State Law

North Dakota Admin. Code-Title 45-Article 45-06-Chapter 45-06-07. Model Reg. to Implement Rules Regarding Contracts and Services of HMOs

08/15/2023 North Dakota Section 45-06-07-06


Network Adequacy

1. Access to care.

a. A health maintenance organization shall establish and maintain adequate arrangements to provide health services for its enrollees, including:

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

(2) Reasonable hours of operation and after-hours services;

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

(4) 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.

b. A health maintenance organization shall make available to each enrollee a primary care physician and provide accessibility to medically necessary specialists through staffing, contracting, or referral. A health maintenance organization shall provide for continuity of care for enrollees referred to specialists.

c. A health maintenance organization shall have written procedures governing the availability of services utilized by enrollees, including at least the following:

(1) Well-patient examinations and immunizations;

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

(3) Treatment of emergencies;

(4) Treatment of minor illness; and

(5) Treatment of chronic illnesses.

2. Basic health care services. A health maintenance organization shall provide, or arrange for the provision of, as a minimum, basic health care services that must include the following:

a. Emergency care services, as defined in subsection 5 of section 45-06-06-03.

b. Inpatient hospital services, meaning medically necessary hospital services including room and board; general nursing care; special diets when medically necessary; use of operating room and related facilities; use of intensive care units and services; x-ray, laboratory, and other diagnostic tests; drugs, medications, biologicals, anesthesia, and oxygen services; special nursing when medically necessary; physical therapy, radiation therapy, and inhalation therapy; administration of whole blood and blood plasma; and short-term rehabilitation services.

c. Inpatient physician care services, meaning medically necessary health care services performed, prescribed, or supervised by physicians or other providers including diagnostic, therapeutic, medical, surgical, preventive, referral, and consultative health care services.

d. Outpatient medical services, meaning preventive and medically necessary health care services provided in a physician’s office, a nonhospital-based health care facility, or at a hospital. Outpatient medical services must include diagnostic services; treatment services; laboratory services; x-ray services; referral services; and physical therapy, radiation therapy, and inhalation therapy. Outpatient services must also include preventive health services that must include at least a broad range of voluntary family planning services, well-child care from birth, periodic health evaluations for adults, screening to determine the need for vision and hearing correction, and pediatric and adult immunizations in accordance with accepted medical practice.

3. Out-of-area services and benefits.

a. Out-of-area services are subject to the same copayment requirements set forth in subsection 6 of section 45-06-07-04.

b. When an enrollee is traveling or temporarily residing out of a health maintenance organization’s service area, a health maintenance organization shall provide benefits for reimbursement for emergency care services and transportation which is medically necessary and appropriate under the circumstances to return the enrollee to a health maintenance organization provider, subject to the following conditions:

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

(2) The enrollee could not reasonably arrange to return to the service area to receive treatment from the health maintenance organization’s provider;

(3) The travel or temporary residence must be for some purpose other than the receipt of medical treatments; and

(4) The health maintenance organization is notified by telephone within twenty-four hours of the commencement of such care unless it is shown that it was not reasonably possible to communicate with the health maintenance organization in such time limits.

c. Services received by an enrollee outside of the health maintenance organization’s service area will be covered only so long as it is unreasonable to return the enrollee to the service area.

4. Supplemental health care services. In addition to the basic health care services required to be provided in subsection 2, a health maintenance organization may offer to its enrollees any supplemental health care services it chooses to provide. Limitations as to time and cost may vary from those applicable to basic health care services.

5. Nonbasic health care services. A health maintenance organization may offer nonbasic health care services to any group or individual on a prepaid basis, subject to the same conditions as for supplemental health care services, as described in subsection 4, except that the health maintenance organization need not provide basic health care services as a condition to providing nonbasic health care services.