Current through Register Vol. 56, No. 18, September 16, 2024
(a) After
issuance of a certificate of authority, the HMO shall undergo a comprehensive
assessment review by the Department on a triennial basis.
(b) The comprehensive assessment review
conducted by the Department may include an on-site review and shall be based
upon the Department's review of the following:
1. A filing of information by the HMO of any
substantial change to operations identified in
11:24-2.7 not previously filed
with the Department. This filing shall not require the submission of any
documents previously filed with the Department, if such documents have remained
valid and unchanged since their original filing;
2. The results of the HMO's external quality
audit, as required at
11:24-7.2;
3. A statement from the HMO attesting that it
or any affiliate certified or licensed as an HMO or health insuror has been in
substantial compliance with all applicable state and Federal rules and/or
regulations for the last 12 months in any other state in which it has been
approved to do business; and
4. All
network adequacy, utilization management, continuous quality improvement,
performance and outcome measurements or other data or information provided for
in this chapter.
(c) The
comprehensive assessment review required at (b) above shall be conducted by the
Department in accordance with the following schedule:
1. For HMOs with a valid certificate of
authority issued between January 1, 1973 and December 31, 1985, the first
review shall be conducted in the year beginning January 1, 1997, no more than
180 days and no less than 90 days prior to the anniversary date of original
issuance;
2. For HMOs with a valid
certificate of authority issued between January 1, 1986 and December 31, 1994,
the first review shall be conducted in the year beginning January 1, 1998, no
more than 180 days and no less than 90 days prior to the anniversary date of
original issuance;
3. For HMOs with
a valid certificate of authority issued between January 1, 1995 and July 1,
1997, the first review shall be conducted in the year beginning January 1,
1999, no more than 180 days and no less than 90 days prior to the anniversary
date of original issuance; and
4.
For HMOs with a valid certificate of authority issued after July 1, 1997,
reviews shall be conducted every third year, no more than 180 days and no less
than 90 days prior to the anniversary date of issuance.
(d) An HMO that does not demonstrate
compliance with the requirements of this chapter based on the Department's
findings resulting from the comprehensive assessment review may be subject to
enforcement actions pursuant to
11:24-2.1 4. Notice of violations
shall be provided, pursuant to
11:24-2.1 3 to the HMO. The
Department may also issue a narrative assessment of HMO performance based upon
the comprehensive assessment review and require a corrective action plan from
the HMO. This report shall become public information in the manner specified in
11:24-2.1 3(d).
