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2023 Alaska Statutes › Title 21. Insurance › Chapter 85. Regulation of Multiple Employer Welfare Arrangements › Sec. 21.85.080. Reporting requirements.

(a) A self-funded multiple employer welfare arrangement shall annually, before March 2, file with the director on forms prescribed by the director, a full and true statement of its financial condition, transactions, and affairs as of the preceding December 31, including
(1) a statement of financial condition;
(2) a statement of change in financial condition for the year accompanied by an actuarial opinion by a qualified actuary that includes
(A) a certification that the unpaid claim liability of the arrangement meets the requirements of AS 21.18.080 - 21.18.086;
(B) the recommended level of specific and aggregate stop-loss insurance the arrangement should maintain;
(C) a description of the actuarial soundness of the arrangement, including any recommended actions the arrangement should take to improve its actuarial soundness;
(3) a statement of the arrangement's contribution rates for the next year;
(4) if the total payments to the arrangement for participation during the prior year of operations exceeded the sum of $2,000,000, certified financial statements for the prior two years, or for each year and partial year that the self-funded multiple employer welfare arrangement has been in business if less than two years;
(5) a report showing the number of participating employers and number of covered lives at the end of the year and contributions received during the year in the state;
(6) additional information the director determines is necessary in order to determine the financial integrity of the arrangement.
(b) A self-funded multiple employer welfare arrangement shall, within 60 days after the end of each quarter, file with the director, on forms prescribed by the director, a full and true statement of its financial condition, transactions, and affairs as of the preceding quarter, including
(1) a statement of financial condition;
(2) a statement of change in financial condition for the period since the end of the prior year;
(3) a report showing the number of participating employers and number of covered lives at the end of the quarter and contributions received during the quarter in the state;
(4) additional information the director determines is necessary in order to determine the financial integrity of the arrangement.
(c) A self-funded multiple employer welfare arrangement shall file with the director a copy of the arrangement's Internal Revenue Service form 5500, including all attachments to the form.
2023 Alaska Statutes › Title 21. Insurance › Chapter 85. Regulation of Multiple Employer Welfare Arrangements › Sec. 21.85.090. Consumer information notice.

A self-funded multiple employer welfare arrangement must provide a written notice to each participating employee at the time that coverage becomes effective. The notice must
(1) be clear and conspicuous;
(2) be in at least 10-point type;
(3) state that
(A) the coverage is issued by a self-funded multiple employer welfare arrangement;
(B) coverage and benefits provided under a self-funded multiple employer welfare arrangement are not protected by the Alaska Life and Health Insurance Guaranty Association; and
(C) if the self-funded multiple employer welfare arrangement does not pay expenses that are eligible for payment under the plan for any reason, the employer or employee covered by the plan may be responsible for the payment of those expenses.
2023 Alaska Statutes › Title 21. Insurance › Chapter 85. Regulation of Multiple Employer Welfare Arrangements › Sec. 21.85.100. Applicability of other provisions.

In addition to the provisions contained or referred to in this chapter, the following chapters and provisions of this title also apply with respect to self-funded multiple employer welfare arrangements to the extent applicable and not in conflict with the express provisions of this chapter and the reasonable implications of the express provisions, and, for the purposes of the application, the arrangements shall be considered to be a mutual insurer:
(1) AS 21.03;
(2) AS 21.06;
(3) AS 21.07;
(4) AS 21.09.100, 21.09.120, 21.09.130, 21.09.140 - 21.09.200, 21.09.210, 21.09.245 - 21.09.270, 21.09.300, and 21.09.320;
(5) AS 21.18.010 - 21.18.050, 21.18.080 - 21.18.086, and 21.18.100;
(6) AS 21.24;
(7) AS 21.33;
(8) AS 21.36;
(9) AS 21.42.120, 21.42.130, and 21.42.345 - 21.42.599;
(10) AS 21.48;
(11) AS 21.54;
(12) AS 21.55;
(13) AS 21.56;
(14) AS 21.78;
(15) AS 21.96.060;
(16) AS 21.97.
2023 Alaska Statutes › Title 21. Insurance › Chapter 85. Regulation of Multiple Employer Welfare Arrangements › Sec. 21.85.500. Definitions.

