Current with changes from the 2024 Legislative Session
Section 354.552 - Community-based health maintenance organizations, requirements1. A community-based health maintenance organization shall have available and accessible a sufficient number and type of physicians, specialists, and other providers as needed to: (1) Provide the benefits covered by the plan;(2) Meet the medical needs of the health plan's enrolled population;(3) Provide members with a reasonable choice of primary care physicians and specialty physicians.2. If a community-based health maintenance organization does not employ or contract with a physician with the expertise necessary to provide medically necessary care covered by the health plan, then the health maintenance organization shall arrange for a referral to a physician with the necessary expertise and ensure that the members obtain the covered benefit at no greater cost to the member than if the benefit were obtained from participating physicians.3. A community-based health maintenance organization's physicians, physician specialists and facilities shall be reasonably available. Primary health care services shall be in reasonable proximity to a member's personal residence or business, with due consideration given to the availability of physicians within the community-based health maintenance organization's service area. This provision shall not preclude a community-based health maintenance organization from arranging for the provision of member care outside the service area for a higher level of skill or specialty care than is available within the service area.