83-41-305 - Requirement of certificate of authority for establishment and operation of health maintenance organization; filing, form and contents of application for certificate and attachments; qualif
§ 83-41-305. Requirement of certificate of authority for establishment and operation of health maintenance organization; filing, form and contents of application for certificate and attachments; qualification of foreign health maintenance organizations; effect of denial of certificate; rules and regulations.
(1) Notwithstanding any law of this state to the contrary, any person may apply to the commissioner for a certificate of authority to establish and operate a health maintenance organization in compliance with this article. No person shall establish or operate a health maintenance organization in this state, without obtaining a certificate of authority under this article. A foreign health maintenance organization may qualify under this article, subject to its registration to do business in this state as a foreign health maintenance organization under Section 79-4-15.01, Mississippi Code of 1972, and compliance with all provisions of this article and other applicable state laws.
(2) Any health maintenance organization which has not previously received a certificate of authority to operate as a health maintenance organization as of July 1, 1995, shall submit an application for a certificate of authority under subsection (3) within sixty (60) days. Each applicant may continue to operate until the commissioner acts upon the application. If an application is denied under Section 83-41-307, the applicant shall thereafter be treated as a health maintenance organization whose certificate of authority has been revoked.
(3) Each application for a certificate of authority shall be verified by an officer or authorized representative of the applicant, shall be in a form prescribed by the commissioner, and shall set forth or be accompanied by the following:
(a) A copy of the organizational documents of the applicant, such as the articles of incorporation, articles of association, partnership agreement, trust agreement, or other applicable documents, and all amendments thereto;
(b) A copy of the bylaws, rules and regulations, or similar document, if any, regulating the conduct of the internal affairs of the applicant;
(c) A list of the names, addresses and official positions and biographical information on forms acceptable to the commissioner of the persons who are to be responsible for the conduct of the affairs and day to day operations of the applicant, including all members of the board of directors, board of trustees, executive committee or other governing board or committee and the principal officers in the case of a corporation, or the partners or members in the case of a partnership or association;
(d) A copy of any contract form made or to be made between any class of providers and the health maintenance organization and a copy of any contract made or to be made between third party administrators, marketing consultants or persons listed in paragraph (c) and the health maintenance organization;
(e) A copy of the form of evidence of coverage to be issued to the enrollees;
(f) A copy of the form of group contract, if any, which is to be issued to employers, unions, trustees or other organizations;
(g) Financial statements showing the applicant's assets, liabilities and sources of financial support. Include both a copy of the applicant's most recent (regular) certified financial statement and an unaudited current financial statement;
(h) A financial feasibility plan which includes detailed enrollment projections, the methodology for determining premium rates to be charged during the first twelve months of operations certified by an actuary or other qualified person, a projection of balance sheets, cash flow statements showing any capital expenditures, purchase and sale of investments and deposits with the state, and income and expense statements anticipated from the start of operations until the organization has had net income for at least one (1) year, and a statement as to the sources of working capital as well as any other sources of funding;
(i) A power of attorney duly executed by the applicant, if not domiciled in this state, appointing the commissioner and his successors in office, and duly authorized deputies, as the true and lawful attorney of the applicant in and for this state upon whom all lawful process in any legal action or proceeding against the health maintenance organization on a cause of action arising in this state may be served;
(j) A statement or map reasonably describing the geographic area or areas to be served;
(k) A description of the internal grievance procedures to be utilized for the investigation and resolution of enrollee complaints and grievances;
(l) A description of the proposed quality assurance program, including the formal organizational structure, methods for developing criteria, procedures for comprehensive evaluation of the quality of care rendered to enrollees, and processes to initiate corrective action and reevaluation when deficiencies in provider or organizational performance are identified;
(m) A description of the procedures to be implemented to meet the protection against insolvency requirements in Section 83-41-325;
(n) A list of the names, addresses, and license numbers of all providers with which the health maintenance organization has agreements and this list must be updated at the end of each calendar quarter.
(o) Any other information as the commissioner may require to make the determinations required in Section 83-41-307.
(4) (a) The commissioner may promulgate rules and regulations as he deems necessary to the proper administration of this article to require a health maintenance organization and other entities subsequent to receiving its certificate of authority to submit the information, modifications or amendments to the items described in subsection (3) of this section to the commissioner, either for his approval or for information only, prior to the effectuation of the modification or amendment, or to require the health maintenance organization to indicate the modifications to both State Health Officer and commissioner at the time of the next succeeding site visit or examination.
(b) Any modification or amendment for which the commissioner's approval is required shall be deemed approved unless disapproved within thirty (30) days. The commissioner may postpone the action for a time, not exceeding an additional thirty (30) days, as necessary for proper consideration.
Sources: Laws, 1995, ch. 613, § 3, eff from and after July 1, 1995.