In this chapter,
(1) “allowable benefit” means a benefit for medical care;
(2) “bona fide association” has the meaning given in AS 21.54.500;
(3) “claims liability” means the total of all incurred and unpaid claims for allowable benefits under a self-funded multiple employer welfare arrangement that are not reimbursed or reimbursable by stop-loss insurance, subrogation, or other sources;
(4) “health benefit plan” has the meaning given in AS 21.54.500;
(5) “multiple employer welfare arrangement” has the meaning given in 29 U.S.C. 1002;
(6) “qualified actuary” means an individual who
(A) is a member in good standing of the American Academy of Actuaries;
(B) meets the qualification standards of the American Academy of Actuaries to sign statements of actuarial opinion;
(C) is familiar with the valuation requirements under AS 21.18; and
(D) has not been disqualified by the director, after notice and hearing under AS 21.06.180, for
(i) a violation of this title or other law pertinent to the duties or responsibilities of a qualified actuary;
(ii) conviction of a fraudulent act;
(iii) conduct considered by the director to reflect incompetence or untrustworthiness;
(iv) resignation or removal as an actuary with a company or a consulting firm within the past five years due to acts or omissions indicated in a report of examination or due to failure to adhere to generally accepted actuarial standards; or
(v) failure to notify the director of an action taken against the actuary by an insurance regulator of another state for grounds that are substantially the same as a provision under this paragraph;
(7) “reserves” means the excess of assets of a self-funded multiple employer welfare arrangement minus the liabilities of the arrangement;
(8) “self-funded multiple employer welfare arrangement” or “arrangement” means a multiple employer welfare arrangement that does not provide for payment of benefits under the arrangement solely through a policy of insurance issued by one or more authorized insurance companies.
2023 Alaska Statutes › Title 21. Insurance › Chapter 86. Health Maintenance Organizations › Sec. 21.86.020. Issuance of certificate of authority; approval of changes.

(a) Within 10 days after receipt of an application for a certificate of authority, the director shall forward a copy of the application to the commissioner of health. Within 60 days after the commissioner of health receives the copy of the application, the commissioner shall make a recommendation regarding the granting of the certificate of authority.
(b) The director shall either issue or deny a certificate of authority within 30 days after receipt of the commissioner of health's recommendation. However, the director may extend the time for issuance or denial of a certificate of authority if additional information is needed in order to make a decision, and notice of the extension is provided to the applicant by the 90th day after the director received the application. A certificate of authority shall be issued if the director determines that the following conditions are met:
(1) the persons responsible for the conduct of the affairs of the applicant are competent and trustworthy;
(2) the applicant will effectively provide or arrange for the provision of basic health care services on a prepaid basis, through insurance or otherwise, except to the extent of reasonable requirements for copayments;
(3) the applicant is financially responsible and may reasonably be expected to meet its obligations to enrollees and prospective enrollees; in determining if this condition is met, the director may consider
(A) the financial soundness of the arrangements for health care services and the schedule of charges used in connection with those services;
(B) the adequacy of working capital;
(C) an agreement with an insurer, a hospital or medical service corporation, a government, or other organization for ensuring the payment of the cost of health care services or providing for automatic applicability of an alternative coverage if the health maintenance organization is discontinued;
(D) an agreement with providers for the provision of health care services; and
(E) a deposit of cash or securities submitted under AS 21.86.140;
(4) the enrollees will be afforded an opportunity to participate in matters of policy and operation as provided in AS 21.86.040;
(5) nothing in the proposed method of operation, as shown by the information submitted under AS 21.86.010 or by independent investigation, is contrary to the public interest;
(6) the information submitted under AS 21.86.010(b)(12) indicates that the applicant will be able to comply with state and federal statutes and regulations regarding the quality of health care.
(c) If a certificate of authority is denied under this section, the applicant may request a hearing under AS 21.86.200.
2023 Alaska Statutes › Title 21. Insurance › Chapter 86. Health Maintenance Organizations › Sec. 21.86.030. Powers of a health maintenance organization.

(a) A health maintenance organization may
(1) purchase, lease, construct, renovate, operate, or maintain hospitals, other health care facilities, their ancillary equipment, and property reasonably required for its principal office or for purposes necessary in the transaction of the business of the organization;
(2) make loans to a medical group under contract with it in furtherance of its program, or make loans to a corporation or corporations under its control for the purpose of acquiring or constructing medical facilities and hospitals or in furtherance of a program providing health care services to enrollees;
(3) furnish health care services through providers that are under contract with or employed by the health maintenance organization;
(4) contract with a person for the performance, on the organization's behalf, of certain functions such as marketing, enrollment, and administration;
(5) contract with an insurance company licensed in this state, or with a hospital or medical service corporation authorized to do business in this state, for the provision of insurance, indemnity, or reimbursement against the cost of health care services provided by the health maintenance organization;
(6) offer other health care services, in addition to basic health care services.
(b) A health maintenance organization shall file a notice and adequate supporting information with the director before the exercise of a power granted in (a)(1), (2), or (4) of this section. The director may disapprove the exercise of a power only if, in the director's opinion, it would substantially and adversely affect the financial soundness of the health maintenance organization and endanger its ability to meet its obligations. If the director does not disapprove the exercise of power within 30 days after the filing of the notice, it is considered approved. The director may adopt regulations exempting from the filing requirement of this section those activities having a minimal effect on the health maintenance organization.
(c) Nothing in this section relieves a health maintenance organization that wishes to exercise the power described in (a)(1) of this section from the requirements of
(1) AS 18.07, regarding obtaining a certificate of need;
(2) AS 47.32, regarding regulation of hospitals; and
(3) other statutes applicable to hospitals or other health care facilities.
2023 Alaska Statutes › Title 21. Insurance › Chapter 86. Health Maintenance Organizations › Sec. 21.86.040. Governing body; enrollee participation.

