590.  Insurance Administration       (Effective 9-7-06)
R590-237.  Access to Health Care Providers in Rural Counties.
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