reglab/statecodes huggingface dataset:
Arizona Administrative Code › Title 20 - COMMERCE, FINANCIAL INSTITUTIONS, AND INSURANCE › Chapter 06 - DEPARTMENT OF INSURANCE AND FINANCIAL INSTITUTIONS - INSURANCE DIVISION › Article 17 - EXAMINATIONS › Section R20-6-1703 - Conduct of Examinations

Current through Register Vol. 30, No. 28, July 12, 2024
A. Upon
				determining that an examination should be conducted, the Director or the
				Director's designee shall issue an examination warrant appointing one or more
				examiners to perform the examination and instructing them as to the scope of
				the examination.
B. Nothing
				contained in this Article shall be construed to limit the Director's authority
				to terminate or suspend any examination in order to pursue other legal or
				regulatory action pursuant to the insurance laws of this state or to pursue
				such action concurrent with the examination.
C. The Director may disclose the content of
				an examination report, preliminary examination report or results, or any matter
				relating thereto, to the insurance department of any other state or country or
				to law enforcement officials of this or any other state or agency of the
				federal government at any time. Prior to making such disclosure, the Director
				may require such other department or office to agree in writing to hold as
				confidential the examination report, preliminary examination report or results
				or any matter relating thereto until such time as the examination report,
				preliminary examination report or results or matter relating thereto are made
				public by the Director.
Arizona Administrative Code › Title 20 - COMMERCE, FINANCIAL INSTITUTIONS, AND INSURANCE › Chapter 06 - DEPARTMENT OF INSURANCE AND FINANCIAL INSTITUTIONS - INSURANCE DIVISION › Article 17 - EXAMINATIONS › Section R20-6-1704 - Examination Reports

Current through Register Vol. 30, No. 28, July 12, 2024
A. All
				examination reports shall be comprised of only facts appearing upon the books,
				records, or other documents of the company, its agents or other persons
				examined, or as ascertained from the testimony of its officers or agents or
				other persons examined concerning its affairs, and such conclusions and
				recommendations as the examiners find warranted from the facts.
B. No later than 60 days following completion
				of the examination, the examiner in charge shall submit to the Department a
				verified written report of examination under oath. Upon receipt of the verified
				report, the Department shall transmit the report to the company examined,
				together with a notice which shall afford the company examined a reasonable
				opportunity of not less than 10 days nor more than 30 days to make a written
				submission or rebuttal with respect to any matters contained in the examination
				report.
C. Within 30 days after the
				end of the period allowed for the receipt of written submissions or rebuttals,
				the Director shall fully consider and review the report, together with any
				written submissions or rebuttals and any relevant portions of the examiner's
				workpapers and shall:
1. File the examination
				report as submitted or with modification or corrections. If the examination
				report reveals that the company is operating in violation of any law,
				regulation or prior order of the Director, the Director may order the company
				to take any action necessary and appropriate to cure such violation;
				or
2. Reject the examination report
				with directions to the examiners to reopen the examination for purposes of
				obtaining additional data, documentation or information, and resubmission
				pursuant to subsection (B).
Arizona Administrative Code › Title 20 - COMMERCE, FINANCIAL INSTITUTIONS, AND INSURANCE › Chapter 06 - DEPARTMENT OF INSURANCE AND FINANCIAL INSTITUTIONS - INSURANCE DIVISION › Article 18 - PREPAID DENTAL PLAN ORGANIZATIONS › Section R20-6-1802 - Application for Certificate of Authority

Current through Register Vol. 30, No. 28, July 12, 2024
A. A person who wishes to operate as prepaid
				dental plan organization in Arizona shall file an application for certificate
				of authority under A.R.S. §
									20-1003
				for the director's Director's review and approval under A.R.S. §
									20-1004.
				The application shall contain all the information required in A.R.S. §
									20-1003
				and this Section.
B. An authorized
				insurer shall issue the fidelity bond required under A.R.S. §
									20-1004(A)(4).
C. An Organization shall not commence
				operation of, or service under, a prepaid dental plan without approval of the
				Director under A.R.S. §
									20-1004.
D. An application is deemed filed with the
				Director when the Director receives it.
E. An applicant not domiciled in this state
				shall file a power of attorney as required by A.R.S. §
									20-1003(A)(11)
				 on a Department-prescribed form, with the
				application.
F.
At the
				  time it submits its application for certificate of authority, an Organization
				  shall submit a written program of compliance with supporting documents that
				  specify how the Organization will comply with the provisions of this Article.
				  The written program of compliance shall contain the following:
1. The responsibilities of and qualifications
				for the following positions:
a. The
				Organization's chief executive officer, and
b. The Organization's dental
				director;
Arizona Administrative Code › Title 20 - COMMERCE, FINANCIAL INSTITUTIONS, AND INSURANCE › Chapter 06 - DEPARTMENT OF INSURANCE AND FINANCIAL INSTITUTIONS - INSURANCE DIVISION › Article 18 - PREPAID DENTAL PLAN ORGANIZATIONS › Section R20-6-1803 - Chief Executive Officer

