<html> <head> <title>Rule 20:06:55:39 Essential community providers.</title> <META NAME="Keywords" Content="Administrative Rules 20:06:55:39"> <META NAME="Description" Content="Administrative Rules 20:06:55:39 Essential community providers."> <meta http-equiv=Content-Type content="text/html; charset=windows-1252"> <meta name=Generator content="Microsoft Word 14 (filtered)"> <style> <!-- /* Font Definitions */ @font-face {font-family:Calibri; panose-1:2 15 5 2 2 2 4 3 2 4;} /* Style Definitions */ p.MsoNormal, li.MsoNormal, div.MsoNormal {margin:0in; margin-bottom:.0001pt; text-align:justify; font-size:12.0pt; font-family:"Times New Roman","serif";} @page WordSection1 {size:8.5in 11.0in; margin:1.0in 1.0in 1.0in 1.0in;} div.WordSection1 {page:WordSection1;} --> </style> </head> <body lang=EN-US> <div class=WordSection1> <p class=MsoNormal style='margin-left:-.7pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>20:06:55:39.&nbsp;&nbsp;Essential community providers.</b> A qualified health plan issuer must have a sufficient number and geographic distribution of essential community providers, where available, to ensure reasonable and timely access to a broad range of such providers for low-income, medically underserved individuals in the qualified health plan's service area.</p> <p class=MsoNormal style='margin-left:-.7pt'>&nbsp;</p> <p class=MsoNormal style='margin-left:-.7pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; A qualified health plan issuer that provides a majority of covered professional services through physicians employed by the issuer or through a single contracted medical group may, with approval from the director, as an alternative to the standard set forth above comply as follows:</p> <p class=MsoNormal style='margin-left:-.7pt'>&nbsp;</p> <p class=MsoNormal style='margin-left:-.7pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; A qualified health plan issuer must have a sufficient number and geographic distribution of employed providers and hospital facilities, or providers of its contracted medical group and hospital facilities to ensure reasonable and timely access for low-income, medically underserved individuals in the qualified health plans service area.</p> <p class=MsoNormal style='margin-left:-.7pt'>&nbsp;</p> <p class=MsoNormal style='margin-left:-.7pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Nothing in this section shall be construed to require any qualified health plan to provide coverage for any specific medical procedure provided by the essential community provider.</p> <p class=MsoNormal style='margin-left:-.7pt'>&nbsp;</p> <p class=MsoNormal style='margin-left:-.7pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>Source:</b> 39 SDR 203, adopted June 10, 2013, effective January 1, 2014.</p> <p class=MsoNormal style='margin-left:-.7pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>General Authority:</b> SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=58-17-87">58-17-87</A>, <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=58-18-79">58-18-79.</A></p> <p class=MsoNormal style='margin-left:-.7pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>Law Implemented:</b> SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=58-17-87">58-17-87</A>, <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=58-18-79">58-18-79</A>, <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=58-18-80">58-18-80.</A></p> <p class=MsoNormal style='margin-left:-.7pt'>&nbsp;</p> </div> </body> </html>