§ 36-6920. Examination of affairs, programs, books, and records - Payment of expenses.

A.  A certificate of authority issued under the Health Maintenance Organization Act of 2003 may be suspended or revoked, and an application for a certificate of authority may be denied, if the Insurance Commissioner finds that any of the following conditions exist:

1.  The health maintenance organization (HMO) is operating significantly in contravention of its basic organizational document or in a manner contrary to that described in any other information submitted under Section 3 of this act, unless amendments to those submissions have been filed with and approved by the Insurance Commissioner;

2.  The health maintenance organization issues an evidence of coverage or uses a schedule of charges for health care services that does not comply with the requirements of Sections 8 and 16 of this act;

3.  The health maintenance organization does not provide or arrange for basic health care services;

4.  The State Commissioner of Health certifies to the Insurance Commissioner that:

a.the health maintenance organization does not meet the requirements of Section 7 of this act, or

b.the health maintenance organization is unable to fulfill its obligations to furnish health care services;

5.  The health maintenance organization is no longer financially responsible and may reasonably be expected to be unable to meet its obligations to enrollees or prospective enrollees;

6.  The health maintenance organization has failed to correct, within the time frame prescribed by subsection C of this section, any deficiency occurring due to the health maintenance organization’s prescribed minimum net worth being impaired;

7.  The health maintenance organization has failed to implement the grievance procedures required by Section 11 of this act in a reasonable manner to resolve valid complaints;

8.  The health maintenance organization, or any person on its behalf, has advertised or merchandised its services in an untrue, misrepresentative, misleading, deceptive or unfair manner;

9.  The continued operation of the health maintenance organization would be hazardous to its enrollees or to the public; or

10.  The health maintenance organization has otherwise failed to comply with the provisions of the Health Maintenance Organization Act of 2003, applicable rules promulgated by the Insurance Commissioner pursuant thereto, or rules promulgated by the State Board of Health pursuant to the provisions of Section 7 of the Health Maintenance Organization Act of 2003.

B.  In addition to or in lieu of suspension or revocation of a certificate of authority pursuant to the provisions of this section, an applicant or health maintenance organization who knowingly violates the provisions of this section may be subject to an administrative penalty of Five Thousand Dollars ($5,000.00) for each occurrence.

C.  The following shall apply when insufficient net worth is maintained:

1.  Whenever the Insurance Commissioner finds that the net worth maintained by any health maintenance organization subject to the provisions of this act is less than the minimum net worth required to be maintained by Section 13 of this act, the Insurance Commissioner shall give written notice to the health maintenance organization of the amount of the deficiency and require filing with the Insurance Commissioner a plan for correction of the deficiency that is acceptable to the Insurance Commissioner, and correction of the deficiency within a reasonable time, not to exceed sixty (60) days, unless an extension of time, not to exceed sixty (60) additional days, is granted by the Insurance Commissioner.  A deficiency shall be deemed an impairment, and failure to correct the impairment in the prescribed time shall be grounds for suspension or revocation of the certificate of authority or for placing the health maintenance organization in conservation, rehabilitation or liquidation; or

2.  Unless allowed by the Insurance Commissioner, no health maintenance organization or person acting on its behalf may, directly or indirectly, renew, issue or deliver any certificate, agreement or contract of coverage in this state, for which a premium is charged or collected, when the health maintenance organization writing the coverage is impaired, and the fact of impairment is known to the health maintenance organization or to the person; provided, however, the existence of an impairment shall not prevent the issuance or renewal of a certificate, agreement or contract when the enrollee exercises an option granted under the plan to obtain a new, renewed or converted coverage.

D.  A certificate of authority shall be suspended or revoked or an application or a certificate of authority denied or an administrative penalty imposed only after compliance with the requirements of this section.

1.  Suspension or revocation of a certificate of authority, denial of an application, or imposition of an administrative penalty by the Insurance Commissioner, pursuant to the provisions of this section, shall be by written order and shall be sent to the health maintenance organization or applicant by certified or registered mail and to the State Commissioner of Health.  The written order shall state the grounds, charges or conduct on which the suspension, revocation or denial or administrative penalty is based.  The health maintenance organization or applicant may, in writing, request a hearing within thirty (30) days from the date of mailing of the order.  If no written request is made, the order shall be final upon the expiration of thirty (30) days.

2.  If the health maintenance organization or applicant requests a hearing pursuant to the provisions of this section, the Insurance Commissioner shall issue a written notice of hearing and send such notice to the health maintenance organization or applicant by certified or registered mail and to the State Commissioner of Health stating:

a.a specific time for the hearing, which may not be less than twenty (20) nor more than thirty (30) days after mailing of the notice of hearing, and

b.that any hearing shall be held at the office of the Insurance Commissioner.

If a hearing is requested, the State Commissioner of Health or a designee shall be in attendance and shall participate in the proceedings.  The recommendations and findings of the State Commissioner of Health with respect to matters relating to the quality of health care services provided in connection with any decision regarding denial, suspension or revocation of a certificate of authority, shall be conclusive and binding upon the Insurance Commissioner.  After the hearing, or upon failure of the health maintenance organization to appear at the hearing, the Insurance Commissioner shall take whatever action is deemed necessary based on written findings.  The Insurance Commissioner shall mail the decision to the health maintenance organization or applicant and a copy to the State Commissioner of Health.

E.  The provisions of the Administrative Procedures Act shall apply to proceedings under this section to the extent they are not in conflict with the provisions of Section 313 of Title 36 of the Oklahoma Statutes.

F.  If the certificate of authority of a health maintenance organization is suspended, the health maintenance organization shall not, during the period of suspension, enroll any additional enrollees except newborn children or other newly acquired dependents of existing enrollees, and shall not engage in any advertising or solicitation whatsoever.

G.  If the certificate of authority of a health maintenance organization is revoked, the HMO shall proceed, immediately following the effective date of the order of revocation, to wind up its affairs and shall conduct no further business except as may be essential to the orderly conclusion of the affairs of the organization.  The HMO shall engage in no further advertising or solicitation whatsoever.  The Insurance Commissioner may, by written order, permit further operation of the HMO if found to be in the best interests of enrollees, to the end that enrollees will be afforded the greatest practical opportunity to obtain continuing health care coverage.

Added by Laws 2003, c. 197, § 20, eff. Nov. 1, 2003.