10.07.11.03

.03 Quality Assurance Requirements — Program Planning and Evaluation.

A. The HMO shall have a written program plan that is updated and reviewed at least every 3 years.

B. The plan shall include the following information:

(1) Statistics on age, sex, and other general demographic data used to determine the health care needs of its population;

(2) Identification of the major health problems in the enrolled population;

(3) Identification of enrolled special groups that have unique health problems such as the poor, the elderly, the mentally ill, and educationally disadvantaged;

(4) A description of community health resources and how they will be used.

C. Priorities and Objectives. The HMO shall state its priorities and objectives in writing, describing how the priorities and objectives relating to the health problems and needs of the enrolled population will be provided for.

D. Services. At the time membership is solicited, the HMO shall provide a general description of services available to enrollees including:

(1) Benefit limitations and exclusions;

(2) Location of facilities or providers; and

(3) Procedures by which a member would obtain medical services.

E. On each enrollment card or application, the HMO shall:

(1) Place the following statement in bold print: "If you have any questions concerning the benefits and services that are provided by or excluded under this agreement, please contact a membership services representative before signing this application or card"; and

(2) Provide information on how a prospective member may contact a membership services representative.

F. The plan shall contain evidence that:

(1) Programs and services offered are based on the health problems of, and the community health services available to, the enrolled population;

(2) There is an active program for preventing illness, disability, and hospitalization among enrollees;

(3) Services designed to prevent the major health problems identified among child and adult enrollees and to improve their general health are provided by the HMO.