32.1-137.2 - Certification of quality assurance; application; issuance; denial; renewal.
§ 32.1-137.2. Certification of quality assurance; application; issuance;denial; renewal.
A. Every managed care health insurance plan licensee shall request acertificate of quality assurance with reference to its managed care healthinsurance plans simultaneously with filing an initial application to theBureau of Insurance for licensure. If already licensed by the Bureau ofInsurance, every managed care health insurance plan licensee may file anapplication for quality assurance certification with the Department of Healthby December 1, 1998, and shall file an application for quality assurancecertification with the Department of Health by December 1, 1999, in order toobtain its certificate of quality assurance by July 1, 2000.
On or before July 1, 2000, the State Health Commissioner shall certify to theBureau of Insurance that a managed care health insurance plan licensee hasbeen issued a certificate of quality assurance by providing the Bureau ofInsurance with a copy of each certificate at the time of issuance.
Application for a certificate of quality assurance shall be made on a formprescribed by the Board and shall be accompanied by a fee based upon apercentage, not to exceed one-tenth of one percent, of the proportion ofdirect gross premium income on business done in this Commonwealthattributable to the operation of managed care health insurance plans in thepreceding biennium, sufficient to cover reasonable costs for theadministration of the quality assurance program. Such fee shall not exceed$10,000 per licensee. Whenever the account of the program shows expenses forthe past biennium to be more than ten percent greater or lesser than thefunds collected, the Board shall revise the fees levied by it forcertification so that the fees are sufficient, but not excessive, to coverexpenses; provided that such fees shall not exceed the limits set forth inthis section.
All applications, including those for renewal, shall require (i) adescription of the geographic area to be served, with a map clearlydelineating the boundaries of the service area or areas, (ii) a descriptionof the complaint system required under § 32.1-137.6, (iii) a description ofthe procedures and programs established by the licensee to assure bothavailability and accessibility of adequate personnel and facilities and toassess the quality of health care services provided, and (iv) a list of thelicensee's managed care health insurance plans.
B. Every managed care health insurance plan licensee certified under thisarticle shall renew its certificate of quality assurance with theCommissioner biennially by July 1, subject to payment of the fee.
C. The Commissioner shall periodically examine or review each applicant forcertificate of quality assurance or for renewal thereof.
No certificate of quality assurance may be issued or renewed unless a managedcare health insurance plan licensee has filed a completed application andmade payment of a fee pursuant to subsection A of this section and theCommissioner is satisfied, based upon his examination, that, to the extentappropriate for the type of managed care health insurance plan underexamination, the managed care health insurance plan licensee has in place andcomplies with: (i) a complaint system for reasonable and adequate proceduresfor the timely resolution of written complaints pursuant to § 32.1-137.6;(ii) a reasonable and adequate system for assessing the satisfaction of itscovered persons; (iii) a system to provide for reasonable and adequateavailability of and accessibility to health care services for its coveredpersons; (iv) reasonable and adequate policies and procedures to encouragethe appropriate provision and use of preventive services for its coveredpersons; (v) reasonable and adequate standards and procedures forcredentialing and recredentialing the providers with whom it contracts; (vi)reasonable and adequate procedures to inform its covered persons andproviders of the managed care health insurance plan licensee's policies andprocedures; (vii) reasonable and adequate systems to assess, measure, andimprove the health status of covered persons, including outcome measures,(viii) reasonable and adequate policies and procedures to ensureconfidentiality of medical records and patient information to permiteffective and confidential patient care and quality review; (ix) reasonable,timely and adequate requirements and standards pursuant to § 32.1-137.9; and(x) such other requirements as the Board may establish by regulationconsistent with this article.
Upon the issuance or reissuance of a certificate, the Commissioner shallprovide a copy of such certificate to the Bureau of Insurance.
D. Upon determining to deny a certificate, the Commissioner shall notify suchapplicant in writing stating the reasons for the denial of a certificate. Acopy of such notification of denial shall be provided to the Bureau ofInsurance. Appeals from a notification of denial shall be brought by acertificate applicant pursuant to the process set forth in § 32.1-137.5.
E. The State Corporation Commission shall give notice to the Commissioner ofits intention to issue an order based upon a finding of insolvency, hazardousfinancial condition, or impairment of net worth or surplus to policyholdersor an order suspending or revoking the license of a managed care healthinsurance plan licensee; and the Commissioner shall notify the Bureau ofInsurance when he has reasonable cause to believe that a recommendation forthe suspension or revocation of a certificate of quality assurance or thedenial or nonrenewal of such a certificate may be made pursuant to thisarticle. Such notifications shall be privileged and confidential and shallnot be subject to subpoena.
F. No certificate of quality assurance issued pursuant to this article may betransferred or assigned without approval of the Commissioner.
(1998, c. 891.)