(a) The governing body of a health maintenance organization may include providers, or other individuals, or both. At least one-third of the governing body must consist of consumers who are substantially representative of enrollees.
(b) The governing body of a health maintenance organization shall establish a mechanism to afford its enrollees an opportunity to participate in matters of policy and operation through the establishment of advisory panels, by the use of advisory referenda on major policy decisions, or through the use of other mechanisms.
2023 Alaska Statutes › Title 21. Insurance › Chapter 86. Health Maintenance Organizations › Sec. 21.86.045. Biographical affidavits.

A domestic health maintenance organization shall file with the director a complete affidavit of biographical information not later than 30 days after the appointment of an officer or member of the governing body of the organization. If requested by the director, a foreign health maintenance organization shall file with the director an affidavit of biographical information for the appointment of an officer or member of the governing body of that organization. A filing under this section must be on a form approved by the director. A filing is not required if a biographical affidavit of the officer or member of the governing body of the organization has been submitted to the director within one year before the date of appointment. A biographical affidavit filed under this section is confidential and not subject to public inspection.
2023 Alaska Statutes › Title 21. Insurance › Chapter 86. Health Maintenance Organizations › Sec. 21.86.050. Fiduciary responsibility.

(a) A director, officer, employee, or partner of a health maintenance organization who receives, collects, disburses, or invests money in connection with the activities of that organization is responsible for that money in a fiduciary relationship to the organization.
(b) A health maintenance organization shall maintain in force a fidelity bond on employees and officers in an amount not less than $100,000 or another amount prescribed by the director. The bond must be written with at least a one-year discovery period and, if written with less than a three-year discovery period, must contain a provision that cancellation or termination of the bond, whether by or at the request of the insured or by the underwriter, does not take effect sooner than 90 days after written notice of cancellation or termination has been filed with the director, unless an earlier cancellation or termination date is approved by the director.
2023 Alaska Statutes › Title 21. Insurance › Chapter 86. Health Maintenance Organizations › Sec. 21.86.060. Provision of services.

(a) A health maintenance organization may provide provider services directly, through provider employees, or may provide the services under arrangements with individual providers or one or more groups of providers.
(b) In addition to basic health care services, a health maintenance organization may provide, or arrange for, other health care services on a prepayment or other financial basis.
(c) Health care services may be provided only by appropriately licensed health care providers.
2023 Alaska Statutes › Title 21. Insurance › Chapter 86. Health Maintenance Organizations › Sec. 21.86.075. Chiropractic health care services.

(a) An enrollee may use the services of a licensed chiropractor of the enrollee's choosing and may not be required to obtain the prior approval of the enrollee's health maintenance organization, a gatekeeper, or primary care physician. Within 10 days after an enrollee's first visit, a chiropractor shall transmit a report containing the enrollee's primary complaint, related history, examination findings, initial diagnosis, and treatment plan to the enrollee's health maintenance organization. If the enrollee and the enrollee's chiropractor determine that the condition of the enrollee has not improved within 30 days after the initial treatment, the chiropractor shall refer the enrollee back to the enrollee's health maintenance organization for examination and possible concurrent care.
(b) If the enrollee's chiropractor recommends chiropractic treatment beyond 30 days, the chiropractor shall conduct a second examination and transmit the findings to the enrollee's health maintenance organization. The transmitted information must include the enrollee's current status regarding the primary complaint, the progress of a revised treatment plan, and the objectives for continued care.
(c) After receiving a 30-day treatment report from a chiropractor under (b) of this section, the enrollee's health maintenance organization may request a review by another chiropractor. The reviewing chiropractor shall conduct a physical examination of the enrollee. The findings of the reviewing chiropractor must be disclosed to the enrollee and the enrollee's chiropractor. Charges for additional chiropractic care recommended by the reviewing chiropractor must be included as covered health care services provided by the health maintenance organization.
(d) If the enrollee's treating chiropractor and the reviewing chiropractor determine that the enrollee's condition has stabilized, ongoing preventative or maintenance care is limited to two chiropractic visits a month. If the treating chiropractor and the reviewing chiropractor disagree on the enrollee's continued treatment, the enrollee and the health maintenance organization shall jointly select a third chiropractor to review the enrollee's chiropractic treatment. Selection of a third chiropractor must occur not more than 60 days after the date of the enrollee's initial treatment by the enrollee's treating chiropractor. Until the third chiropractor's opinion is received in writing by the enrollee and the health maintenance organization, the enrollee may receive chiropractic treatment recommended by the treating chiropractor. The opinion of the third chiropractor as to continued chiropractic treatment is binding on the enrollee and the health maintenance organization. This subsection does not apply if a new documented injury or a substantial exacerbation of the enrollee's previous primary complaint occurs.
2023 Alaska Statutes › Title 21. Insurance › Chapter 86. Health Maintenance Organizations › Sec. 21.86.078. Choice of health care provider.

