D.C. Mun. Regs. tit. 26, r. 26-A3500

Current through Register 71, No. 45, November 7, 2024

Rule 26-A3500 - ESTABLISHMENT OF HEALTH MAINTENANCE ORGANIZATIONS AND RENEWAL OF CERTIFICATE OF AUTHORITY

3500.1

Any person seeking to operate an HMO in the District of Columbia shall file an application for a certificate of authority accompanied by the required supporting documentation with the Commissioner of Insurance and Securities Regulation ("Commissioner"), and is responsible for paying the following fees:

(a) An initial filing fee in the amount of five hundred dollars ($ 500.00).

(b) The renewal fee for certificates of authority in the amount of two hundred dollars ($200.00).

(c) The renewal fee must be received by the Commissioner by April 1 of each renewal year.

3500.2

The application for a certificate of authority shall be accompanied by the following supporting ducumentation:

(a) A copy of the organizational documents of the applicant such as the articles of incorporation, articles of association, partnership agreement, trust agreement, or other applicable documents and all amendments thereto;

(b) A copy of the by-laws, rules and regulations or similar documents regulating the conduct of the internal affairs of the applicant;

(c) A list of the names, addresses, official positions and biographical information for those persons responsible for the conduct of the affairs and day-to-day operations of the applicant, including:

(1) the members of the board of directors, board of trustees, executive committee, or other governing body; and

(2) the principal officers in the case of a corporation, or partners or members in the case of a partnership or association;

(d) A sample of any contract form made, or to be made, between any class of providers and the HMO and a copy of any contract form made, or to be made, between third party administrators, marketing consultants or persons listed in paragraph (c) and the HMO;

(e) A copy of the form of evidence of coverage to be issued to the enrollees;

(f) A copy of the form of group contract, if any, to be issued to employers, unions, trustees or organizations;

(g) Financial statements showing the applicant's assets, liabilities, and sources of financial support, including both a copy of the applicant's most recent certified financial statement and an unaudited current financial statement;

(h) A financial feasibility plan (except for a person that holding an unencumbered certificate of authority to operate an HMO in Maryland or Virginia) which shall include:

(1) detailed enrollment projections;

(2) methodology for determining dues to be charged during the first 12 months of operation as certified by an actuary;

(3) projection of balance sheets;

(4) cash flow statements showing any capital expenditures;

(5) purchase/sale of investments and deposits with the District government;

(6) income and expense statements anticipated from the start of operations until the organization has had net income for at least one (1) year; and

(7) sources of working capital as well as any other sources of funding.

(i) If not domiciled in the District, the applicant shall execute a power of attorney appointing the Commissioner, or his or her successors in office and duly authorized deputies, as the true and lawful attorney of the applicant in and for the District upon whom all lawful process in any legal action or proceeding against the HMO on a cause of action arising in the District may be served;

(j) A statement and map of the geographical area or areas to be served;

(k) A description of the proposed quality assurance program;

(l) A description of procedures to be implemented which meet the requirements for protection against insolvency as required under section 13 of the Act, D.C. Code § 35-4512;

(m) A list of the names, addresses and license numbers of providers that have agreements with the HMO, provided that:

(1) the license numbers of the providers shall be maintained in the HMO's administrative office; and

(2) the list of the license numbers shall be available for review by the Commissioner during on-site visits;

(n) The method of determining situs of each group contract;

(o) Any other information the Commissioner deems necessary to make the determination whether to issue a certificate of authority.

3500.3

After receiving its certificate of authority, an HMO shall submit to the Commissioner information concerning any modification or amendment to the information contained in its orignal application for a certificate of authority and supporting documentation prior to effecting a modification or amendment for the items listed in subsection 3500.2(a) through (f), (h) (5), and (o). Information or supporting documentation for an amendment for items not listed in this subsection shall be provided to the Commissioner at the next succeeding site visit or examination.

3500.4

The Commissioner shall have thirty (30) days to approve a modification or amendment when his or her approval is required. On written notice to the applicant, an additional thirty (30) days may be taken by the Commissioner, if additional time is needed to properly consider the modification or amendment. If the Commissioner fails to disapprove the modification or amendment within the original thirty (30) day period, as extended by any additional period of thirty (30) days, the application will be considered approved.

3500.5

Licensure packages may be requested from the Department of Insurance and Securities Regulation, Insurance Bureau, Consumer and Professional Services Division.

D.C. Mun. Regs. tit. 26, r. 26-A3500

Final Rulemaking published at 46 DCR 7291(September 17, 1999); as Final Rulemaking published at 50 DCR 5576(July 11, 2003)