Utah Department of Administrative Services Division of Administrative Rules

Utah Administrative Code

The Utah Administrative Code is the body of all effective administrative rules as compiled and organized by the Division of Administrative Rules (Subsection 63G-3-102(5); see also Sections 63G-3-701 and 702).

NOTE: For a list of rules that have been made effective since October 1, 2014, please see the codification segue page.

NOTE TO RULEFILING AGENCIES: Use the RTF version for submitting rule changes.


R590. Insurance Administration.

Rule R590-237. Access to Health Care Providers in Rural Counties.

As in effect on October 1, 2014

Table of Contents

R590-237-1. Authority.

This rule is promulgated pursuant to Subsections 31A-2-201(2), 31A-2-201(3)(a), and 31A-8-501(7)(c) wherein the commissioner is empowered to administer and enforce Title 31A and make administrative rules to implement Section 31A-8-501.

R590-237-2. Purpose.

The purpose of this rule is to

(1) identify the counties with a population density of less than 100 people per square mile;

(2) identify independent hospitals;

(3) identify federally qualified health centers in Utah; and

(4) describe how a health maintenance organization (HMO) shall:

(a) use the information identifying the counties, independent hospitals and federally qualified health centers described in (1), (2), and (3) above; and

(b) notify the subscribers, independent hospitals and federally qualified health centers; and

(c) ensure an HMO provides the notice required by Subsection 31A-8-501(7)(d)(ii).

R590-237-3. Applicability and Scope.

This rule applies to all licensed health maintenance organizations as defined in Subsection 31A-8- 101(8).

R590-237-4. Definitions.

In addition to the definitions in Sections 31A-1-301 and 31A-8-101, the following definitions apply to this rule:

(1) "Board of Directors," for the purpose of this rule, means the local board of directors for the independent hospital that is directly responsible for the daily policy and financial decisions. board of directors does not include a corporate board of directors for the entity that owns the independent hospital.

(2) "Credentialed staff member" means a health care provider with active staff privileges at an independent hospital or a federally qualified health center. A credentialed staff member is not required to be an employee of the independent hospital or federally qualified health center.

(3) "Federally Qualified Health Center," as defined in the Social Security Act 42 U.S.C., Sec. 1395x, means an entity which:

(a)(i) is receiving a grant under Section 330, other than Subsection (h) of the Public Health Service Act 42 U.S.C, 254b; or

(ii)(A) is receiving funding from a grant under a contract with the recipient of such a grant; and

(B) meets the requirements to receive a grant under Section 330, other than Subsection (h) of the Public Health Service Act 42 U.S.C. 254b;

(b) based on the recommendation of the Health Resources and Services Administration within the Public Health Service is determined by the Secretary of Health and Human Services to meet the requirements for receiving such a grant;

(c) was treated by the Secretary of Health and Human Services as a comprehensive Federally funded health center as of January 1, 1990; or

(d) is an outpatient health program or facility operated by a tribe or tribal organization under the Indian Self-Determination Act, 25 U.S.C. 450f, or by an urban Indian organization receiving funds under title V of the Indian Health Care Improvement Act, 25 U.S.C. 1651.

(4) "Local practice location" means the provider's office where services are rendered which is:

(a) permanently located within a county with a population density of less than 100 people per square mile; and

(b) is within 30 miles of paved roads of:

(i) the place where the enrollee lives or resides; or

(ii) the location of the independent hospital or federally qualified health center at which the enrollee may receive covered benefits pursuant to Subsection 31A-8-501(2) or (3).

(5) "Policy and financial decisions" means the day-to-day decisions made by the local Board of directors with regard to hospital policy and financial solvency.

(6) "Provider" means any person who:

(a) furnishes health care directly to the enrollee; and

(b) is licensed or otherwise authorized to furnish the health care in this state.

(7) "Referral" means:

(a) the request by a health care provider for an item, service, test, or procedure to be performed by another health care provider;

(b) the request by a physician for a consultation with another physician; or

(c) the request or establishment of a plan of care by a physician.

(8) "Rural County" means a county as described in Subsection 31A-8-501(2)(b).

R590-237-5. Rural Counties.

(1) For the purposes of Subsection 31A-8-501(2)(b), rural counties where independent hospitals built prior to December 31, 2000 include all Utah counties except Davis, Salt Lake, Utah and Weber.

(2) For the purposes of Subsection 31A-8-501(2)(b), rural counties where independent hospitals built after December 31, 2000 include all Utah counties except Cache, Davis, Salt Lake , Utah, Washington and Weber.

