate to
the situations.
d. Ensures the
participation of persons with authority to take corrective action.
e. Ensures that the decision be made by a
physician , dentist , or clinical peer not previously involved in the
case.
f. Ensures the confidentiality
of the enrollee .
g. Ensures
issuance of a written decision to the enrollee for each appeal which shall
contain an adequate explanation of the action taken and the reason for the
decision.
h. Maintains a log of the
appeals which is made available to the department at its request.
i. Ensures that the participating health or
dental plan's written appeal procedures be provided to each newly covered
enrollee .
j. Requires that the
participating health or dental plan make quarterly reports to the department
summarizing appeals and resolutions.
(8)
Appeals to the
department Rescinded lAB 1/13/99, effective 1/1/99.
(9)
Records and reports. The
participating health and dental plans shall maintain records and reports as
follows:
a. The health or dental plan shall
comply with the provisions of rule
441-79.3 (249A) regarding
maintenance and retention of clinical and fiscal records and shall file a
letter with the commissioner of insurance as described in Iowa Code section
228.7.
In addition, the health or dental plan or subcontractor of the health or dental
plan, as appropriate, must maintain a medical or dental records system that:
(1) Identifies each medical or dental record
by hawki enrollee identification number.
(2) Maintains a complete medical or dental
record for each enrollee .
(3)
Provides a specific medical or dental record on demand.
(4) Meets state and federal reporting
requirements applicable to the hawki program .
(5) Maintains the confidentiality of medical
or dental records information and releases the information only in accordance
with established policy below:
1. All medical
and dental records of the enrollee shall be confidential and shall not be
released without the written consent of the enrollee or responsible
party.
2. Written consent is not
required for the transmission of medical or dental records information to
physicians, dentists, other practitioners, or facilities that are providing
services to enrollees under a subcontract with the health or dental plan. This
provision also applies to specialty providers who are retained by the health or
dental plan to provide services which are infrequently used, which provide a
support system service to the operation of the health or dental plan, or which
are of an unusual nature. This provision is also intended to waive the need for
written consent for department staff assisting in the administration of the
program , reviewers from the peer review organization (PRO), monitoring
authorities from the Centers for Medicare and Medicaid Services (CMS), the
health or dental plan itself, and other subcontractors which require
information as described under numbered paragraph "5" below.
3. Written consent is not required for the
transmission of medical or dental records information to physicians, dentists,
or facilities providing emergency care pursuant to paragraph
86.15(2)"h."
4.
Written consent is required for the transmission of the medical or dental
records information of a former enrollee to any physician or dentist not
connected with the health or dental plan.
5. The extent of medical or dental records
information to be released in each instance shall be based upon a test of
medical or dental necessity and a "need to know" on the part of the
practitioner or a facility requesting the information.
6. Medical and dental records maintained by
subcontractors shall meet the requirements of this rule.
EXCEPTION: Written consent is required for the transmission of medical records relating to substance abuse, HIV, or mental health treatment in accordance with state and federal laws.
b. Each health or dental plan
shall provide at a minimum reports and plan information to the department as
follows:
(1) A list of providers of services
under the plan.
(2) Encounter data
on a monthly basis as required by the department .
(3) Other information as directed by the
department .
c. Each
health or dental plan shall at a minimum provide reports and health or dental
plan information to the department as follows:
(1) Information regarding the plan's appeal
process.
(2) A plan for a health
improvement program .
(3) Periodic
financial, utilization and statistical reports as required by the
department .
(4) Time-specific
reports which define activity for child health care, appeals and other
designated activities which may, at the department 's discretion, vary among
plans, depending on the services covered or other differences.
(5) Other information as directed by the
department .
(10)
System. The
participating health or dental plan shall maintain data files that are
compatible with the department 's system.
(11)
Payment to the participating
health or dental plan.
a. In
consideration for all services rendered by a health or dental plan, the health
or dental plan shall receive a payment each month for each enrollee . This
capitation rate represents the total obligation of the department with respect
to the costs of medical or dental care and services provided to the
enrollees.
b. The capitation rate
shall be actuarially determined by the department July of 2000 and each fiscal
year thereafter using statistics and data assumptions and relevant experience
derived from similar populations.
c. The capitation rate does not include any
amounts for the recoupment of losses suffered by the health or dental plan for
risks assumed under the current or any previous contract . The health or dental
plan accepts the rate as payment in full for the contracted services. Any
savings realized by the health or dental plan due to lower utilization from a
less frequent incidence of health or dental problems among the enrolled
population shall be wholly retained by the health or dental plan.
d. If an enrollee has third-party coverage or
a responsible party other than the hawki program available for purposes of
payment for medical or dental expenses, it is the right and responsibility of
the health or dental plan to investigate these third-party resources and
attempt to obtain payment. The health or dental plan shall retain all funds
collected through third-party sources. A complete record of all income from
these sources must be maintained and made available to the
department .
(12)
Quality assurance. The health or dental plan shall have in
effect an internal quality assurance system.
Notes
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