(a) The Insurance Commissioner may suspend or revoke any certificate of authority issued to a health maintenance organization under this chapter if the commissioner finds that any of the following conditions exist:
(1) The health maintenance organization is operating in contravention of its basic organizational document, its healthcare plan, or in a manner contrary to that described in and reasonably inferred from any other information submitted under § 23-76-107, unless amendments to the submissions have been filed with and approved by the commissioner;
(2) The health maintenance organization issues evidence of coverage or uses a schedule of charges for healthcare services which do not comply with the requirements of § 23-76-112;
(3) The healthcare plan does not provide or arrange for basic healthcare services;
(4) The health maintenance organization:
(A) Does not meet the requirements of § 23-76-108; or
(B) Is unable to fulfill its obligations to furnish healthcare services as required under its healthcare plan;
(5) The health maintenance organization is no longer financially responsible and may reasonably be expected to be unable to meet its obligations to enrollees or prospective enrollees;
(6) The health maintenance organization has failed to implement a mechanism affording the enrollees an opportunity to participate in matters of policy and operation under § 23-76-110;
(7) The health maintenance organization has failed to implement the complaint system required by § 23-76-116 in a manner to reasonably resolve valid complaints;
(8) 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;
(9) The continued operation of the health maintenance organization would be hazardous to its enrollees; or
(10) The health maintenance organization has otherwise failed to substantially comply with this chapter.
(b) A certificate of authority shall be suspended or revoked only after compliance with the requirements of § 23-76-126.
(c) When the certificate of authority of a health maintenance organization is suspended, during the period of the suspension the health maintenance organization shall not:
(1) Enroll any additional enrollees except newborn children or other newly acquired dependents of existing enrollees; and
(2) Engage in any advertising or solicitation whatsoever.
(d) (1) When the certificate of authority of a health maintenance organization is revoked, the health maintenance organization shall:
(A) Proceed to wind up its affairs immediately following the effective date of the order of revocation;
(B) Conduct no further business except as may be essential to the orderly conclusion of the affairs of the health maintenance organization; and
(C) Engage in no further advertising or solicitation whatsoever.
(2) By written order, the commissioner may permit the further operation of the health maintenance organization as the commissioner 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 healthcare coverage.
Section: Previous 23-76-116 23-76-117 23-76-118 23-76-119 23-76-120 23-76-121 23-76-122 23-76-123 23-76-124 23-76-125 23-76-126 23-76-127 23-76-128 23-76-129 23-76-130 NextLast modified: November 15, 2016