Current through Register Vol. 30, No. 28, July 12, 2024
A.
				The governing authority shall appoint a chief executive officer (CEO). The CEO
				shall have:
1. The education and experience
				to manage the Organization, and
2.
				Responsibility for the geographic area in Arizona that the Organization serves,
				including:
a. Implementing the policies of
				the governing authority, and
b.
				Maintaining adequate personnel to ensure compliance with applicable Arizona
				statutes and rules.
Arizona Administrative Code › Title 20 - COMMERCE, FINANCIAL INSTITUTIONS, AND INSURANCE › Chapter 06 - DEPARTMENT OF INSURANCE AND FINANCIAL INSTITUTIONS - INSURANCE DIVISION › Article 18 - PREPAID DENTAL PLAN ORGANIZATIONS › Section R20-6-1804 - Dental Director

Current through Register Vol. 30, No. 28, July 12, 2024
A. The
				governing authority or CEO shall appoint as the Organization's dental director
				a dentist licensed to practice dentistry in any state or territory of the
				United States or the District of Columbia.
B. The dental director shall perform at least
				the following functions for the Organization's geographic area in Arizona:
1. Participate on the Organization's quality
				improvement committee required under Section
				R20-6-1811;
2. Oversee the Organization's program and
				processes for:
a. Maintaining and improving
				clinical quality of care, including continuity of care;
b. Provider relations;
c. Facility and dental record reviews;
				and
d. Provider credentialing and
				recredentialing;
3. Be
				knowledgeable about and participate in decisions regarding the Organization's
				operations;
4. Comply with A.R.S.
				§
										20-2510(B)
				and (C) when directly denying, on the basis
				of medical necessity, a health care provider's request for prior authorization;
				and
5. Timely respond to matters
				within the Organization's Arizona geographic area that require personal onsite
				attention or ensure that a designee who meets the requirements specified in
				subsection (D) timely responds to those matters.
Arizona Administrative Code › Title 20 - COMMERCE, FINANCIAL INSTITUTIONS, AND INSURANCE › Chapter 06 - DEPARTMENT OF INSURANCE AND FINANCIAL INSTITUTIONS - INSURANCE DIVISION › Article 18 - PREPAID DENTAL PLAN ORGANIZATIONS › Section R20-6-1805 - Required Reporting

Current through Register Vol. 30, No. 28, July 12, 2024
A. On or
				before March 1 of each year, an Organization shall submit the following
				information to the Department for the previous calendar year:
1. Member satisfaction survey results and
				supporting data;
2. A spreadsheet
				that lists the name, address, and telephone number of each provider and whether
				the provider: is accepting new members, is a general dentist or specialist, and
				has graduated from a specialty graduate program accredited by the American
				Dental Association;
3. A list of
				all contracted network general dentists and specialists that have been added or
				deleted since the previous annual report;
4. The total number of members and the number
				of members assigned to each general dentist's office;
5. The average member wait time measured in
				weeks for an appointment for each network dentistry office; and
6. A website link to its current provider
				directory.
Arizona Administrative Code › Title 20 - COMMERCE, FINANCIAL INSTITUTIONS, AND INSURANCE › Chapter 06 - DEPARTMENT OF INSURANCE AND FINANCIAL INSTITUTIONS - INSURANCE DIVISION › Article 18 - PREPAID DENTAL PLAN ORGANIZATIONS › Section R20-6-1806 - Basic Dental Services