(3) For purposes of Subsection 31A-8-501(5)(b)(i), non-contracting provider referrals to non- contracting providers are allowed in all counties except: Cache, Davis, Salt Lake, Utah, Washington, and Weber counties.

R590-237-6. Independent Hospitals.

The following are the independent hospitals that fall under Section 31A-8-501:

(1) Allen Memorial Hospital, Moab, Grand County, Utah

(2) Ashley Valley Medical Center, Vernal, Uintah County, Utah

(3) Beaver Valley Hospital, Beaver, Beaver County, Utah

(4) Brigham City Community Hospital, Brigham City, Box Elder County, Utah

(5) Cache Specialty Hospital, Logan, Cache County, Utah (Subject to the provisions of Subsection 31A- 8-501(2)).

(6) Central Valley Medical Center, Nephi, Utah

(7) Garfield Memorial Hospital, Panguitch, Utah

(8) Gunnison Valley Hospital, Gunnison, Sanpete County, Utah

(9) Kane County Hospital, Kanab, Kane County, Utah

(10) Milford Valley Memorial Hospital, Milford, Beaver County, Utah

(11) Mountain West Medical Center, Tooele, Tooele County, Utah

(12) San Juan Hospital, Monticello, San Juan County, Utah

(13) Uintah Basin Medical Center, Roosevelt, Duchesne County, Utah

R590-237-7. Federally Qualified Health Centers.

The following are the federally qualified health centers that fall under Section 31A-8-501:

(1) Beaver Medical Clinic, Beaver, Beaver County, Utah

(2) Blanding Family Practice/Blanding Medical Center, Blanding, Utah

(3) Bryce Valley Clinic, Cannonville, Utah

(4) Carbon Medical Services, Carbon, Carbon County, Utah

(5) Circleview Clinic, Circleview, Piute County, Utah

(6) Duchesne Valley Medical Clinic, Duchesne, Duchesne County, Utah

(7) Emery Medical Center, Castledale, Emery County, Utah

(8) Enterprise Valley Medical Clinic, Enterprise, Washington County, Utah

(9) Garfield Memorial Clinic, Panguitch, Garfield County, Utah

(10) Green Valley/River Clinic, Green River, Emery/Grand Counties, Utah

(11) Halchita Clinic, San Juan County, Utah

(12) Hurricane Family Practice Clinic, Hurricane, Washington County, Utah

(13) Kamas Health Center, Kamas, Summit County, Utah

(14) Kazan Memorial Clinic, Escalante, Garfield County, Utah

(15) Long Valley Medical, Kane County, Utah

(16) Milford Valley Clinic, Milford, Beaver County, Utah

(17) Montezuma Creek Health Center, Montezuma Creek, San Juan County, Utah

(18) Monument Valley Health Center, Monument Valley, Utah

(19) Navajo Mountain Health Center, San Juan County, Utah

(20) Wayne County Medical Clinic, Bicknell, Wayne County, Utah

R590-237-8. Rural Health Notification.

(1) An HMO shall provide its subscribers with the notice required by Subsection 31A-8-501(7)(d)(ii) no later than the time of enrollment or the time the group or individual contract and evidence of coverage are issued and upon request thereafter. This information must be included and easily accessible on the HMO's website. When rural counties, independent hospitals, or federally qualified health centers change, the HMO shall provide an updated notice to its affected subscribers within 30 days.

(2) An HMO shall provide to the independent hospitals and federally qualified health centers in the HMO service area the notice required by Subsection 31A-8-501(7)(d)(ii) within 30 days.

R590-237-9. Penalties.

An HMO found, after a hearing or other regulatory process, to be in violation of this rule shall be subject to penalties as provided under Section 31A-2-308.

R590-237-10. Enforcement Date.

The commissioner will begin enforcing the provisions of this rule 45 days from the effective date of the rule.

R590-237-11. Severability.

If any provision of this rule or the application of it to any person or circumstance is for any reason held to be invalid, the remainder of the rule and the application of the provision to other persons or circumstances may not be affected by it.

KEY

health care providers

Date of Enactment or Last Substantive Amendment

September 7, 2006

Notice of Continuation

September 1, 2011

Authorizing, Implemented, or Interpreted Law

31A-2-201; 31A-8-501


Additional Information

Contact

For questions regarding the content or application of rules under Title R590, please contact the promulgating agency (Insurance Administration). A list of agencies with links to their homepages is available at http://www.utah.gov/government/agencylist.html or from http://www.rules.utah.gov/contact/agencycontacts.htm.