(a) A health maintenance organization shall offer to every enrollee a point-of-service plan option that would allow a covered person to receive covered services from an out-of-network health care provider without obtaining a referral or prior authorization from the health maintenance organization. The point-of-service plan option may require that an enrollee pay a higher deductible or copayment and higher premium for the plan.
(b) A health maintenance organization shall provide each enrollee with an opportunity at the time of enrollment and during the annual open enrollment period to enroll in the point-of-service plan option. The health maintenance organization shall provide written notice of the point-of-service plan option to each enrollee and shall include in that notice a detailed explanation of the financial costs to be incurred by an enrollee who selects that option.
2023 Alaska Statutes › Title 21. Insurance › Chapter 86. Health Maintenance Organizations › Sec. 21.86.080. Annual statement; additional reports.

(a) A health maintenance organization shall file an annual statement with the director under AS 21.09.200 and shall provide a copy to the commissioner of health. The annual statement shall be verified by at least two principal officers of the organization. The director may require additional reports that are reasonably necessary and appropriate in order for the director or the commissioner of health to carry out the duties prescribed by this chapter.
(b) The director may require a health maintenance organization to file quarterly financial statements. If quarterly financial statements are required, the statements must follow for a given quarter the reporting specified in the quarterly financial statement blank form and instructions most recently approved by the National Association of Insurance Commissioners.
(c) A filing under this section is subject to AS 21.09.200 and 21.09.205.
2023 Alaska Statutes › Title 21. Insurance › Chapter 86. Health Maintenance Organizations › Sec. 21.86.100. Complaint system; report.

(a) A health maintenance organization shall establish and maintain a complaint system to provide reasonable procedures for the resolution of written complaints initiated by its enrollees. A complaint system must provide a procedure for forwarding to the commissioner of health a duplicate copy of a complaint relating to patient care or facility operation.
(b) A health maintenance organization shall annually, on or before March 1, submit to the director, in a form prescribed by the director, a report covering the preceding calendar year. The health maintenance organization shall provide a copy of this report to the commissioner of health. The report submitted under this subsection must include
(1) a description of the procedures used in its complaint system;
(2) the total number of complaints handled through its complaint system and a compilation of the causes underlying the complaints filed; and
(3) the number, amount, and disposition of malpractice claims made by an enrollee that were settled during the year by the health maintenance organization; information concerning malpractice claims shall be held confidential by the director and by the commissioner of health, and is not subject to public disclosure.
(c) The director or the commissioner of health may, at any time during normal business hours, examine the complaint system in any place of business of the health maintenance organization in order to determine compliance with this section.
2023 Alaska Statutes › Title 21. Insurance › Chapter 86. Health Maintenance Organizations › Sec. 21.86.110. Recovery of health care costs.

If a health maintenance organization determines that an enrollee has received health care services that the enrollee is not entitled to receive under the terms of the health maintenance agreement, the organization may not recover an amount above the actual cost of providing the health care service. This section does not apply if the enrollee gave or withheld information to the health maintenance organization with the intent to mislead or misinform the organization as to the enrollee's right to receive the health care services.
2023 Alaska Statutes › Title 21. Insurance › Chapter 86. Health Maintenance Organizations › Sec. 21.86.120. Return of agreement.

A person who enters into a health maintenance agreement may return the agreement to the health maintenance organization or the agent from whom it was purchased within 10 days of the delivery of the agreement to the person if the person is not satisfied for any reason. Upon return of the agreement, the health maintenance organization shall promptly refund the fee paid for the agreement. Notice of the substance of this section must be printed on the face of the agreement.
2023 Alaska Statutes › Title 21. Insurance › Chapter 86. Health Maintenance Organizations › Sec. 21.86.160. Regulation of agents.