Current through Register Vol. 30, No. 28, July 12, 2024
A. A
				prepaid dental plan shall provide the basic dental services listed below:
1. Emergency dental services on a
				24-hour-per-day basis,
2.
				Diagnostic services,
3. Preventive
				services, and
4. Restorative
				services.
Arizona Administrative Code › Title 20 - COMMERCE, FINANCIAL INSTITUTIONS, AND INSURANCE › Chapter 06 - DEPARTMENT OF INSURANCE AND FINANCIAL INSTITUTIONS - INSURANCE DIVISION › Article 18 - PREPAID DENTAL PLAN ORGANIZATIONS › Section R20-6-1807 - System for Delivery of Services

Current through Register Vol. 30, No. 28, July 12, 2024
A.
				An Organization shall have a system for delivery of services that includes:
1. An adequate network of general dentists.
				To determine network adequacy, the Department shall consider the following:
a. Geographic distribution of network general
				dentists' offices,
b. The number of
				dental offices accepting new members,
c. The percentage of all network members who
				are able to schedule an appointment within nine weeks,
d. The availability of trained clinical
				support staff in the Arizona geographic area,
e. The ratio of population growth to the
				increase or decrease in the number of dentists in the Arizona geographic area,
				and
f. Current availability for
				appointments in all general dentist practices in Arizona; and
Arizona Administrative Code › Title 20 - COMMERCE, FINANCIAL INSTITUTIONS, AND INSURANCE › Chapter 06 - DEPARTMENT OF INSURANCE AND FINANCIAL INSTITUTIONS - INSURANCE DIVISION › Article 18 - PREPAID DENTAL PLAN ORGANIZATIONS › Section R20-6-1808 - Geographic Areas

Current through Register Vol. 30, No. 28, July 12, 2024
A. An
				Organization shall designate the geographic areas in Arizona in which the
				Organization intends to provide dental services that are reasonably convenient
				to the prospective members. The Organization shall provide a description of the
				geographic areas and locations of all facilities in which dental care will be
				provided under the prepaid dental plan. This information shall accompany or be
				included in any advertisements or sales materials provided to prospective
				employer groups and prospective members.
B. An Organization shall define its
				geographic areas by
local government
				  jurisdictions, such as cities or counties
.
Arizona Administrative Code › Title 20 - COMMERCE, FINANCIAL INSTITUTIONS, AND INSURANCE › Chapter 06 - DEPARTMENT OF INSURANCE AND FINANCIAL INSTITUTIONS - INSURANCE DIVISION › Article 18 - PREPAID DENTAL PLAN ORGANIZATIONS › Section R20-6-1809 - Contract Requirements

Current through Register Vol. 30, No. 28, July 12, 2024
A. An
				Organization shall have a written contract with each provider that documents
				the requirements for providing services under the prepaid dental plan and the
				terms of the agreements between the parties. The Organization shall ensure that
				the provider complies with all contract requirements.
B. In addition to the requirements in
				subsection (A), an Organization shall ensure that its contract with a provider
				includes the following provisions:
1. That the
				Organization has authority to review the provider's records,
2. That the provider is responsible to
				implement and maintain a process to inform assigned members of the need to
				schedule periodic preventive dental services based on the member's oral health
				status, and
3. That the provider is
				responsible to complete any procedure undertaken upon a member if the contract
				is terminated or expires.
Arizona Administrative Code › Title 20 - COMMERCE, FINANCIAL INSTITUTIONS, AND INSURANCE › Chapter 06 - DEPARTMENT OF INSURANCE AND FINANCIAL INSTITUTIONS - INSURANCE DIVISION › Article 18 - PREPAID DENTAL PLAN ORGANIZATIONS › Section R20-6-1810 - Records

Current through Register Vol. 30, No. 28, July 12, 2024
A. Dental records
				are the property of the provider and shall not be removed from the provider's
				possession, except:
1. With the patient's
				permission, including for routing records to a dental or medical practitioner
				for consultation or evaluation; or
2. When subpoenaed by a court or
				BODEX.
Arizona Administrative Code › Title 20 - COMMERCE, FINANCIAL INSTITUTIONS, AND INSURANCE › Chapter 06 - DEPARTMENT OF INSURANCE AND FINANCIAL INSTITUTIONS - INSURANCE DIVISION › Article 18 - PREPAID DENTAL PLAN ORGANIZATIONS › Section R20-6-1811 - Quality Improvement

