CHAPTER 44:18:01
HEALTH CARE QUALIFICATIONS
Section
44:18:01:01 Definitions.
44:18:01:02 Availability and accessibility.
44:18:01:03 Quality of services.
44:18:01:04 Statistical reports.
44:18:01:01. Definitions. Terms defined in SDCL 58-41-1 and 58-41-2 have the same meaning in this chapter. In addition, terms used in this chapter mean:
(1) "Emergency care," those professional health services immediately necessary to preserve life or stabilize health due to the sudden, severe, and unforeseen onset of illness or accidental bodily injury;
(2) "Health care delivery system," a regularly interacting and interdependent group of providers who furnish comprehensive health maintenance services;
(3) "HMO," the acronym for health maintenance organization as defined in SDCL 58-41-2;
(4) "Out-of-area health care services," those services provided outside of the HMO's geographic service area, as the area is described in the HMO's application for a certificate of authority and in subsequent changes to the application filed with the secretary;
(5) "Primary care physician," a person who is licensed to practice medicine in South Dakota by the South Dakota board of medical and osteopathic examiners and who provides direct patient care and practices principally in one of the four primary care specialties, general or family practice, general internal medicine, pediatrics, and obstetrics and gynecology; and
(6) "Timely provision of care," health care services which are administered within a time which does not compromise the patient's health condition and is within a waiting period comparable to the acceptable practices of the existing health care delivery systems in the proposed geographic area, as determined by the secretary, unless uncontrollable circumstances exist.
Source: 12 SDR 50, effective September 29, 1985.
General Authority:SDCL 58-41-67.
Law Implemented:SDCL 58-41-12.
44:
(1) Comprehensive health maintenance services, as described in SDCL 58-41-1(5), 58-41-35.1, and 58-41-35.3, shall be provided by the applicant or through contractual arrangements with other providers;
(2) The ratio of potential enrollees to staff, including health professionals, administrative, and other supporting staff, directly or through referrals, shall assure that all services offered by the plan are accessible to enrollees and meet their anticipated needs without delays detrimental to the health of the enrollees. There shall be at least one full-time equivalent primary care physician to each 2,500 enrollees;
(3) Provision shall be made for emergency and out-of-area health care services;
(4) The geographical location or locations and hours of operation of the HMO or the HMO providers shall facilitate the delivery of health care services to enrollees considering the utilization patterns of the existing health care delivery system in the proposed geographic area; and
(5) A documented system for monitoring and evaluating accessibility of care shall be maintained, including a system for addressing problems that develop, including but not limited to waiting time and appointments.
Source: 12 SDR 50, effective September 29, 1985.
General Authority:SDCL 58-41-67.
Law Implemented:SDCL 58-41-12.
44:18:01:03. Quality of services. The quality of health care provided by an HMO shall be evaluated by methods that include the following:
(1) Provisions for meeting the standards of quality review set forth in the Social Security Amendments of 1972, United States code, title 42, sections 1320c to 1320c-19;
(2) Written or on-site examinations of the HMO and providers with whom the HMO has contracts and agreements. The department of health shall make the examinations as often as the department considers necessary, but at least once every three years. In lieu of the examination, the department may accept the report from the director, the state department of health of another state or jurisdiction, the federal government or its designee agency, or contract with an outside organization to assess the quality of care being provided by the HMO;
(3) An ongoing internal peer review quality assurance program, supervised by a physician in the HMO and involving a broad spectrum of health professionals in the organization. The objectives of the internal quality assurance program shall be to assure that health care services meet the patient's needs in a quality manner and to assure that the organization and administration support the timely provision of quality care;
(4) A defined set of criteria and procedures used by the HMO in selecting providers to serve enrollees and the retention of the records revealing the method used to scrutinize and screen individual provider applications for consideration of contractual arrangement with the HMO; and
(5) To ascertain enrollee satisfaction as part of the overall quality evaluation program, provision to the secretary, upon request, of individual or family enrollee names, where applicable, and respective addresses for the purpose of conducting surveys.
Source: 12 SDR 50, effective September 29, 1985.
General Authority:SDCL 58-41-12, 58-41-67.
Law Implemented:SDCL 58-41-12, 58-41-13, 58-41-70, 58-41-71.
44:18:01:04. Statistical reports. Each HMO shall continually develop, compile, and evaluate statistics. The following statistics, consisting of at least 12 months of information, shall be submitted to the secretary by March 1 in the annual report required by SDCL 58-41-63:
(1) Average income per enrollee per month and expense per enrollee per month;
(2) Cost statistics reflecting the cost required to provide services by the 20 most frequently occurring primary diagnoses;
(3) Gross utilization totals, including use by the 20 most frequently occurring primary diagnoses, hospital discharges, surgical hospital discharges, hospital bed days, outpatient visits, laboratory tests and X rays, physician encounters, and nonmedical encounters;
(4) Service area demographic characteristics, including the age, sex, and geographic residence of enrollees who use HMO services;
(5) Statistics indicating the number of total enrollees whose source of premium payment is by medicare, medicaid, employer paid, and private pay;
(6) A list of personnel and office hours revealing the availability of services; and
(7) Enrollee disease-specific and age-specific mortality rates.
Source: 12 SDR 50, effective September 29, 1985.
