§ 26.1-18.1-02 — Establishment of health maintenance organizations

North Dakota § 26.1-18.1-02

• Jurisdiction: North Dakota
• Title 26.1: Insurance
• Ch. 26.1-18.1: Health Maintenance Organizations

Text

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 chapter. No person may establish or
operate a health maintenance organization in this state without obtaining a certificate
of authority under this chapter. A foreign corporation may qualify under this chapter,
subject to obtaining a certificate of authority as a foreign corporation under section
10-19.1-136 and compliance with all provisions of this chapter and other applicable
state laws.
2. Any health maintenance organization that has not previously received a certificate of
authority to operate as a health maintenance organization as of August 1, 1993, shall
submit an application for a certificate of authority under subsection 3 within thirty days
of August 1, 1993. Each applicant may continue to operate until the commissioner acts
upon the application. In the event that an application is denied under section
26.1-18.1-03, the applicant must thereafter be treated as a health maintenance
organization whose certificate of authority has been revoked.
3. Each application for a certificate of authority must be verified by an officer or
authorized representative of the applicant, must be in a form prescribed by the
commissioner, and must 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 subdivision 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, including both a copy of the applicant's most recent and regular
certified financial statement and an unaudited current financial statement.
h. A financial feasibility plan that 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 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 the commissioner's 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 re-evaluation 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 26.1-18.1-12.
n. A list of the names, addresses, and license numbers of all providers with which
the health maintenance organization has agreements.
o. Such other information as the commissioner may require to make the
determinations required in section 26.1-18.1-03.
4. a. The commissioner may adopt rules as the commissioner deems necessary to the
proper administration of this chapter to require a health maintenance
organization, subsequent to receiving its certificate of authority, to submit the
information, modifications, or amendments to the items described in subsection 3
to the commissioner, either for the commissioner's 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 the
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 is deemed approved unless disapproved within thirty days, provided that
the commissioner may postpone the action for such further time, not exceeding
an additional thirty days, as necessary for proper consideration.