(a) The director may adopt regulations necessary to provide for the licensing of health maintenance organization agents.
(b) The director may, by regulation, exempt certain classes of persons from the requirement of obtaining an agent license if
(1) the function the class performs does not require special competence or trustworthiness, or the regulatory surveillance made possible by licensing; or
(2) other existing safeguards make regulation through licensing unnecessary.
2023 Alaska Statutes › Title 21. Insurance › Chapter 86. Health Maintenance Organizations › Sec. 21.86.170. Powers of insurers and of hospital or medical service corporations.

(a) An insurer licensed in this state, or a hospital or medical service corporation authorized to do business in this state, may, either directly or through a subsidiary or affiliate, organize and operate a health maintenance organization under the provisions of this chapter. Two or more insurance companies, hospitals or medical service corporations, or subsidiaries or affiliates of them, may jointly organize and operate a health maintenance organization. The business of insurance is considered to include providing health care by a health maintenance organization owned or operated by an insurer or subsidiary of an insurer.
(b) An insurer or hospital or medical service corporation may contract with a health maintenance organization to provide insurance or similar protection against the cost of care provided through a health maintenance organization and to provide coverage in the event of the failure of the health maintenance organization to meet its obligations. The enrollees of a health maintenance organization constitute a permissible group under this title. Under a contract authorized by this subsection, the insurer or hospital or medical service corporation may make benefit payments to health maintenance organizations for health care services rendered by providers.
2023 Alaska Statutes › Title 21. Insurance › Chapter 86. Health Maintenance Organizations › Sec. 21.86.180. Examinations.

(a) The director shall examine the affairs and transactions of a health maintenance organization in the same manner as prescribed for an insurer in AS 21.06.140 - 21.06.180.
(b) As often as is reasonably necessary for the protection of the interests of the people of the state, but at least once every three years, the director shall require submission of an independent review of the quality of care provided by a health maintenance organization either directly or indirectly through contract, agreement, or other arrangement for provisions of health care services to enrollees of the health maintenance organization. The review required under this subsection shall be done by a review organization approved by the Department of Health and shall be done under regulations adopted by that department. The health maintenance organization shall pay the cost of the review.
2023 Alaska Statutes › Title 21. Insurance › Chapter 86. Health Maintenance Organizations › Sec. 21.86.190. Suspension or revocation of certificate of authority.

(a) After compliance with AS 21.86.200, the director may suspend or revoke a certificate of authority issued to a health maintenance organization under this chapter if
(1) the health maintenance organization is operating significantly in contravention of its basic organizational document or in a manner contrary to that described in other information submitted under AS 21.86.010 or 21.86.020;
(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 AS 21.86.070;
(3) the health maintenance organization does not provide or arrange for the provision of basic health care services;
(4) the health maintenance organization is not in compliance with state and federal statutes and regulations as required under AS 21.86.010(b)(12), or 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 implement a mechanism affording the enrollees an opportunity to participate in matters of policy and operation under AS 21.86.040;
(7) the health maintenance organization has failed to implement the complaint system required by AS 21.86.100 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;
(10) the health maintenance organization has otherwise failed substantially to comply with this chapter.
(b) If the certificate of authority of a health maintenance organization is suspended, the health maintenance organization may not, during the period of the suspension, enroll additional enrollees except newborn children or other newly acquired dependents of existing enrollees, and may not engage in advertising or solicitation. The director may, by written order, specify limitations in the operation of the organization during the period of suspension as the director finds to be in the best interests of enrollees.
(c) If the certificate of authority of a health maintenance organization is revoked, the organization shall, immediately following the effective date of the order of revocation, proceed to wind up its affairs, and may not conduct further business except that essential to the orderly conclusion of the affairs of the organization. The organization may not engage in further advertising or solicitation. The director may, by written order, permit continued operation of the organization as the director finds to be in the best interest of enrollees, so that enrollees will be afforded the greatest practical opportunity to obtain continuing health care coverage.
2023 Alaska Statutes › Title 21. Insurance › Chapter 86. Health Maintenance Organizations › Sec. 21.86.200. Administrative procedures.

