83-41-339 - Grounds and procedure for revocation, suspension or denial of certificate of authority; administrative penalty generally; correction of deficiencies in net worth; proceedings upon suspensi
§ 83-41-339. Grounds and procedure for revocation, suspension or denial of certificate of authority; administrative penalty generally; correction of deficiencies in net worth; proceedings upon suspension or revocation of certificate of authority; appeals.
(1) Any certificate of authority issued under this article may be suspended or revoked, and any application for a certificate of authority may be denied, if the commissioner after a hearing finds that any of the conditions listed below exist:
(a) The health maintenance organization is operating significantly in contravention of its basic organizational document or in a manner contrary to that described in any other information submitted under Section 83-41-305, unless amendments to the submissions have been filed with and approved by the commissioner;
(b) The health maintenance organization issues an evidence of coverage or uses a schedule of charges for health care services which do not comply with the requirements of Sections 83-41-315 and 83-41-331;
(c) The health maintenance organization does not provide or arrange for basic health care services;
(d) The State Health Officer certifies to the commissioner that:
(i) The health maintenance organization does not meet the requirements of Section 83-41-307(1)(b); or
(ii) The health maintenance organization is unable to fulfill its obligations to furnish health care services;
(e) The health maintenance organization operating in a "hazardous condition", and is no longer financially responsible and may reasonably be expected to be unable to meet its obligations to enrollees or prospective enrollees;
(f) The health maintenance organization has failed to correct, within the time prescribed by subsection (3), any deficiency occurring due to such health maintenance organization's prescribed minimum net worth being impaired;
(g) The health maintenance organization has failed to implement the grievance procedures required by Section 83-41-321 in a reasonable manner to resolve valid complaints;
(h) The health maintenance organization, or any person on its behalf, has advertised or merchandised its services in an untrue, misrepresentative, misleading, deceptive or unfair manner;
(i) The continued operation of the health maintenance organization would be hazardous to its enrollees; or
(j) The health maintenance organization has otherwise failed substantially to comply with this article.
(2) In addition to or in lieu of suspension or revocation of a certificate of authority pursuant to this section, the applicant or health maintenance organization may be subjected to an administrative penalty of up to One Thousand Dollars ($1,000.00) for each violation.
(3) The following shall pertain when insufficient net worth is maintained:
(a) Whenever the commissioner finds that the net worth maintained by any health maintenance organization subject to the provisions of this article is less than the minimum net worth required to be maintained by Section 83-41-325, he shall give written notice to the health maintenance organization of the amount of the deficiency and require: (i) filing with the commissioner a plan for correction of the deficiency acceptable to the commissioner and (ii) correction of the deficiency within a reasonable time, not to exceed sixty (60) days, unless an extension of time, not to exceed sixty (60) additional days, is granted by the commissioner. The deficiency shall be deemed an impairment, and failure to correct the impairment in the prescribed time shall be grounds for suspension or revocation of the certificate of authority or for placing the health maintenance organization in administrative supervision, rehabilitation or liquidation as per the insurance laws of this State.
(b) Unless allowed by the commissioner no health maintenance organization or person acting on its behalf may, directly or indirectly, renew, issue or deliver any certificate, agreement or contract of coverage in this state, for which a premium is charged or collected, when the health maintenance organization writing such coverage is impaired, and the fact of such impairment is known to the health maintenance organization or to such person.
However, the existence of an impairment shall not prevent the issuance or renewal of a certificate, agreement or contract when the enrollee exercises an option granted under the plan to obtain a new, renewed or converted coverage.
(4) A certificate of authority shall be suspended or revoked or an application or a certificate of authority denied or an administrative penalty imposed only after compliance with the requirements of this section.
(a) Suspension or revocation of a certificate of authority or the denial of an application or the imposition of an administrative penalty pursuant to this section shall be by written order and shall be sent to the health maintenance organization or applicant by certified or registered mail and to the State Health Officer. The written order shall state the grounds, charges or conduct on which suspension, revocation or denial or administrative penalty is based. The health maintenance organization or applicant may in writing request a hearing within twenty (20) days from the date of mailing of the order. The said request must be filed with the commissioner within the twenty (20) day period. If no written request is made, such order shall be final upon the expiration of said twenty (20) days.
(b) If the health maintenance organization or applicant requests a hearing pursuant to this section, the commissioner shall issue a written notice of hearing and send it to the health maintenance organization or applicant by certified or registered mail and to the State Health Officer stating:
(i) A specific time for the hearing, which may not be less than twenty (20) days after mailing of the notice of hearing; and
(ii) A specific place for the hearing which shall be at the discretion of the commissioner and which may be either in Jackson, Hinds County, Mississippi or in the county where the health maintenance organization's or applicant's principal place of business is located.
(iii) If a hearing is requested, the State Health Officer or his designated representative shall be in attendance and shall participate in the proceedings. The recommendations and findings of the State Health Officer with respect to matters relating to the quality of health care services provided in connection with any decision regarding denial, suspension or revocation of a certificate of authority, shall be conclusive and binding upon the commissioner.
After the hearing, or upon failure of the health maintenance organization to appear at the hearing, the commissioner shall take whatever action he deems necessary based on written findings and shall mail his decision to the health maintenance organization or applicant with a copy to the State Health Officer. The action of the commissioner and the recommendation and findings of the State Health Officer shall be subject to review under the Administrative Rules of Practice and Procedure Act.
(5) When the certificate of authority of a health maintenance organization is suspended, the health maintenance organization shall not, during the period of such suspension, enroll any additional enrollees except newborn children or other newly acquired dependents of existing enrollees, and shall not engage in any advertising or solicitation whatsoever.
(6) When the certificate of authority of a health maintenance organization is revoked, such organization shall proceed, immediately following the effective date of the order of revocation, to wind up its affairs, and shall conduct no further business except as may be essential to the orderly conclusion of the affairs of such organization under supervision of the commissioner. It shall engage in no further advertising or solicitation whatsoever. The commissioner may, by written order, permit such further operation of the organization as he may find to be in the best interest of enrollees, to the end that enrollees will be afforded the greatest practical opportunity to obtain continuing health care coverage.
(7) Any appeal from a decision of the commissioner under this section shall be to the Chancery Court of the First Judicial District of Hinds County, Mississippi within thirty days (30) from the final Order of the commissioner.
Sources: Laws, 1995, ch. 613, § 20, eff from and after July 1, 1995.