33-31-201. Establishment of health maintenance organizations. (1) Notwithstanding any law of this state to the contrary, a person may apply to the commissioner for and obtain a certificate of authority to establish and operate a health maintenance organization in compliance with this chapter. A person may not establish or operate a health maintenance organization in this state except as authorized by a subsisting certificate of authority issued to it by the commissioner. A foreign person may qualify for a certificate of authority if it first registers with the secretary of state to transact business in this state as a foreign corporation under 35-14-1502.

(2)Each application of a health maintenance organization, whether separately licensed or not, for a certificate of authority must:

(a)be verified by an officer or authorized representative of the applicant;

(b)be in a form prescribed by the commissioner;

(c)contain:

(i)the applicant’s name;

(ii)the location of the applicant’s home office or principal office in the United States, if a foreign person;

(iii)the date of organization or incorporation;

(iv)the form of organization, including whether the providers affiliated with the health maintenance organization will be salaried employees or group or individual contractors;

(v)the state or country of domicile; and

(vi)any additional information that the commissioner may reasonably require; and

(d)set forth the following information or be accompanied by the following documents, as applicable:

(i)a copy of the applicant’s organizational documents, such as its corporate charters or articles of incorporation, articles of association, partnership agreement, trust agreement, or other applicable documents, and all amendments to those documents, certified by the public officer with whom the originals were filed in the state or country of domicile;

(ii)a copy of the bylaws, rules, and regulations, or similar document, if any, regulating the conduct of the applicant’s internal affairs, certified by its secretary or other officer having custody of the documents;

(iii)a list of the names, addresses, and official positions of the persons responsible for the conduct of the applicant’s affairs, including all members of the board of directors, board of trustees, executive committee, or other governing board or committee, the principal officers in the case of a corporation, and the partners or members in the case of a partnership or association;

(iv)a copy of any contract made or to be made between:

(A)any provider and the applicant; or

(B)any person listed in subsection (2)(d)(iii) and the applicant. The applicant may file a list of providers executing a standard contract and a copy of the contract instead of copies of each executed contract.

(v)the extent to which any of the following will be included in provider contracts and the form of any provisions that:

(A)limit a provider’s ability to seek reimbursement for basic health care services or health care services from an enrollee;

(B)permit or require a provider to assume a financial risk in the health maintenance organization, including any provisions for assessing the provider, adjusting capitation or fee-for-service rates, or sharing in the earnings or losses; and

(C)govern amending or terminating an agreement with a provider;

(vi)a financial statement showing the applicant’s assets, liabilities, and sources of financial support. If the applicant’s financial affairs are audited by independent certified public accountants, a copy of the applicant’s most recent certified financial statement satisfies this requirement unless the commissioner directs that additional or more recent financial information is required for the proper administration of this chapter.

(vii)a description of the proposed method of marketing, a financial plan that includes a projection of operating results anticipated until the organization has had net income for at least 1 year, and a statement as to the sources of working capital as well as any other source of funding;

(viii)a statement reasonably describing the geographic service area or areas to be served, by county, including:

(A)a chart showing the number of primary and specialty care providers, with locations and service areas by county;

(B)the method of handling emergency care, with the location of each emergency care facility; and

(C)the method of handling out-of-area services;

(ix)a description of the way in which the health maintenance organization provides services to enrollees in each geographic service area, including the extent to which a provider under contract with the health maintenance organization provides primary care to those enrollees;

(x)a description of the complaint procedures to be used as required under 33-31-303;

(xi)a description of the mechanism by which enrollees will be afforded an opportunity to participate in matters of policy and operation under 33-31-222;

(xii)a summary of the way in which administrative services will be provided, including the size and qualifications of the administrative staff and the projected cost of administration in relation to premium income. If the health maintenance organization delegates management authority for a major corporate function to a person outside the organization, the health maintenance organization shall include a copy of the contract in its application for a certificate of authority. Contracts for delegated management authority must be filed with the commissioner in accordance with the filing provisions of 33-31-301(2). However, this subsection (2)(d)(xii) does not deprive the health maintenance organization of its right to confidentiality of any proprietary information, and the commissioner may not disclose that proprietary information to any other person. All contracts must include:

(A)the services to be provided;

(B)the standards of performance for the manager;

(C)the method of payment, including any provisions for the administrator to participate in the profits or losses of the plan;

(D)the duration of the contract; and

(E)any provisions for modifying, terminating, or renewing the contract.