(a) If the director has reason to believe that grounds for the denial, suspension, or revocation of a certificate of authority exist, the director shall notify the applicant or the health maintenance organization in writing, specifically stating the grounds for denial, suspension, or revocation. A person aggrieved by a decision of the director regarding denial, suspension, or revocation of a certificate of authority may request a hearing under AS 21.06.180. If a hearing is requested, it shall be held under the procedures in AS 21.06.170 - 21.06.220, except that AS 21.06.190 does not apply in the case of a hearing regarding denial of a certificate.
(b) After a hearing under (a) of this section, or upon the failure of an applicant or health maintenance organization to appear at such a hearing, the director shall make written findings and issue an order, that shall be mailed to the applicant or health maintenance organization and concurrently provided to the commissioner of health. An appeal of the director's order may be made in the manner provided by AS 21.06.230.
2023 Alaska Statutes › Title 21. Insurance › Chapter 86. Health Maintenance Organizations › Sec. 21.86.210. Rehabilitation, liquidation, or conservation.

(a) A rehabilitation, liquidation, or conservation of a health maintenance organization is considered to be a rehabilitation, liquidation, or conservation of an insurer, and shall be conducted under AS 21.78. The director may apply to the superior court for an order directing the rehabilitation, liquidation, or conservation of a health maintenance organization upon one or more of the grounds contained in AS 21.78.040, 21.78.050, or 21.78.060, or if, in the director's opinion, the continued operation of the organization would be hazardous to either enrollees or to the people of the state.
(b) Enrollees of a health maintenance organization have the same priority in the event of liquidation or rehabilitation as AS 21.78 provides to policyholders of an insurer. A claim made by a health care provider in a liquidation or rehabilitation that pertains to services provided to an enrollee, has the same priority as an enrollee if the provider agrees not to assert the claim against an enrollee and if any payment fully discharges the obligation of the enrollee.
2023 Alaska Statutes › Title 21. Insurance › Chapter 86. Health Maintenance Organizations › Sec. 21.86.230. Fees.

(a) A health maintenance organization shall pay fees to the director as provided under AS 21.06.250.
(b) A health maintenance organization shall pay to the commissioner of health fees, as established in regulations adopted by the commissioner of health, that relate to the regulatory functions performed by that department under this chapter.
2023 Alaska Statutes › Title 21. Insurance › Chapter 86. Health Maintenance Organizations › Sec. 21.86.250. Penalties and enforcement.

(a) Instead of, or in addition to, suspending or revoking a certificate of authority, the director may, in an order issued under AS 21.86.200, impose an administrative penalty in an amount not less than $1,000 nor more than $25,000 for each violation of an applicable provision of this chapter or a regulation adopted under this chapter.
(b) The director may issue an order directing a health maintenance organization or a person representing a health maintenance organization to stop engaging in an act or practice that is in violation of this chapter or a regulation adopted under this chapter. Within five days after service of a stop order under this subsection, the respondent may request, in writing, a hearing on the question of whether the act or practice has occurred in violation of this chapter or a regulation adopted by the director. The hearing shall commence within 10 days after the written request for the hearing has been received by the director unless the respondent requests that the hearing take place at a later date and the director agrees to the later hearing date.
2023 Alaska Statutes › Title 21. Insurance › Chapter 86. Health Maintenance Organizations › Sec. 21.86.260. Statutory construction and relationship to other law.

(a) Except as provided in AS 21.36, AS 21.42, AS 21.54, AS 21.56, AS 21.79, and in this chapter, this title does not apply to a health maintenance organization that obtains a certificate of authority under this chapter. This subsection does not apply to an insurer licensed under AS 21.09 or a hospital or medical service corporation licensed under AS 21.87 except with respect to its health maintenance organization activities authorized by and regulated under this chapter.
(b) Solicitation of enrollees by a health maintenance organization that has obtained a certificate of authority or by its licensed agents or authorized employee representatives, may not be construed to violate a law of this state relating to solicitation or advertising by health care professionals.
(c) A health maintenance organization that obtains a certificate of authority under this chapter is not considered to be practicing medicine, and is exempt from a law of this state relating to the practice of medicine. However, this subsection does not exempt a health care provider from a licensing requirement, or from another law of this state regarding providers.
2023 Alaska Statutes › Title 21. Insurance › Chapter 86. Health Maintenance Organizations › Sec. 21.86.270. Filings and reports as public documents.

Except for information described in AS 21.86.100(b)(3) and except for trade secrets, privileged, confidential commercial, or financial information as determined by the director, all applications, filings, and reports required under this chapter, including annual financial statements that are required under AS 21.86.080, are public documents.
2023 Alaska Statutes › Title 21. Insurance › Chapter 86. Health Maintenance Organizations › Sec. 21.86.300. Acquisition of control or merger of a health maintenance organization.

