Alabama Administrative Code
Title 420 - ALABAMA STATE BOARD OF HEALTH
Chapter 420-5-6 - HEALTH MAINTENANCE ORGANIZATIONS
Section 420-5-6-.02 - Content Of Application For Certificate Of Authority
Universal Citation: AL Admin Code R 420-5-6-.02
Current through Register Vol. 42, No. 11, August 30, 2024
(1) Each application for a certificate of authority under Code of Ala. 1975, §§ 27-21A-1, et seq., shall be made to the Commissioner of the Department of Insurance and to the State Health Officer. "Certificate of Authority" means the document issued by the State Insurance Commissioner permitting a person to establish, maintain and operate a health maintenance organization. The application specific to the Alabama Department of Public Health shall contain the following:
(a) Copies of the basic organizational
documents such as the certificate of incorporation, bylaws, rules, articles of
association, partnership agreement, trust agreement or other applicable
documents and agreements regulating the conduct of the internal affairs of the
applicant and all amendments thereto;
(b) A list and organization chart of the
names and addresses and official positions of the members of the board of
directors, officers, controlling persons, owners, or partners, the medical
director and the administrator of the proposed health maintenance organization
and any other persons responsible for the health services system of the health
maintenance organization;
(c) A
resume of the medical director, administrator and all department managers;
1. "Administrator" means a person who
demonstrates competence and experience in health maintenance organization
management; who is assigned the responsibility for the interpretation,
implementation, and proper application of policies and programs established by
the governing body; is assigned responsibility for the establishment and
maintenance of effective management, control, and operation of the services
provided; and, is responsible for coordination of activities and communication
between the Department, the governing body, and the health delivery systems.
The administrator shall be available and accessible to the Department. In the
absence of the administrator, an individual shall be designated, in writing,
who shall be authorized to act on the administrator's behalf.
2. "Medical Director" means a physician who
oversees medical aspects of the plan, supervises the quality improvement and
utilization management programs and advises the governing body on the adoption
and enforcement of policies concerning medical services. A medical director
must have a current license to practice medicine granted by the Medical
Licensure Commission of Alabama. Alternately, an HMO may employ, for no longer
than 12 months, an individual as medical director provided that the individual
is eligible in all respects for licensure as an Alabama physician and the
individual has a current active application for licensure on file with the
Medical Licensure Commission of Alabama.
(d) A detailed description of the proposed
health maintenance organization's potential ability to assure both the
availability and accessibility of adequate personnel and facilities to serve
enrollees in a manner enhancing availability, accessibility, and
continuity;
(e) A description of
the service area of the proposed health maintenance organization (geographic
boundaries, demographic data, and identification of population groups of
enrollees);
(f) Information
regarding proposed practice site locations and hours of operation;
(g) A list of proposed providers with
physical address and phone number;
(h) A copy of the applicant's proposed
contracts and marketing documents with enrollees and group contracts with
employers, unions, trustees, or other organizations, setting forth the
corporation's contractual obligation to provide a minimum of basic health
services;
(i) Applicant's provider
contracts with physicians, groups of physicians organized on a group practice
or individual practice basis, hospitals, and other providers of health care
services enabling it to provide basic and frequently utilized specialty health
services to an enrolled population;
(j) A detailed description of the applicant's
proposed complaint system whereby the complaints of the enrollees may be acted
upon promptly and satisfactorily;
(k) A detailed description of the applicant's
arrangements for ongoing quality-of-health-care assurance program;
(l) A detailed description of the applicant's
capability to collect and analyze necessary data relating to the utilization of
health care services;
(m) Job
descriptions of the medical director, administrator and department
managers;
(n) A procedure for
referral of enrollees to nonparticipating specialists;
(o) A copy of written procedures for
provision and payment of emergency services;
(p) A copy of the written procedures
regarding the method for providing frequently utilized services required by
420-5-6-.06(11);
(q) An organizational chart demonstrating the
delegation of authority and control of the health services delivery system,
from the highest authority (governing body) to the physician, with support
documentation demonstrating that all personnel at each level of authority have
the requisite expertise for their particular area of authority.
(r) A detailed description of how medical
records will be maintained;
(s)
Evidence that the proposed health maintenance organization has complied with
Alabama Health Planning Laws, §§
22-21-260
et
seq.;
(t) Any other pertinent information;
and
(u) A health maintenance
organization shall not materially alter, amend, modify, suspend, or delete any
of the provisions of any document submitted in connection with an application
for a Certificate of Authority unless in accordance with Code of
Ala. 1975, §
27-21A-2(d)(1).
The State Health Officer will forward in a timely manner a recommendation to
the Commissioner of Insurance that the requested alteration, modification,
amendment, suspension, addition or deletion be approved or disapproved in
accordance with Code of Ala. 1975, §
27-21A-17(a)(1).
Author: Department of Public Health
Statutory Authority: Code of Ala. 1975, §§ 22-2-2(6), et seq., 22-21-20, et seq., 27-21A-1, et seq.
Disclaimer: These regulations may not be the most recent version. Alabama may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
This site is protected by reCAPTCHA and the Google
Privacy Policy and
Terms of Service apply.
