Current through Register No. 40, October 3, 2024
Ins
2201.04 Certificate of Authority.
(a) Any health maintenance organization
seeking to do insurance business in this state shall complete and submit an
original copy of the National Association of Insurance Commissioners (NAIC)
Uniform Certificate of Authority Application (UCAA) as a health maintenance
organization.
(b) The UCAA includes
3 applications, http://www.naic.org/industry_ucaa_corp_amend.html,
available as noted in Appendix B:
(1) The
Primary Application - UCAA Form 2P, revised 08/18/14, for use by newly formed
companies seeking a Certificate of Authority in their domicile state and by
companies wishing to re-domesticate to a uniform state;
(2) The Expansion Application - UCAA Form 2E,
revised 08/18/14, for use by companies in good standing in their state of
domicile that wish to expand their business into a uniform state; and
(3) The Corporate Amendments
Application - UCAA Form 2C, revised 12/19/14, for use by an existing company
for requesting amendments to its certificate of authority.
(c) The UCAA application shall be complete,
provided, however, that where a form mentions perjury, perjury shall mean any
applicable penalty found in RSA 641, falsification in official matters,
including
RSA 641:3,
unsworn falsification.
(d) The UCAA
application shall also include all required information and attachments, and
shall include the following state specific information and requirements:
(1) If the applicant is not domiciled in this
state, a power of attorney duly executed and appointing the commissioner and
his successors in office, and duly authorized deputies, as true and lawful
attorney for the applicant for service of process in this state pursuant to
RSA
420-B:4;
(2) Payment by check or other draft of
required application fees as set forth in
RSA
400-A:29;
(3) Basic organizational documents, articles
of incorporation, and all amendments thereto;
(4) Copies of all by-laws,
rules, and regulations of the applicant;
(5) Copies of the organizational chart of the
applicant, including the titles, names, and salaries, if any, of officers and
key management personnel dealing in marketing, administration, enrollment,
grievance procedures, quality assurance, contract negotiations, and financial
matters;
(6) A list of members of
the board of directors, or similar policymaking body of the applicant, with the
name, principal occupation, and employer of each;
(7) A description of the applicant's proposed
system for handling complaints that shall include procedures for the
registration of complaints and procedures for the resolution of
complaints;
(8) Financial reports
for the prior 3 fiscal years, with the qualification that financial reports
submitted by insurance companies or hospital, medical, or health service
corporations applying for a certificate of authority to operate a health
maintenance organization as a subsidiary or affiliate pursuant to
RSA
420-B:19 shall be restricted in subject
matter to the finances of such subsidiary or affiliate;
(9) Financial statements projecting the
results of the applicant's operations for the next 3 years from the date of
application, on a quarterly basis for years one and 2 and annually for year 3,
including the following:
a. Balance
sheet;
b. Statement of income from
all sources, and expenses;
c. Cash
flow;
d. Present and anticipated
capital expenditures;
e. Repayment
schedules for existing or anticipated loans or alternative financing
arrangements;
f. Statement
indicating when the applicant estimates that income from enrollments and other
operations will equal expenses; and
g. Detailed statements underlying assumptions
used and the basis thereof;
(10) A detailed statement of the health
maintenance organization's plan to establish and maintain reserves or other
funds necessary to cover any risks projected and not otherwise assumed by
another entity, carrier, or reinsurer;
(11) A detailed statement of current and
projected reserve-establishment calculations, as well as amounts, purpose and
uses of the reserves, and assumptions and bases therefor, including, but not
limited to, identification of reserves set aside to meet uncovered reinsurance
items;
(12) Copies of all
reinsurance, conversion, or other arrangements with other insurers, health
providers, medical service corporations, hospital service corporations, health
service corporations, governmental agencies or organizations, or other health
maintenance organizations that provide payment schedules for contracted-for
health care services, or made directly to provide services, in the event the
health maintenance organization is unable or ceases to provide contracted-for
health services for any reason;
(13) A copy of the applicant's official
notification of status as a federally qualified health maintenance
organization, if it is so designated;
(14) A statement of insurance or funded
self-insurance for:
a. Protection against loss
of property and liability of the applicant;
b. Workers' compensation to protect against
claims arising from work-related injuries of the applicant's employees;
and
c. Medical malpractice
liability insurance for the applicant and its providers;
(15) A listing of shareholders or other
equity holders, or members with holdings of 5 percent or more of capital
shares, partnership interest, or other evidence of equity holdings, listed by
name, address, number and percentage of shares or other interest held, and any
other affiliations with the applicant;
(16) A listing of the applicant's legal,
accounting, and actuarial representatives by name and address;
(17) A statement that fidelity bond coverage
exists for all officers and employees entrusted with the handling of funds for
the applicant;
(18) A statement of
enrollment practices and procedures;
(19) An enrollment projection of members per
month for the next 3 years from the date of application, on a quarterly basis
for years one and 2, and annually for year 3, including:
a. The current total enrollment of the
applicant;
b. The current
categories of membership of the applicant:
1.
