South Carolina Code 38-33-180. Suspension or revocation of certificate of authority
(1) The health maintenance organization is operating significantly in contravention of its basic organizational document or in a manner contrary to that described in other information submitted under § 38-33-30, unless amendments to the submissions have been filed with and approved by the director or his designee.
Terms Used In South Carolina Code 38-33-180
- Basic health care services: means emergency care, inpatient hospital and physician care, and outpatient medical services. See South Carolina Code 38-33-20
- Complaint: A written statement by the plaintiff stating the wrongs allegedly committed by the defendant.
- Department: means the Department of Insurance of South Carolina. See South Carolina Code 38-1-20
- Director: means the person who is appointed by the Governor upon the advice and consent of the Senate and who is responsible for the operation and management of the Department of Insurance, including all of its divisions. See South Carolina Code 38-33-20
- Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.
- Health care services: means services included in furnishing an individual medical or dental care or hospitalization or incident to the furnishing of care or hospitalization, and other services to prevent, alleviate, cure, or heal human illness, injury, or physical disability. See South Carolina Code 38-33-20
- Health maintenance organization: means a person who undertakes to provide or arrange for basic health care services to enrollees for a fixed prepaid premium. See South Carolina Code 38-33-20
- Person: means a natural or an artificial person including, but not limited to, individuals, partnerships, associations, trusts, or corporations. See South Carolina Code 38-33-20
- Policy: means a contract of insurance. See South Carolina Code 38-1-20
(2) The health maintenance organization issues evidence of coverage or uses a schedule of charges for health care services which do not comply with the requirements of § 38-33-80.
(3) The health maintenance organization does not provide or arrange for basic health care services.
(4) The health maintenance organization does not meet the requirements of § 38-33-40 or is unable to fulfill its obligations to furnish health care services.
(5) The health maintenance organization is financially unsound or reasonably may be expected to be unable to meet its obligations to enrollees or prospective enrollees.
(6) The health maintenance organization has failed to implement a mechanism affording the enrollees an opportunity to participate in matters of policy and operation under § 38-33-60.
(7) The health maintenance organization has failed to implement the complaint system required by § 38-33-110 in a reasonable manner to resolve valid complaints.
(8) The health maintenance organization, or a person on its behalf, advertised or merchandised its services in an untrue, misrepresentative, misleading, deceptive, or unfair manner.
(9) The continued operation of the health maintenance organization is hazardous to its enrollees.
(10) The health maintenance organization otherwise has failed to comply with this chapter or regulations promulgated under it by the department.
(B) A certificate of authority is suspended or revoked only after compliance with the requirements of § 38-33-210.
(C) When the certificate of authority of a health maintenance organization is suspended, the health maintenance organization, during the suspension, may not enroll additional enrollees except newborn children or other newly acquired dependents of existing enrollees and may not engage in advertising or solicitation.
(D) When the certificate of authority of a health maintenance organization is revoked, the organization shall proceed, immediately following the effective date of the order of revocation, to wind up its affairs and may conduct no further business except as may be essential to the orderly conclusion of the affairs of the organization. It may not engage in further advertising or solicitation. The director or his designee, by written order, may permit further operation of the organization he finds to be in the best interest of enrollees, to the end that enrollees are afforded the greatest practical opportunity to obtain continuing health care coverage.