SECTION 365:40-5-20. Basic health care services

  Basic health care services shall include:

(1)   Physician services including consultant and referral services by a physician, and other health professional services as necessary to provide allopathic, osteopathic, chiropractic, podiatric, optometric, and psychological services. If a service of a physician may also be provided under applicable State law by another type of health professional, an HMO may provide the service through these other health professionals.

(2)   Outpatient services including diagnostic services, treatment services and x-ray services, for patients who are ambulatory and may be provided in a non-hospital based health care facility or at a hospital.

(3)   Inpatient hospital services including room and board, general nursing care, meals and special diets when medically necessary, use of operating room and related facilities, use of intensive care unit and services, x-ray services, laboratory, and other diagnostic tests, drugs, medications, biologicals, anesthesia and oxygen services, special duty nursing when medically necessary, radiation therapy, inhalation therapy, perfusion, and administration of whole blood and blood plasma.

(4)   Outpatient services and inpatient hospital services including short-term rehabilitation services and physical therapy which the HMO expects can result in the significant improvement of an enrollee's condition within two months,

(5)   Medically necessary emergency health services, which shall include instructions to enrollees on how to get medically necessary emergency health services both in and out of the service area.

(6)   Twenty outpatient visits per enrollee per year, as may be necessary and appropriate for short-term evaluative or crisis intervention mental health services, or both.

(7)   Diagnosis, medical treatment and referral services (including referral services to appropriate ancillary services) for the abuse of or addiction to alcohol and drugs, including

(A)   Diagnosis and medical treatment for the abuse of or addiction to alcohol and drugs including detoxification for alcoholism or drug abuse on either an outpatient or inpatient basis, whichever is medically determined to be appropriate, in addition to the other required basic health care services for the treatment of other medical conditions.

(B)   Referral services for either medical or for nonmedical ancillary services. Medical ancillary services shall be a part of basic health care services; nonmedical ancillary services (such as vocational rehabilitation and employment counseling) and prolonged rehabilitation services in a specialized inpatient or residential facility need not be a part of basic health care services.

(8)   Diagnostic laboratory and diagnostic and therapeutic radiological services in support of basic health care services.

(9)   Home health services provided at an enrollee's home by health care personnel, as prescribed or directed by the responsible physician or their authority designated by the HMO.

(10)   Preventive health services, which shall be made available to enrollees and shall include at least the following:

(A)   Services for children from birth to age 21 as determined by the American Academy of Pediatrics in "Guidelines for Health Supervision";

(B)   Immunizations for adults and children as recommended by the Advisory Committee on Immunization Practices

(ACIP)   Centers for Disease Control and Prevention, except those required for foreign travel and employment;

(C)   Periodic health evaluations for adults to include voluntary family planning services; and

(D)   Preventive services identified through the HMO quality assurance program designed to contribute to achieving the U.S. Department of Health and Human Services "Healthy People 2010" objectives.

(11)   Medically necessary eye care services for detection and treatment of diseases or injury to the eye.

(12)   Inpatient and outpatient care for treatment of the birth defect known as cleft lip or cleft palate or both including medically necessary oral surgery, orthodontics, and otologic, audiological, and speech/language treatment.

[Source: Added at 21 Ok Reg 77, eff 11-1-03 (emergency); Added at 21 Ok Reg 1672, eff 7-14-04]