(xiii)a summary of all financial guaranties by providers, sponsors, affiliates, or parents within a holding company system or any other guaranties that are intended to ensure the financial success of the plan, including hold harmless agreements by providers, insolvency insurance, reinsurance, or other guaranties;

(xiv)a summary of benefits to be offered enrollees, including any limitations and exclusions and the renewability of all contracts to be written;

(xv)evidence that it can meet the requirement of 33-31-216(10); and

(xvi)any other information that the commissioner may reasonably require to make the determinations required in 33-31-202.

(3)Each health maintenance organization shall file each substantial change, alteration, or amendment to the information submitted under subsection (2) with the commissioner at least 30 days prior to its effective date, including changes in articles of incorporation and bylaws, organization type, geographic service area, provider contracts, provider availability, plan administration, financial projections and guaranties, and any other change that might affect the financial solvency of the plan. The commissioner may, after notice and hearing, disapprove any proposed change, alteration, or amendment to the business plan. The commissioner may adopt reasonable rules exempting from the filing requirements of this subsection those items that the commissioner considers unnecessary.

(4)An applicant or a health maintenance organization holding a certificate of authority shall file with the commissioner all contracts of reinsurance and any modifications to the contracts. An agreement between a health maintenance organization and an insurer is subject to Title 33, chapter 2, part 12. A reinsurance agreement must remain in full force and effect for at least 90 days following written notice of cancellation by either party by certified mail to the commissioner.

(5)Each health maintenance organization shall maintain at its administrative office and make available to the commissioner upon request executed copies of all provider contracts.

(6)The commissioner may adopt reasonable rules exempting an insurer or health service corporation operating a health maintenance organization as a plan from the filing requirements of this section if information requested in the application has been submitted to the commissioner under other laws and rules administered by the commissioner.

(7)(a) The commissioner may waive the requirements of this section for a PACE organization that has entered into a PACE program agreement pursuant to 42 U.S.C. §§ 1396u-4.

(b)A request for waiver must be submitted in a form prescribed by the commissioner. The waiver application must be filed and approved annually. The annual renewal process must be completed by June 30 of each year.

(c)The factors that the commissioner may take into account when granting a waiver include but are not limited to the financial condition of the PACE organization, any consumer complaints against the PACE organization, and the length of time the PACE organization has been in business.

(d)The PACE organization shall submit an audited financial statement for the organization as a whole and a financial statement for the PACE program specifically with the initial waiver application and annually on June 30. The commissioner may request additional information necessary to evaluate the waiver request.

(e)The waiver automatically expires if the certification of the PACE organization by the centers for medicare and medicaid services or the department of public health and human services expires or is terminated.

(f)The PACE organization shall notify the commissioner within 30 days if the centers for medicare and medicaid services takes adverse action or issues any warnings regarding the continuation of the PACE organization.

(8)(a) (i) The commissioner may waive the requirements of this section for an accountable care organization. Upon establishment of a medicare shared savings program pursuant to 42 U.S.C. § 1395jjj, an accountable care organization shall demonstrate compliance with the program requirements in a manner determined by the commissioner.

(ii)The commissioner shall follow the medicare shared savings program structure in developing compliance criteria needed for obtaining a waiver.

(b)A request for waiver must be submitted in a form prescribed by the commissioner. The waiver application must be filed and approved every 3 years. The renewal process must be completed by June 30 of every third year.

(c)The factors that the commissioner may take into account when granting a waiver include but are not limited to the financial condition of the accountable care organization, any consumer complaints against the organization, and the length of time the organization has been in business.

(d)The accountable care organization shall submit an audited financial statement for the organization as a whole and a financial statement for the accountable care organization program specifically with the initial waiver application and annually by June 30. The commissioner may request additional information necessary to evaluate the waiver request.

(e)The waiver automatically expires if certification of the accountable care organization under the medicare shared savings program or the department of public health and human services expires or is terminated.