(a) A person may not acquire control of the voting securities of a domestic health maintenance organization, if, after the consummation of the transaction, that person would, directly or indirectly, or by conversion or by exercise of any right to acquire, be in control of the health maintenance organization, or enter into an agreement to merge or consolidate with, or otherwise to acquire control of, a health maintenance organization.
(b) Subsection (a) of this section does not apply to a person who at the time the offer, request, or invitation is made or the agreement is entered into, or before the acquisition of the securities if no offer or agreement is involved, has filed with the director and has sent to the health maintenance organization, information required by AS 21.22 and the offer, request, invitation, agreement, or acquisition has been approved by the director. Approval by the director under this subsection is governed by AS 21.22.
(c) In this section,
(1) “acquire control of ” means to make a tender for, make a request or invitation for tenders of, enter into an agreement to exchange securities for, or acquire in the open market or otherwise;
(2) “domestic” means formed under the laws of this state.
2023 Alaska Statutes › Title 21. Insurance › Chapter 86. Health Maintenance Organizations › Sec. 21.86.310. Dual choice.

(a) An employer in this state, whether public or private, that offers its employees a health benefit plan and employs 25 or more employees during any week of the calendar year, and an employee benefit fund in this state that offers its members any form of health benefit, shall make available to its employees or members the option to enroll in at least one health maintenance organization, holding a valid certificate of authority, that provides health care services in the geographic areas in which substantial numbers of the employees or members reside. If employees of the employer are members of a collective bargaining unit, the option of enrollment in a health maintenance organization shall first be submitted to the bargaining representative of the bargaining unit. If the option is approved by the bargaining representative, the option of enrollment shall then be made to each represented employee.
(b) An employer in this state is not required to pay more for employee health benefits as a result of the application of this section than would be required if this section did not apply to the employer. If an employee chooses enrollment in a health maintenance organization, the employer is required to pay, on behalf of that employee, only an amount equal to the lesser of
(1) the amount that would have to be paid to an insurer on behalf of its employees for substantially similar health benefits; or
(2) the health maintenance organization's charge for coverage that is approved by the director under AS 21.86.070.
(c) This section does not apply to an employer whose employees or members reside in an area where health care services are not provided by a health maintenance organization.
2023 Alaska Statutes › Title 21. Insurance › Chapter 86. Health Maintenance Organizations › Sec. 21.86.900. Definitions.

In this chapter,
(1) “affiliation period” means a period of time under a contract with a health maintenance organization
(A) that must expire before coverage becomes effective;
(B) during which the health maintenance organization is not required to provide health care services or benefits; and
(C) for which no premium is charged to the participant or beneficiary for coverage during the period;
(2) “agent” means a person who is appointed by a health maintenance organization and who engages in solicitation of membership in the organization; “agent” does not include a person enrolling health maintenance organization members on behalf of an employer, a union, or other organization to whom a master subscriber contract has been issued, or an employee, who is not an independent contractor, of the health maintenance organization;
(3) “basic health care services” means emergency care, inpatient hospital and physician care, and outpatient medical services, but does not include mental health services or services for alcohol or drug abuse;
(4) “beneficiary” has the meaning given in AS 21.54.500;
(5) “enrollee” means an individual who is enrolled in a health maintenance organization;
(6) “enrollment date” has the meaning given in AS 21.54.500;
(7) “evidence of coverage” means a certificate, agreement, or contract issued to an enrollee, setting out the coverage to which the enrollee is entitled;
(8) “group market” has the meaning given in AS 21.54.500;
(9) “health care services” means services for medical or dental care, or hospitalization, or services incident to the furnishing of that care or hospitalization, and includes services for the purpose of preventing, alleviating, curing, or healing human illness, injury, or physical disability;
(10) “health maintenance organization” means a person that undertakes to provide or arrange for basic health care services to enrollees on a prepaid basis;
(11) “health status factor” has the meaning given in AS 21.54.500;
(12) “participant” has the meaning given in AS 21.54.500;
(13) “person” has the meaning given in AS 01.10.060 and includes a joint venture;
(14) “preexisting condition exclusion” has the meaning given in AS 21.54.500;
(15) “provider” means a physician, hospital, or other person licensed or otherwise authorized in this state to furnish health care services;
(16) “uncovered expenditures” means the costs of health care services that are covered by a health maintenance organization, but for which an enrollee would also be liable if the organization became insolvent;
(17) “waiting period” has the meaning given in AS 21.54.500.
2023 Alaska Statutes › Title 21. Insurance › Chapter 87. Hospital and Medical Service Corporations › Sec. 21.87.010. Applicability.

