§ 36-6913. Minimum net worth required - Deposit with Insurance Commissioner - Determination of liabilities - Liability of subscriber for health maintenance organization's debts - Insolvency plan - Notice of termination of agreement.

A.  1.  Before issuing any certificate of authority, the Insurance Commissioner shall require that the health maintenance organization have an initial net worth of One Million Five Hundred Thousand Dollars ($1,500,000.00) and that the HMO shall thereafter maintain the minimum net worth required under paragraph 2 of this subsection.

2.  Except as provided in paragraphs 3 and 4 of this subsection, every health maintenance organization shall maintain a minimum net worth equal to the greater of:

a.One Million Five Hundred Thousand Dollars ($1,500,000.00),

b.two percent (2%) of annual premium revenues as reported on the most recent annual financial statement filed with the Insurance Commissioner on the first One Hundred Fifty Million Dollars ($150,000,000.00) of premium and one percent (1%) of annual premium on the premium in excess of One Hundred Fifty Million Dollars ($150,000,000.00),

c.an amount equal to the sum of three (3) months of uncovered health care expenditures as reported on the most recent financial statement filed with the Insurance Commissioner, or

d.an amount equal to the sum of:

(1)eight percent (8%) of annual health care expenditures, except those paid on a capitated basis or managed hospital payment basis, as reported on the most recent financial statement filed with the Insurance Commissioner, and

(2)four percent (4%) of annual hospital expenditures paid on a managed hospital payment basis, as reported on the most recent financial statement filed with the Insurance Commissioner.

3.  Every health maintenance organization licensed before the effective date of this act shall maintain a minimum net worth of the greater of Seven Hundred Fifty Thousand Dollars ($750,000.00) or:

a.twenty-five percent (25%) of the amount required by paragraph 2 of this subsection by December 31, 2003,

b.fifty percent (50%) of the amount required by paragraph 2 of this subsection by December 31, 2004,

c.seventy-five percent (75%) of the amount required by paragraph 2 of this subsection by December 31, 2005, and

d.one hundred percent (100%) of the amount required by paragraph 2 of this subsection by December 31, 2006.

4.a.              In determining net worth, no debt shall be considered fully subordinated unless the subordination clause is in a form acceptable to the Insurance Commissioner.  An interest obligation relating to the repayment of any subordinated debt shall be similarly subordinated.

b.The interest expenses relating to the repayment of a fully subordinated debt shall be considered covered expenses.

c.A debt incurred by a note meeting the requirements of this section, and otherwise acceptable to the Insurance Commissioner, shall not be considered a liability and shall be recorded as equity.

B.  1.  Unless otherwise provided below, each health maintenance organization shall deposit with the Insurance Commissioner or, at the discretion of the Insurance Commissioner, with any organization or trustee acceptable to the Insurance Commissioner through which a custodial or controlled account is utilized, cash, securities, or any combination of these or other measures that are acceptable to the Insurance Commissioner, which at all times shall have a value of not less than Five Hundred Thousand Dollars ($500,000.00).

2.  The deposit shall be an admitted asset of the health maintenance organization in the determination of net worth.

3.  All income from deposits shall be an asset of the organization.  A health maintenance organization that has made a securities deposit may withdraw that deposit or any part thereof after making a substitute deposit of cash, securities, or any combination of these or other measures of equal amount and value.  Any securities shall be approved by the Insurance Commissioner before being deposited or substituted.

4.  The deposit shall be used to protect the interests of the health maintenance organization’s enrollees and to ensure continuation of health care services to enrollees of a health maintenance organization that is in rehabilitation or conservation.  The Insurance Commissioner may use the deposit for administrative costs directly attributable to a receivership or liquidation.  If a health maintenance organization is placed in receivership or liquidation, the deposit shall be an asset subject to the provisions of the Uniform Insurers Liquidation Act.

5.  The Insurance Commissioner may reduce or eliminate the deposit requirement if a health maintenance organization deposits with the State Treasurer, Insurance Commissioner, or other official body of the state or jurisdiction of domicile for the protection of all subscribers and enrollees of the health maintenance organization, wherever located, cash, acceptable securities or surety, and delivers to the Insurance Commissioner a certificate to that effect, duly authenticated by the appropriate state official holding the deposit.

C.  1.  Every health maintenance organization shall, when determining liabilities, include an amount estimated in the aggregate to provide for:

a.              any unearned premium,

b.              the payment of all claims for incurred health care expenditures, whether reported or unreported, that are unpaid and for which the organization is or may be liable, and

c.              the expense of adjustment or settlement of those claims.

2.  The liabilities shall be computed in accordance with rules promulgated by the Insurance Commissioner upon reasonable consideration of the ascertained experience and character of the health maintenance organization.

D.  1.  Every contract between a health maintenance organization and a participating provider of health care services shall be in writing and shall provide that, in the event the health maintenance organization fails to pay for health care services as set forth in the contract, a subscriber or an enrollee shall not be liable to the provider for any sums owed by the health maintenance organization.

2.  In the event that the participating provider contract has not been reduced to writing as required by this subsection or that the contract fails to contain the required prohibition, the participating provider shall not collect or attempt to collect from a subscriber or an enrollee sums owed by the health maintenance organization.

3.  No participating provider or the provider’s agent, trustee or assignee may maintain an action at law against a subscriber or enrollee to collect sums owed by the health maintenance organization.

E.  The Insurance Commissioner shall require that each health maintenance organization have a plan for handling insolvency that allows for continuation of benefits for the duration of the contract period for which premiums have been paid and continuation of benefits to subscribers or enrollees who are confined on the date of insolvency in an inpatient facility until their discharge or expiration of benefits.  In considering such a plan, the Insurance Commissioner may require:

1.  Insurance to cover the expenses to be paid for continued benefits after an insolvency;

2.  Provisions in provider contracts that obligate the provider to provide services for the duration of the period after the health maintenance organization’s insolvency for which premium payment has been made and until the enrollees’ discharge from inpatient facilities;

3.  Insolvency reserves;

4.  Acceptable letters of credit; or

5.  Any other arrangements to ensure continuation of benefits as specified above.

F.  An agreement to provide health care services between a provider and a health maintenance organization shall require that if the provider terminates the agreement, the provider shall give the organization at least ninety (90) days' advance notice of such termination.

Added by Laws 2003, c. 197, § 13, eff. Nov. 1, 2003.