State Law

Arizona Admin. Code-Title 20-Chapter 6-Article 19. Health Care Services Organizations Oversight

06/15/2020 Arizona Section R20-6-1904

Health Care Plan

Network Adequacy

A. An HCSO shall submit a statement to the Department that describes the proposed health care plan.

B. The HCSO shall have an organized system for the delivery of health care services contained in subsection (D) that includes the following:

1. Contracted providers that provide services under the plan;

2. An effective process to promote a continuing relationship between an enrollee and the same PCP; and

3. An effective process for referrals that ensures continuity of care to an enrollee.

C. The HCSO shall list:

1. The proposed or actual enrollment;

2. The number and names of contracted, employed, or HCSO-owned providers that will serve the enrollees and the board eligibility or certification of each physician, if applicable; and

3. The plan for providing covered services to enrollees as required under this Article.

D. The HCSO’s health care plan shall provide within the geographic area served the following basic health care services covered by the monthly charges in the evidence of coverage:

1. Emergency care that includes emergency services and inpatient emergency care;

2. Inpatient care;

3 Specialty care, primary care, or ancillary care that includes diagnostic and therapeutic services;

4. Outpatient care;

5. Preventive care; and

6. Emergency ambulance services under A.R.S. § 20-2801(2), and other ambulance services when approved by a plan physician.

E. The HCSO shall provide appropriate coverage for out-of-area emergency care to an enrollee traveling outside the area served by the HCSO.