Private;
2. Group;
3. Non-group;
4. Medicaid;
5. Medicare;
6. Federal employees;
7. State employees; and
c. A detailed statement of assumptions used,
and the basis therefor;
(20) A description of the geographical area
to be served, including:
a. Present
population figures for each city or town within the current area; and
b. Projections of future population trends
for each city and town within the current area for the next 5 years from the
date of application; and
(21) A statement certifying to the
commissioner that the health maintenance organization is in compliance with all
federal laws and regulations pertaining to health maintenance
organizations.
(e) The
application documents shall be compiled in the order in which they are
required.
(f) The applicant shall
state the reasons for the absences of any items required, but not included in
the application.
(g) In the event
that the commissioner finds the application incomplete, the commissioner shall
provide the applicant written notice specifying the additional documents or
information required under this part.
(h) The applicant shall have 30 days from
receipt of the notice in which to file the additional material required by (d)
above or the application shall be deemed rejected.
(i) Prior to the issuance of a certificate of
authority to operate a health maintenance organization, an applicant may:
(1) Engage in such activities as are
necessary to the gathering of information for applications for certification as
a federally qualified health maintenance organization, and for certification
pursuant to RSA 420-B and these parts;
(2) Make contact with potential enrolled
participants, employers, or both for the purposes of determining the
feasibility of establishing a health maintenance organization in a given area,
and for the purpose of generally acquainting the potential enrolled
participants, employers, or both with the general benefits of the applicant's
proposed program; and
(3) Engage in
the establishment of physical facilities for the operation of the health
maintenance organization.
(j) In no event, shall an applicant make a
commitment to render services or initiate a contract between the applicant and
enrolled participants, employers, or both until a certificate of authority has
been issued by the department.
(k)
The applicant company may continue to operate pursuant to
Ins
2201.04(i), above, until such time as
its application shall be denied.
(l) Before issuing a certificate of authority
to an applicant, the commissioner shall be satisfied, by examination and
evidence that the applicant has complied, and will continue to comply with the
requirements of RSA 420-B and this part.
(m) The commissioner shall act upon an
application for a certificate of authority within 90 days after the filing of a
completed application.
(n) The
commissioner shall notify the applicant, in writing, of the approval of the
application or its denial, and if the application is denied, the reasons
therefor.
(o) If the applicant
wishes a hearing before the commissioner concerning the denial of the
certificate of authority, it may make an application for such hearing pursuant
to
RSA 400-A:17 and the
hearing shall be conducted in accordance with the provisions of RSA 400-A and
Ins 200.
(p) Each certificate of
authority issued under this part shall be renewed pursuant to
RSA
420-B:5-a unless revoked or suspended by the
commissioner, provided that the health maintenance organization commences
operations within one year after the date on which the certificate of authority
was issued.
(q) Failure to commence
operations within the period in (p) above shall invalidate the certificate of
authority and a new application shall be submitted before another certificate
of authority will be issued.
(r)
Grounds for revocation or suspension of certificate of authority shall include:
(1) An unsound financial condition;
(2) Business policies or methods are unsound
or improper;
(3) Management
conditions that render the further transaction of business hazardous to the
public or to its members;
(4) The
committing of acts prohibited by
RSA
420-B:12; and
(5) Officers or agents that have refused to
submit to an examination as provided for in
RSA
420-B:10.
(s) Any denial or approval of the application
shall be public, however, all documents and workpapers submitted or used in the
course of analysis by the department of the financial condition of the
applicant shall be confidential in accordance with
RSA 400-A:37 and not
subject to disclosure under RSA 91-A. Any other information submitted as part
of the UCAA application by the health maintenance organization that is
confidential commercial information, proprietary information, information
protected as a trade secret, information that is confidential by law, or
information that, if disclosed, would constitute an invasion of privacy shall
be marked by the health maintenance organization as confidential and shall not
be subject to disclosure under RSA 91-A.
#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5655,
eff 7-1-93; ss by #7018, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
New. #9335, eff
12-5-08
