(1) Each
cooperative organized pursuant to this part 10 shall:
(a) Establish the conditions of cooperative membership;
(b) Provide to cooperative members and their eligible employees clear,
standardized information about each provider network, licensed provider network,
carrier, or other provider contracted with by the cooperative, including, but not
limited to, information on price, benefits, costs, quality, patient satisfaction,
membership, and responsibilities and obligations;
(c) Offer dependent coverage;
(d) Repealed.
(e) Obtain the necessary contact information and resources to provide to
members and their eligible employees the information described in paragraph (b) of
this subsection (1);
(f) Contract only for insurance functions listed in section 10-3-903, with
entities authorized to do business in this state by the commissioner pursuant to this
title that have:
(I) The capacity to administer the health benefit plan or services to be
offered;
(II) The ability to monitor and evaluate the quality and cost-effectiveness of
care and applicable procedures;
(III) The ability to report quality and outcomes information necessary for the
cooperative to report quality information to members and their eligible employees;
and
(IV) The ability to assure members and their eligible employees adequate
access to health-care providers, including an adequate number and type of
providers for the risk pool involved;
(g) Develop and implement a marketing plan that will widely publicize the
cooperative to potential members and their eligible employees and develop and
implement methods for informing the public about the cooperative and its services;
(h) State clearly all administrative and broker or agent fees associated with
membership in all materials published for the purpose of soliciting members and
their eligible employees or that may be used by potential members in deciding
whether to join the cooperative;
(i) Establish administrative and accounting procedures for the operation of
the cooperative and members' services, prepare an annual cooperative budget, and
prepare annual program and fiscal reports on cooperative operations;
(j) Maintain all records, reports, and other information of the cooperative;
(k) Maintain a trust account or accounts for the deposit of premium moneys
collected pursuant to subsection (3)(e) of this section, to be paid to carriers or
licensed provider networks or licensed individual providers for coverage offered
through the cooperative. A cooperative shall have a fiduciary duty with respect to
premium moneys collected for carriers and licensed provider networks offered
through the cooperative.
(l) Annually report on operations of the cooperative, including program and
financial operations, and provide for internal and independent audits;
(m) Disclose to members and potential members whether or not the
cooperative has been granted a temporary certificate of authority pursuant to
section 10-16-1005 (1)(b);
(n) Offer the same premiums and any negotiated health-care prices to all
member classes, if any, equally; except that a cooperative may offer different
premiums or negotiated health-care prices to members who are not small
employers;
(o) Consider all individuals in all individual health benefit plans offered
through the cooperative, including those individuals who do not enroll in the plans
through the exchange, to be members of a single risk pool;
(p) Consider all covered persons in small employer health benefit plans
offered through the cooperative, including those covered persons who do not enroll
in plans through the exchange, to be members of a single risk pool.
(2) A self-insured employer may join a cooperative in order to have access to
the discounted provider rates that the cooperative may negotiate on behalf of its
self-insured members.
(3) Each cooperative organized pursuant to this part 10 may:
(a) Repealed.
(b) Set reasonable fees for membership in the cooperative that will finance
all reasonable and necessary costs incurred in administering the cooperative;
(c) and (d) Repealed.
(e) Subject to paragraph (l) of subsection (1) of this section, provide premium
collection services for plans and licensed provider networks or licensed individual
providers offered through the cooperative;
(f) Reject, or allow a carrier to reject, an employer from membership or drop,
or allow a carrier to drop, an employer from membership if the employer or any of
its employee members fails to pay premiums or engages in fraud or material
misrepresentation in connection with a plan purchased through the cooperative. If
an employee is dropped from membership due to the employer's failure to pay
premiums or engagement in fraud or material misrepresentation, the cooperative
may offer a special enrollment period in accordance with section 10-16-105.7 (3) to
allow the employee to enroll in the individual member class, if available.
(g) Contract with qualified independent third parties for any service
necessary to carry out the powers and duties authorized or required by this part 10;
(h) Contract with licensed insurance agents or brokers to market coverage
made available through the cooperative to its members. A cooperative shall use a
uniform fee schedule for all agents and brokers. Such fee schedule shall not vary
based on the actual or expected health status or medical utilization of the group to
which coverage is sold.
(i) Exclude any carrier, provider network, or provider or freeze enrollment in
any carrier, provider network, or provider for failure to achieve established quality,
access, or information reporting standards of the cooperative;
(j) Prohibit members who drop coverage through the cooperative from
reenrolling for up to twelve months in coverage purchased through the cooperative;
(k) Repealed.
(l) Offer coverage for individuals who are members;
(m) Establish employer contribution requirements. Such requirements may
differ by benefit plan, benefit package, or carrier.
(4) No cooperative organized pursuant to this part 10 may:
(a) Exclude from membership in the cooperative any prospective members,
or dependents of prospective members, who agree to pay fees for membership and
any premium for coverage through the cooperative and who abide by the bylaws
and rules of the cooperative and satisfy the requirements of the benefit plan
selected;
(b) Differentiate classes of membership on the basis of industry type, race,
religion, gender, education, health status, or income;
(c) Commit any act constituting a rebate prohibited by section 10-3-1104
(1)(g). The commissioner shall enforce this paragraph (c) pursuant to part 11 of
article 3 of this title.
(d) Prohibit any hospital, health maintenance organization, or other provider,
as a condition of contracting to provide services through the cooperative, from
providing services through a subcontract or subcontracts with any other hospital,
health maintenance organization, or other provider meeting the cooperative's
quality standards;
(e) Charge any fee not directly related to health care or the administration of
health-care purchasing functions;
(f) As a condition of membership, require any member, eligible employee, or
dependent to subscribe to non-health-care-related products or services;
(g) Knowingly operate the cooperative or market the cooperative in a county
or primary metropolitan statistical area in a way that would cause the cooperative
to select a risk pool with actuarially projected health-care utilization over a two-year period that is below the projected average for all individuals residing in that
county or primary metropolitan statistical area. Such measurement and comparison
of projected utilization by members of the cooperative to all individuals shall be
done on a county or primary metropolitan statistical area basis and not across all
members of the cooperative.
(h) Knowingly authorize or select any carrier, provider, licensed provider
network, licensed individual provider, or individual provider that does not comply
with or conform to the applicable requirements or standards of this title.