Title 33, Chapter 21, Section 5
( 33-21-5)
(a) The Commissioner of Insurance may suspend or revoke any
certificate of authority issued to a health maintenance organization
under this chapter if he finds that any of the following conditions
exist: (1) The health maintenance organization is operating significantly in contravention of its basic organizational document, its health benefits plan, or in a manner contrary to that described in and reasonably inferred from any other information submitted under Code Section 33-21-2, unless amendments to the submissions have been filed with and approved by the Commissioner of Insurance; (2) The health maintenance organization issues evidence of coverage or uses a schedule of charges for health care services which do not comply with the requirements of Code Section 33-21-13; (3) The health benefits plan does not provide or arrange for basic
health care services; (4) The commissioner of human resources certifies to the
Commissioner of Insurance that: (A) The health maintenance organization does not meet the requirements of subsection (b) of Code Section 33-21-3; or (B) The health maintenance organization is unable to fulfill its
obligations to furnish health care services as required under
its health benefits 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 Code Section 33-21-6; (7) The health maintenance organization has failed to implement the complaint system required by Code Section 33-21-9 in a manner to resolve valid complaints reasonably; (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 violated any
provision of this chapter or of the rules and regulations of the
Commissioner of Insurance or of the rules and regulations of the
commissioner of human resources. (b) The Commissioner of Insurance may, without advance notice or a
hearing thereon, suspend immediately the certificate of authority of
any health maintenance organization as to which proceedings for
receivership, conservatorship, rehabilitation, or other delinquency
proceedings have been commenced in any state. (c) When the certificate of authority of a health maintenance
organization is suspended, the health maintenance organization shall
not, during the period of the suspension, enroll any additional
enrollees except newborn children or other newly acquired dependents
of existing enrollees and shall not engage in any advertising or
solicitation whatsoever. (d) When the certificate of authority of a health maintenance
organization is revoked, such organization shall proceed,
immediately following the effective date of the order of revocation,
to wind up its affairs and shall conduct no further business except
as may be essential to the orderly conclusion of the affairs of such
organization. It shall engage in no further advertising or
solicitation whatsoever. The Commissioner of Insurance may, by
written order, permit such further operation of the organization as
he 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 health care coverage. |