Md. Code Regs. 10.67.03.03

Current through Register Vol. 51, No. 25, December 13, 2024

Section 10.67.03.03 - Organization, Operations, and Financing

Except as provided in Regulation .02B of this chapter, an MCO applicant shall include the following information or descriptions in its application:

A. An indication whether the applicant is an operating HMO with a certificate of authority from the Maryland Insurance Administration;

B. A written legal history of the applicant, specific as to dates and parties involved, that includes, but is not limited to:

(1) Predecessor corporations,

(2) Mergers,

(3) Reorganizations, and

(4) Changes of ownership;

C. A copy of the articles of incorporation of the applicant, and any amendments to it, certified by the Maryland Department of Assessments and Taxation;

D. A copy of the applicant's current bylaws, certified by the appropriate corporate officer;

E. A written description providing a reason if the applicant has ever defaulted on a contract or otherwise had a contract terminated;

F. If the applicant is an HMO, the most recent annual loss ratio report provided to the Maryland Insurance Administration pursuant to Insurance Article, § 5-605, Annotated Code of Maryland;

G. A copy of the applicant's business plan provided to the Maryland Insurance Administration pursuant to Insurance Article, § 5-605, Annotated Code of Maryland.

H. Evidence of compliance with Maryland Workers' Compensation Law, as follows:

(1) Except as provided in §H(2) of this regulation, the applicant shall submit:

(a) The policy number of its Workers' Compensation insurance coverage; and

(b) The name of its Workers' Compensation insurance carrier; or

(2) If self-insured, the applicant shall submit a certificate of compliance evidencing employee coverage under Workers' Compensation Law, as provided in Labor and Employment Article, Title 9, Annotated Code of Maryland;

I. The names, addresses, and official capacities of the managing employees or other individuals responsible for the conduct of the affairs of the applicant, including concise position descriptions and background, citing education, training, and experience, for, but not limited to, the applicant's:

(1) Plan administrator,

(2) Medical director,

(3) Medical records director,

(4) Enrollment/disenrollment director,

(5) Quality assurance director,

(6) Case management director,

(7) Utilization control manager, and

(8) Grievance director and marketing director;

J. A full disclosure of the extent and nature of any contracts or arrangements, including any possible conflicts of interest between the applicant and any individual specified in §I of this regulation;

K. The name and address of each person with a 5 percent or more ownership or controlling interest in the applicant or in any subcontractor or supplier in which the applicant has direct or indirect ownership of 5 percent or more, including identifying whether any person named is related to any other named person as either spouse, parent, child, or sibling;

L. A list of any subcontractors or suppliers owned by the applicant, indicating the percent of financial interest held;

M. A history of any subcontractors with whom the applicant has had business transactions totaling more than $25,000 during the 12-month period ending on the date of application;

N. A description of the applicant's corporate and organizational structure, and an organizational chart, with detailed lines of authority indicating the relationships among the board of directors, the administrative component, and the medical and health service delivery component of the applicant including, but not limited to, staff positions responsible for the plan's key management functions enumerated in §I of this regulation;

O. A description of all current contractual relationships between the applicant and subcontractors for administrative/management, health, and marketing services, including the subcontractors' names;

P. A description of any contracts the applicant intends to enter into before beginning operation as an MCO;

Q. The name of any person or persons holding an ownership or controlling interest in excess of 5 percent in the applicant, or who is an agent or managing employee of the applicant, who has been subject to a conviction as defined at 42 U.S.C. § 1320a-7(i), or a sanction for a Program-related offense;

R. Copies of all standard subcontracts with service and administrative providers who are not salaried employees of the applicant, including identification of any provision in subcontracts which differ from the standard subcontract;

S. A description of the method by which the applicant will accomplish cost avoidance or recovery in the case of third-party liability; and

T. Copies of the applicant's written Medicaid marketing plan including:

(1) A description of how the applicant plans to address the special access provisions in COMAR 10.67.66.01D; and

(2) Sample version of all material and communication the applicant would like to distribute to potential enrollees, including but not limited to:

(a) Brochures;

(b) Fact sheets; and

(c) Posters.

Md. Code Regs. 10.67.03.03

Regulations .03 recodified from 10.09.64.03 effective 46:22 Md. R. 976, eff. 11/1/2019