(1)(a) Repealed.
(b)The commissioner shall determine whether the applicant for a certificate
of authority, with respect to health-care services to be furnished:
(I)Has demonstrated the willingness and potential ability to assure that such
health-care services will be provided in a manner to assure both availability and
accessibility of adequate personnel and facilities and in a manner enhancing
availability, accessibility, and continuity of service;
(II)Has arrangements, established in accordance with regulations
promulgated by the commissioner, for an ongoing quality of health care assurance
program concerning health-care processes and outcomes; and
(III)Has a procedure, established in accordance with regulations of the
commissioner, to develop, compile, evaluate, and repo
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(1) (a) Repealed.
(b) The commissioner shall determine whether the applicant for a certificate
of authority, with respect to health-care services to be furnished:
(I) Has demonstrated the willingness and potential ability to assure that such
health-care services will be provided in a manner to assure both availability and
accessibility of adequate personnel and facilities and in a manner enhancing
availability, accessibility, and continuity of service;
(II) Has arrangements, established in accordance with regulations
promulgated by the commissioner, for an ongoing quality of health care assurance
program concerning health-care processes and outcomes; and
(III) Has a procedure, established in accordance with regulations of the
commissioner, to develop, compile, evaluate, and report statistics relating to the
cost of its operations, the pattern of utilization of its services, the availability and
accessibility of its services, and such other matters as may be reasonably required
by the commissioner.
(c) Repealed.
(2) The commissioner shall issue a certificate of authority upon payment of
the application fee prescribed in section 10-16-110 (2) if the commissioner is
satisfied that the following conditions are met:
(a) The persons responsible for the conduct of the affairs of the applicant
are competent, trustworthy, and possess good reputations;
(b) The commissioner determines in accordance with subsection (1) of this
section that the health maintenance organization's proposed plan of operation
meets the requirements of subsection (1)(b) of this section;
(c) (I) The health maintenance organization will effectively provide or arrange
for the provision of basic health-care services, through insurance or otherwise,
except to the extent of reasonable requirements for copayments, deductibles, and
payments for out-of-network services received pursuant to section 10-16-704 (2).
(II) Nothing in this paragraph (c) shall prohibit a carrier from offering to a
small employer additional options of a health benefit plan that:
(A) Provides for different benefits for insureds and dependents of insureds
covered by the same policy; and
(B) Encourages appropriate health-care condition management based on
clinical guidelines by providing case management benefits to covered persons.
(d) The health maintenance organization is financially responsible and may
reasonably be expected to meet its obligations to enrollees and prospective
enrollees. In making this determination, the commissioner may consider:
(I) The financial soundness of the health-care plan's arrangements for
health-care services and the schedule of charges used in connection therewith;
(II) The adequacy of working capital;
(III) Any agreement with an insurer, a nonprofit hospital, medical-surgical,
and health service corporation, a government, or any other organization for insuring
the payment of the cost of health-care services or the provision for automatic
applicability of an alternative coverage in the event of discontinuance of the plan;
(IV) Any agreement with providers for the provision of health-care services;
(V) Any surety bond or deposit of cash or securities submitted in accordance
with section 10-16-412 as a guarantee that the obligations will be duly performed.
(e) The enrollees will be afforded an opportunity to participate in matters of
policy and operation pursuant to section 10-16-404;
(f) Nothing in the proposed method of operation, as shown by the information
submitted pursuant to section 10-16-401 or by independent investigation, is
contrary to the public interest;
(g) Any deficiencies certified by the commissioner have been corrected.
(3) A certificate of authority shall be denied only after compliance with the
requirements of section 10-16-419.
(4) A certificate of authority shall expire on the last day of June in each year
and shall be renewed annually if the company has continued to comply with the
laws of this state.