(a) This chapter applies to every individual, person, firm, corporation, association, or organization of any kind hereafter engaging or purporting to engage in the provision of all or part of a health care service as defined in AS 21.87.330, for its subscribers in exchange for periodic prepayments in identifiable amount by or as to the subscribers.
(b) This chapter does not apply to
(1) insurers or fraternal benefit societies authorized to transact the kind of insurance involved under other chapters of this title;
(2) fraternal and other organizations exempted from AS 21.24;
(3) health care services provided by an employer to employees and their dependents, with or without contribution to the costs thereof by the employees, through health care service facilities owned, employed, or controlled by the employers;
(4) infrequent instances of prepayment by or for the patient direct to the physician or hospital for specific services thereafter rendered to the patient by the physician or hospital;
(5) [Repealed, § 3 ch 13 SLA 2014.]
2023 Alaska Statutes › Title 21. Insurance › Chapter 87. Hospital and Medical Service Corporations › Sec. 21.87.020. Purpose and interpretation.

(a) It is the purpose of this chapter to regulate in the public interest the formation and operation of prepaid health care service organizations, in order that the services may be made available upon a basis of fair and equitable contracts through state-licensed nonprofit organizations meeting reasonable standards as to administration, reserves, and financial soundness.
(b) This chapter shall be liberally interpreted to effectuate the purpose declared in (a) of this section.
2023 Alaska Statutes › Title 21. Insurance › Chapter 87. Hospital and Medical Service Corporations › Sec. 21.87.040. Incorporation and certificate of authority required.

A person otherwise subject to this chapter may not engage or purport to engage in the provision of any part or all of a health care service for its subscribers in exchange for periodic prepayments in identifiable amount unless it is a service corporation incorporated under the laws of this state, and currently authorized as such a service corporation under a certificate of authority issued by the director under this chapter.
2023 Alaska Statutes › Title 21. Insurance › Chapter 87. Hospital and Medical Service Corporations › Sec. 21.87.050. Incorporation, approval of articles and amendments.

(a) A service corporation shall be formed as a nonprofit, nonstock medical service corporation, or hospital service corporation, or a combination medical and hospital service corporation, consistent with the applicable requirements of this chapter under the statutes of this state governing the formation of nonprofit, nonstock corporations in general.
(b) Before the articles of incorporation of the proposed corporation formed after July 1, 1966, are filed with the commissioner of commerce, community, and economic development, they shall be submitted to the director, and the commissioner may not file the articles unless the director's approval is endorsed thereon. The director shall approve the articles unless the director finds that they do not comply with law. If not approved, the director shall return the proposed articles of incorporation to the incorporators together with a written statement of particulars of the reasons for nonapproval.
(c) An amendment of the articles of incorporation of a service corporation may not be filed with the commissioner unless it is first submitted to and approved by the director, and bears the director's approval endorsed on it. The director shall approve the amendment unless the director finds that it was not lawfully adopted or that the articles of incorporation as amended would be unlawful. If not approved, the director shall return the proposed amendment to the corporation together with a written statement of the particulars of the reasons for nonapproval.
2023 Alaska Statutes › Title 21. Insurance › Chapter 87. Hospital and Medical Service Corporations › Sec. 21.87.060. Name of corporation.

A service corporation may not have or use a corporate or business name that includes the words “insurance,” “casualty,” “surety,” “health and accident,” “mutual,” or other terms descriptive of an insurer or insurance business. A service corporation may not have or use a name so similar to that of another corporation transacting business in this state when the service corporation was formed that it would tend to confuse or mislead the public.
2023 Alaska Statutes › Title 21. Insurance › Chapter 87. Hospital and Medical Service Corporations › Sec. 21.87.070. Qualifications for certificate of authority.

The director may not issue or permit to exist a certificate of authority to be or act as a service corporation to a corporation that does not fulfill the following qualifications:
(1) it must be incorporated as provided in AS 21.87.050, as either a medical service corporation, or as a hospital service corporation, or as a combined medical and hospital service corporation;
(2) it must intend to and actually conduct its business in good faith as a nonprofit corporation;
(3) if a hospital service corporation, it must have in force at all times while so authorized, service agreements with participant hospitals located in the areas of the subscribers' residences, convenient as to location and sufficient as to capacity and facilities reasonably to furnish the hospital services provided or proposed to be provided by the corporation to its subscribers;
(4) if a medical service corporation, it must have in force service agreements with participant providers located in the areas of the subscribers' residences convenient as to location and sufficient in numbers and facilities reasonably to furnish the medical and surgical services provided or proposed to be provided by the corporation to its subscribers;
(5) if a newly formed corporation, it must possess sufficient available working funds to pay all reasonably anticipated cost of acquisition of new business and operating expenses, other than payment for hospital or medical services, for a period of not less than the six months following the date of issuance of the certificate of authority, if issued, or $100,000, whichever amount is greater;
(6) it must fulfill all other applicable requirements of this chapter.