§ 36-6941. Regulatory action level event - Definition - Duties of Insurance Commissioner - Challenge to adjusted RBC report or revised RBC plan - Use of actuaries, investment experts and other consultants.

A.  “Regulatory Action Level Event” means, with respect to a health maintenance organization, any of the following events:

1.  The filing of an RBC report by the health maintenance organization that indicates that the health maintenance organization’s total adjusted capital is greater than or equal to its Authorized Control Level RBC but less than its Regulatory Action Level RBC;

2.  Notification by the Commissioner to a health maintenance organization of an adjusted RBC report that indicates a Regulatory Action Level Event specified in paragraph 1 of this subsection, provided the health maintenance organization does not challenge the adjusted RBC report under Section 44 of this act;

3.  If, pursuant to the provisions of Section 44 of this act, the health maintenance organization challenges an adjusted RBC report that indicates a Regulatory Action Level Event specified event in paragraph 1 of this subsection, the notification by the Commissioner to the health maintenance organization that the Commissioner has, after a hearing, rejected the health maintenance organization’s challenge;

4.  The failure of the health maintenance organization to file an RBC report by the filing date, unless the health maintenance organization has provided an explanation for the failure that is satisfactory to the Commissioner and has corrected the failure within ten (10) days after the filing date;

5.  The failure of the health maintenance organization to submit an RBC plan to the Commissioner within the time period provided in subsection C of Section 40 of this act;

6.  Notification by the Commissioner to the health maintenance organization that:

a.the RBC plan or revised RBC plan submitted by the health maintenance organization is, in the judgment of the Commissioner, unsatisfactory, and

b.notification constitutes a Regulatory Action Level Event with respect to the health maintenance organization, provided the health maintenance organization has not challenged the determination under Section 44 of this act;

7.  If, pursuant to the provisions of Section 44 of this act, the health maintenance organization challenges a determination by the Commissioner under paragraph 6 of this subsection, the notification by the Commissioner to the health maintenance organization that the Commissioner has, after a hearing, rejected the challenge;

8.  Notification by the Commissioner to the health maintenance organization that the health maintenance organization has failed to adhere to its RBC plan or revised RBC plan, but only if the failure has a substantial adverse effect on the ability of the health maintenance organization to eliminate the Company Action Level Event in accordance with its RBC plan or revised RBC plan and the Commissioner has so stated in the notification, provided the health maintenance organization has not challenged the determination under Section 44 of this act; or

9.  If, pursuant to the provisions of Section 44 of this act, the health maintenance organization challenges a determination by the Commissioner under paragraph 8 of this subsection, the notification by the Commissioner to the health maintenance organization that the Commissioner has, after a hearing, rejected the challenge.

B.  In the event of a Regulatory Action Level Event the Commissioner shall:

1.  Require the health maintenance organization to prepare and submit an RBC plan or, if applicable, a revised RBC plan;

2.  Perform such examination or analysis of the assets, liabilities and operations of the health maintenance organization as the Commissioner deems necessary, including a review of the HMO’s RBC plan or revised RBC plan; and

3.  Subsequent to the examination or analysis, issue a corrective order specifying such corrective actions as the Commissioner shall determine are required.

C.  In determining corrective actions, the Commissioner may take into account factors the Commissioner deems relevant with respect to the health maintenance organization based upon the Commissioner’s examination or analysis of the assets, liabilities and operations of the health maintenance organization including, but not limited to, the results of any sensitivity tests undertaken pursuant to the RBC instructions.  The RBC plan or revised RBC plan shall be submitted:

1.  Within forty-five (45) days after the occurrence of the Regulatory Action Level Event;

2.  If the health maintenance organization challenges an adjusted RBC report pursuant to the provisions of Section 44 of this act and the challenge is not frivolous, in the judgment of the Commissioner, within forty-five (45) days after the notification to the health maintenance organization that the Commissioner has, after a hearing, rejected the health maintenance organization’s challenge; or

3.  If the health maintenance organization challenges a revised RBC plan pursuant to the provisions of Section 44 of this act and the challenge is not frivolous, in the judgment of the Commissioner, within forty-five (45) days after the notification to the health maintenance organization that the Commissioner has, after a hearing, rejected the health maintenance organization’s challenge.

D.  The Commissioner may retain such actuaries, investment experts and other consultants as may be necessary, in the judgment of the Commissioner, to review the health maintenance organization’s RBC plan or revised RBC plan, examine or analyze the assets, liabilities and operations, including contractual relationships of the health maintenance organization, and formulate the corrective order with respect to the health maintenance organization.  The fees, costs and expenses relating to consultants shall be borne by the affected health maintenance organization or such other party as directed by the Commissioner.

Added by Laws 2003, c. 197, § 41, eff. Nov. 1, 2003.