2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 1 - Insurance Generally (§§ 101 — 4513) › Chapter 19 - Health Services Organizations (§§ 1901 — 1928) › § 1904 - Issuance of certificate of authority

(1)
(a) Upon receiving an application for the issuance of a certificate of authority, the Commissioner shall immediately send to the Secretary of Health a copy of said application and of the accompanying documents.
(b) In connection with the health care services to be provided by the applicant for a certificate of authority, the Secretary of Health shall determine whether:
(i) It has the capacity, the personnel and adequate facilities to insure that the health care services shall be rendered in such a way as to guarantee the availability, accessibility and continuity of the services.
(ii) It meets the requirements established in the regulations the Secretary of Health may promulgate or may have promulgated, to insure the continuous quality of the health care program as to its procedures and results.
(iii) It has established a procedure in accordance with the regulations of the Secretary of Health to develop, compile, evaluate and report statistics related to the cost of operations, the pattern of utilization of the services, the availability and accessibility of the services, and any other related matter that the Secretary of Health may reasonably require.
(iv) Every applicant shall comply with the provisions of §§ 331–333p of Title 24, which shall be informed by the Secretary of Health to the Commissioner.
(c) Within thirty (30) days after receiving the application for the issuance of a certificate of authority, the Secretary of Health shall certify to the Commissioner if the health services organization meets the requirements of clause (b) of this subsection. If the Secretary of Health certifies that the health services organization does not meet the requirements, he shall specify in what aspects the organization is deficient.
(2) The Commissioner may issue or deny a certificate of authority to any person who files an application as provided in § 1903 of this title within ninety (90) days after receiving the certification from the Secretary of Health. The issuance of the certificate of authority shall be granted subject to the payment of the application fees established in section 19.230, provided that the Commissioner determines that the applicant meets the following requirements:
(a) That the persons responsible for the management of the business of the health services organization be competent, reliable and of good reputation.
(b) That the Secretary of Health certify pursuant to the provisions of subsection (1) that the plan of operations proposed by the health services organization meets the requirements established in subsection (1)(b).
(c) That their health care plans provide adequate mechanisms through which the health services organization will provide the basic health care services directly to the subscribers or through providers contracted directly thereby, or through insurance or other means which has previously been approved by the Insurance Commissioner by regulations.
(d) That the health services organization has financial stability. In making this finding the Commissioner may consider:
(i) The financial solidness of the health care plan as regards the services it will provide and the fees it will fix for said services.
(ii) Adequacy of operating capital.
(iii) Any agreement with any other health services organization to insure the payment of the cost of the health services or the provisions for the automatic application of a substitute coverage in the event that the health services organization does not fulfill its obligations with the subscriber.
(iv) Any agreement with the providers to offer health care services; and
(v) Any bond or deposit in cash or securities submitted pursuant to the provision of § 1914 of this title as guarantee that the obligations will be performed.
(e) That the subscribers be granted the opportunity to participate in the direction and operation of the organization pursuant to the provision in § 1906 of this title.
(f) That the proposed operating method not be contrary to the public interest, as shown in the information submitted to the Commissioner as provided in § 1903 of this title, or by independent investigations ordered by the Commissioner; and
(g) That any of the deficiencies pointed out by the Secretary of Health has been corrected.
(3) A certificate of authority may be denied only after having complied with the requirements established in § 1921 of this title.
History —Ins. Code, added as § 19.040 on June 2, 1976, No. 113, p. 313, § 1; July 2, 1987, No. 88, p. 337, § 3.