Section 4521.130  Basic Health Care Services

The provision of Basic Health Care Services shall not discriminate against any class of physician.  The following minimum standards shall meet the requirements for Basic Health Care Services, provided that services are medically necessary as determined by the enrollee's primary care physician and, if required by the HMO, are authorized on a prospective and timely basis by the HMO's Medical Director:

a)         Physician services, including primary care, consultation, referral, surgical, anesthesia or other as needed by the enrollee in any level of service delivery.  Physician services need not include organ transplants unless specifically authorized by a primary care physician and approved by the HMO's Medical Director;

b)         Outpatient diagnostic imaging, pathology services and radiation therapy;

c)         Non-mental health inpatient services, including all professional services, medications, surgically implanted devices and supplies used by the enrollee while an inpatient;

d)         Emergency services for accidental injury or emergency illness 24 hours per day, and 7 days per week.  Emergency services are covered benefits inside and out of the plan's service area.  Emergency treatment shall include outpatient visits and referrals for emergency mental health problems;

e)         Maternity care, including prenatal and post-natal care and care for complication of pregnancy of mother and care with respect to a newborn child from the moment of birth, which shall include the care and treatment of illness, injury, congenital defects, birth abnormalities and premature birth;

f)         Blood transfusion services, processing and the administration of whole blood and blood components and derivatives;

g)         Preventive health services as appropriate for the patient population, including a health evaluation program and immunizations to prevent or arrest the further manifestation of human illness or injury including but not limited to allergy injections and allergy serum.  A health evaluation program shall include at least periodic physical examinations and medical history, hearing and vision testing or screening, routine laboratory testing or screening, blood pressure testing, and uterine cervical cytological testing, and low dose mammography testing as required by Section 4-6.1 of the Act;

h)         45 days inpatient mental health care per year.  Care in a day hospital, residential non-hospital or intensive outpatient mode may be substituted on a two-to-one basis for inpatient hospital services as deemed appropriate by the primary care physician.  60 individual outpatient mental health care visits per enrollee per year, as appropriate for evaluation, short-term treatment and crisis intervention services.  Group outpatient mental health care visits may be substituted on a two-to-one basis for individual mental health care visits as deemed appropriate by the primary care physician;

i)          Alcoholism and Drug Abuse

1)         Diagnosis, detoxification and treatment of the medical complications of the abuse of or addiction to alcohol or drugs on either an inpatient or outpatient basis.

2)         Rehabilitation services on an inpatient basis, for up to 45 days inpatient care per year.  Care in a day hospital, residential non-hospital or intensive outpatient treatment mode may be substituted on a two-to-one basis for inpatient hospital services as deemed appropriate by the primary care physician.  60 individual outpatient care visits per enrollee per year as appropriate for evaluation, short-term treatment, and crisis intervention services.  Group outpatient care visits may be substituted on a two-to-one basis for individual outpatient visits as deemed appropriate by the primary care physician.  Prolonged rehabilitation services in a specialized inpatient or residential facility need not be a part of Basic Health Care Services;

j)          Outpatient Rehabilitative therapy (including but not limited to:  speech therapy, physical therapy, and occupational therapy directed at improving physical functioning of the member) up to 60 treatments per year for conditions which are expected to result in significant improvement within two months as determined by the primary care physician and if required by the HMO, are authorized on a prospective and timely basis by the HMO's Medical Director;

k)         Preventive services required pursuant to 42 USC 300gg-13;

l)          Essential health benefits as provided in 50 Ill. Adm. Code 2001.11;

m)        Additional minimum standards may apply under the ACA, including but not limited to plans required to provide Essential Health Benefits under sections 1302(a) and (b) and the Mental Health Parity and Addiction Equity Act (P.L. 110‑343).

(Source:  Amended at 38 Ill. Reg. 23437, effective November 25, 2014)