Insurance

Administration

Rule R590-237: Access to a Health Care Provider in a Rural County

Effective Date: 06/21/2023

Admin. Code Reference: R590-237

Rule Type: Current Rule

R590. Insurance, Administration.

R590-237. Access to a Health Care Provider in a Rural County.

R590-237-1. Authority.

This rule is promulgated by the commissioner pursuant to Sections 31A-2-201 and 31A-45-501.

R590-237-2. Purpose and Scope.

(1) The purpose of this rule is to:

(a) identify each county with a population density of less than 100 people per square mile;

(b) identify independent hospitals;

(d) describe how a managed care organization:

(i) uses the information described in Subsections (1)(a), (b), and (c);

(ii) notifies enrollees, independent hospitals, and federally qualified health centers of the information described in Subsections (1)(a), (b), and (c); and

(iii) provides notice required by Subsection 31A-45-501(8)(d)(ii).

(2) This rule applies to a managed care organization.

R590-237-3. Definitions.

Terms used in this rule are defined in Sections 31A-1-301 and 31A-45-102. Additional terms are defined as follows:

(1)(a) "Board of directors" means a local board of directors for an independent hospital that is directly responsible for the daily policy and financial decisions of the hospital.

(b) A board of directors does not include a corporate board of directors for an entity that owns an independent hospital.

(2)(a) "Local practice location" means a provider's office where services are provided.

(b) A local practice location is:

(i) permanently located within a county with a population density of:

(A) less than 100 people per square mile before December 31, 2000; or

(B) less than 30 people per square mile; and

(ii) within 30 miles of paved roads of:

(A) the place where an enrollee lives or resides; or

(B) the location of an independent hospital or federally qualified health center where an enrollee may receive health care services.

(3) "Policy and financial decision" means a day-to-day decision made by a board of directors regarding an independent hospital's policy and financial solvency.

(4) "Provider" means a person who:

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

(b) is licensed or authorized to furnish health care.

(5) "Referral" means:

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

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

(6) "Rural county" means a county with a population density of less than 100 people per square mile.

R590-237-4. Rural Counties.

(1) Under Subsection 31A-45-501(8)(c)(ii)(A), a county with a population density of less than 100 people per square mile, as reported by the Utah Office of Vital Statistics as of February 11, 2019, includes each county except:

(a) Cache;

(b) Davis;

(d) Utah; and

(e) Weber.

(2) Under Subsection 31A-45-501(2)(b), a rural county where an independent hospital was built before December 31, 2000, includes each county except:

(a) Davis;

(b) Salt Lake;

(d) Weber.

(3) Under Subsection 31A-45-501(2)(b), a rural county where an independent hospital was built after December 31, 2000, includes each county except;

(a) Cache;

(b) Davis;

(d) Utah;

(e) Washington; and

(f) Weber.

(4) Under Subsection 31A-45-501(6)(b)(i), a non-contracting provider referral to a non-contracting provider is allowed in each county except:

(a) Cache;

(b) Davis;

(d) Utah;

(e) Washington; and

(f) Weber.

R590-237-5. Independent Hospitals.

The following are independent hospitals under Subsections 31A-45-501(1)(e) and 31A-45-501(2)(b):

(1) Beaver Valley Hospital, Beaver, Beaver County;

(2) Blue Mountain Hospital, Blanding, San Juan County;

(3) Central Valley Medical Center, Nephi, Juab County;

(4) Gunnison Valley Hospital, Gunnison, Sanpete County;

(5) Kane County Hospital, Kanab, Kane County;

(6) Milford Valley Memorial Hospital, Milford, Beaver County;

(7) Moab Regional Hospital, Moab, Grand County;

(8) San Juan Hospital, Monticello, San Juan County; and

(9) Uintah Basin Medical Center, Roosevelt, Duchesne County.

R590-237-6. Federally Qualified Health Centers.

The following are federally qualified health centers under Subsection 31A-45-501(3)(b):

(1) Bear Lake Community Health Center, Garden City, Rich County;

(2) Bear River Health Clinic, Tremonton, Box Elder County;

(3) Blanding Family Chiropractic, Blanding, San Juan County;

(4) Blanding Family Practice Community Health Center, Blanding, San Juan County;

(5) Blanding Family Vision Center, Blanding, San Juan County;

(6) Box Elder Community Health Center, Brigham City, Box Elder County;

(7) Brigham City Community Health Center, Brigham City, Box Elder County;

(8) Carbon Medical Service Association -- Helper Clinic, Helper, Carbon County;

(9) Carbon Medical Service Association, Sunnyside, Carbon County;

(10) Cedar Community Health Center, Cedar City, Iron County;

(11) Family Healthcare, Cedar City, Iron County;

(12) Green River Medical Center, Green River, Emery County;

(13) Kanosh Community Health Center, Kanosh, Millard County;

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

(15) Koosharem Community Health Center, Richfield, Sevier County;

(16) Montezuma Creek Community Health Center, Montezuma Creek, San Juan County;

(17) Mountainlands Community Health Center, Vernal, Uintah County;

(18) Southwest WCHC Mental Health, Panguitch, Garfield County;

(19) Wayne Community Health Center, Hanksville, Wayne County; and

(20) Wayne Community Health Center, Bicknell, Wayne County.

R590-237-7. Rural Health Notification.

(1) A managed care organization shall provide to an enrollee the notice under Subsection 31A-45-501(8)(d)(ii) no later than:

(a) at the time of enrollment; or

(b) when the group or individual contract and certificate of coverage are issued.

(2) A managed care organization shall provide the notice under Subsection 31A-45-501(8)(d)(ii) upon request thereafter.

(3) The notice shall be easily accessible on the managed care organization's website.

(4) When a rural county, independent hospital, or federally qualified health center is reclassified, the managed care organization shall provide an updated notice to each affected enrollee within 30 days of the change.

(5) When an independent hospital or federally qualified health center is reclassified, a managed care organization shall provide notice to the independent hospital or federally qualified health center within 30 days of the change.

R590-237-8. Severability.

If any provision of this rule, R590-237, or its application to any person or situation is held invalid, such invalidity does not affect any other provision or application of this rule that can be given effect without the invalid provision or application. The remainder of this rule shall be given effect without the invalid provision or application.

KEY: health care providers

Date of Last Change: June 21, 2023

Notice of Continuation: July 21, 2026

Authorizing, and Implemented or Interpreted Law: 31A-2-201; 31A-45-501