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  • PART I ADMINISTRATION OF THE GOVERNMENT
  • TITLE XXII CORPORATIONS
  • CHAPTER 176G HEALTH MAINTENANCE ORGANIZATIONS
  • Section 14 Licensure applicants; documents required; approval by commissioner

Section 14. Each applicant for a health maintenance organization license shall upon initial application submit to the commissioner for his approval such materials as the commissioner shall by regulation require, in a form approved by the commissioner. A health maintenance organization shall annually notify the commissioner of any material change to the information submitted, in a form and at a time approved by the commissioner. Said materials shall include, but not be limited to:

(1) a copy of the basic organization document such as the articles of incorporation, articles of association, partnership agreement, trust agreement, or other applicable documents establishing the health maintenance organization;

(2) a copy of the by-laws, rules and regulations, or similar document, regulating the conduct of the internal affairs of the applicant;

(3) a statement generally describing the health maintenance organization, its health care plan or plans, facilities and personnel;

(4) an internal operations plan, including an organizational chart, description of organizational structure, a description of the service area and provider network, the roles, functions, responsibilities of and interrelationships among providers, and the methods of provider reimbursement and risk-sharing arrangements;

(5) a provider inventory, including a listing of providers by specialty, a calculation of physician to population ratios, and an inventory of owned, operated, contracting and participating provider facilities, including, but not limited to, hospitals, skilled nursing facilities, home health care and medical care services;

(6) a copy of every contract form made or to be made between the applicant and any providers of health services, copies of administrative contracts, and a statement of written procedures and standards for the prior review and approval by the applicant of provider subcontracts;

(7) a copy of the form of evidence of coverage to be issued to the members;

(8) a copy of the form of group contract, if any, which is to be issued to employers, unions, trustees, or other organizations;

(9) financial statements showing the applicant’s assets, liabilities, and sources of working capital and other sources of financial support and projections of the results of operations for the succeeding three years;

(10) a financial plan, including a statement indicating when the applicant estimates that income from operations will equal expenses, a statement of the applicant’s plan to establish and maintain sufficient reserves to cover projected risks, copies of reinsurance or other agreements to provide for provision of contracted health services in the event the applicant is unable to provide such services for any reason, and a detailed description of mechanisms to monitor the financial solvency of any organization contraction with the applicant that assumes substantial financial risk for the provision of health services;

(11) a plan for compliance with section 15, including copies of any contract or agreement with a carrier for reinsurance;

(12) an enrollment and marketing plan describing the marketing methods, anticipated enrollment, the service area population and utilization rates projected for health services delivered in the organization’s service area;

(13) a utilization plan describing inpatient and outpatient utilization review measures and a statement of actuarial review and certification of actuarial assumptions made regarding utilization as applied to projected financial statements;

(14) premium rates for all products offered;

(15) a member services plan, including a statement of procedures to be used to maintain member confidentiality of medical records, grievances, and quality assurance study responses;

(16) a detailed description of the quality assurance system;

(17) a detailed description of the formal internal grievance system including procedures for the registration and resolution of member grievances, and, for renewal applications only, the total number and disposition of malpractice claims and other claims relating to the service or care rendered by the health maintenance organization made by, or on behalf of, members of the organization that were settled or resulted in a judgment during the year by the health maintenance organization; and

(18) evidence of compliance with chapter 176O. Any applicant accredited by the managed care bureau established under section 2 of said chapter 176O shall be deemed to meet the requirements of this chapter with respect to requirements with any utilization review standards.

A license granted to a health maintenance organization pursuant to this section shall be renewed every 2 years. The fee for such renewal, in an amount determined by the commissioner, shall be not less than $1,000.