(2) file with the department a copy of the
form of the written contract with an ANHC or provider HMO, in accordance with
§
11.301(5) of
this title (relating to Filing Requirements), that:
(A) requires that the ANHC or provider HMO
cannot terminate the contract without 90-days written notice;
(B) contains a hold-harmless provision that
prohibits the ANHC or provider HMO and its contracted physicians and providers
from billing for or attempting to collect from HMO members, except for
authorized copayments and deductibles, charges for covered services under any
circumstance, including the insolvency of the primary HMO, ANHC, or provider
HMO;
(C) contains a provision
stating that nothing in the contract will be construed to in any way limit the
HMO's authority or responsibility to comply with all of the department's
regulatory requirements;
(D)
includes the ANHC's or provider HMO's acknowledgment and agreement that:
(i) the primary HMO is required to establish,
operate, and maintain a health care delivery system, quality assurance system,
physician and provider credentialing system, and other systems and programs
meeting department standards and is directly accountable for compliance with
the standards;
(ii) the role of the
ANHC or provider HMO in contracting with the primary HMO is limited to
implementing certain systems of the primary HMO, utilizing standards approved
by the primary HMO, and subject to the primary HMO's oversight and monitoring
of the ANHC's or provider HMO's performance; and
(iii) the primary HMO may take necessary
action to ensure that all HMO systems and functions that are delegated or
assigned under the contract with the ANHC or provider HMO are in full
compliance with all department regulatory requirements;
(E) requires the ANHC to make available to
the primary HMO the ANHC's contracts with physicians and providers to ensure
compliance with contractual requirements set out in subparagraphs (B) and (C)
of this paragraph;
(F) requires the
ANHC to provide the primary HMO with evidence of both financial solvency and
financial ability to perform, such as a certified financial audit of the ANHC
conducted by an independent certified public accountant, using generally
accepted accounting and auditing principles; and
(G) requires the ANHC or provider HMO to
provide the primary HMO, on at least a monthly basis and in a usable form
necessary for audit purposes, the data necessary for the HMO to comply with
department reporting requirements with respect to any services provided under
the HMO-ANHC or HMO-provider HMO agreement, including the following data:
(i) number of primary HMO enrollees served or
assigned to the ANHC or primary HMO to receive services, including the number
added and terminated since the last reporting period;
(ii) form of the contracts and subcontracts
between the ANHC and physicians and providers who will be providing services to
enrollees of the primary HMO and any material changes to the contracts and
subcontracts;
(iii) copayments
received by the ANHC or provider HMO;
(iv) summary of the amounts paid by the ANHC
or provider HMO to physicians and providers;
(v) methods by which physicians and providers
were paid by the ANHC or provider HMO, for example, capitation,
fee-for-services, or other risk-sharing arrangements;
(vii) summary of the amounts paid by the ANHC
or provider HMO for administrative services relating to the primary
HMOs;
(viii) the time that claims
and debts related to claims owed by the ANHC or provider HMO have been
pending;
(ix) information required
for the primary HMO to be able to file claims for reinsurance, coordination of
benefits, and subrogation;
(x)
physician and provider and enrollee satisfaction data;
(xii) documentation of any inquiry or
investigation of the ANHC or provider HMO, or any individual subcontracting
physician or provider, made by regulatory agencies, and documentation of the
final resolution of the inquiry or investigation; and
(xiii) any other data necessary to ensure
proper monitoring and control of the primary HMO delivery network by the
primary HMO;