Current through Register Vol. 30, No. 28, July 12, 2024
A. An
				Organization shall have a governing authority.
B. The governing authority shall appoint a
				quality improvement committee that consists of the chief executive officer or
				designee, the dental director, the person who manages the Organization's
				quality improvement process, and at least one dental health professional. The
				committee may also include network allied health professionals and members of
				the plan.
C. The quality
				improvement committee shall:
1. Meet at least
				quarterly,
2. Review and evaluate
				dental services delivered under the Organization's plan, and
3. Establish procedures for recordkeeping and
				distribution of committee reports.
Arizona Administrative Code › Title 20 - COMMERCE, FINANCIAL INSTITUTIONS, AND INSURANCE › Chapter 06 - DEPARTMENT OF INSURANCE AND FINANCIAL INSTITUTIONS - INSURANCE DIVISION › Article 18 - PREPAID DENTAL PLAN ORGANIZATIONS › Section R20-6-1812 - Confidentiality of Records

Current through Register Vol. 30, No. 28, July 12, 2024
An Organization shall not disclose information obtained
				  pertaining to the diagnosis, treatment, or health of a member to any person
				  except:
1. To the extent necessary to
				carry out this Article;
2. Upon the
				express written consent of the member, applicant, provider, or Organization, as
				appropriate; or
3. Under statute or
				court order for the production or discovery of evidence or as part of a civil
				or criminal investigation.
Arizona Administrative Code › Title 20 - COMMERCE, FINANCIAL INSTITUTIONS, AND INSURANCE › Chapter 06 - DEPARTMENT OF INSURANCE AND FINANCIAL INSTITUTIONS - INSURANCE DIVISION › Article 18 - PREPAID DENTAL PLAN ORGANIZATIONS › Section R20-6-1813 - Assignment of Members

Current through Register Vol. 30, No. 28, July 12, 2024
A. Within 30
				days of enrollment, an Organization shall assign a member to the provider the
				member chooses. The Organization, however, shall choose and assign a provider
				to a member within 30 days of any of the following:
1. Receipt of a member enrollment form that
				does not designate a provider, or receipt of a member enrollment form that
				designates a provider who is unavailable;
2. The date of the notice that the member's
				assigned provider intends to cease providing services; or
3. The date the member's assigned provider
				becomes unavailable, for any reason.
Arizona Administrative Code › Title 20 - COMMERCE, FINANCIAL INSTITUTIONS, AND INSURANCE › Chapter 06 - DEPARTMENT OF INSURANCE AND FINANCIAL INSTITUTIONS - INSURANCE DIVISION › Article 19 - HEALTH CARE SERVICES ORGANIZATIONS OVERSIGHT › Section R20-6-1901 - Applicability

Current through Register Vol. 30, No. 28, July 12, 2024
A. This Article
				applies to:
1. All proposed and existing
				health care services organizations (HCSOs), and
2. Each product offered by an HCSO under the
				HCSO's certificate of authority.
Arizona Administrative Code › Title 20 - COMMERCE, FINANCIAL INSTITUTIONS, AND INSURANCE › Chapter 06 - DEPARTMENT OF INSURANCE AND FINANCIAL INSTITUTIONS - INSURANCE DIVISION › Article 19 - HEALTH CARE SERVICES ORGANIZATIONS OVERSIGHT › Section R20-6-1903 - Documentation

Current through Register Vol. 30, No. 28, July 12, 2024
The CEO shall ensure that the HCSO's policies, procedures,
				  plans, class specifications, orders, reports, minutes of meetings, contracts,
				  agreements, records, and duty schedules are in writing, compiled and indexed in
				  one or more manuals, and readily available for inspection by the
				  Director.
Arizona Administrative Code › Title 20 - COMMERCE, FINANCIAL INSTITUTIONS, AND INSURANCE › Chapter 06 - DEPARTMENT OF INSURANCE AND FINANCIAL INSTITUTIONS - INSURANCE DIVISION › Article 19 - HEALTH CARE SERVICES ORGANIZATIONS OVERSIGHT › Section R20-6-1904 - Health Care Plan

Current through Register Vol. 30, No. 28, July 12, 2024
A. An HCSO
				shall submit a statement to the Department that describes the proposed health
				care plan.
B. The HCSO shall have
				an organized system for the delivery of health care services contained in
				subsection (D) that includes the following:
1.
				Contracted providers that provide services under the plan;
2. An effective process to promote a
				continuing relationship between an enrollee and the same PCP; and
3. An effective process for referrals that
				ensures continuity of care to an enrollee.
Arizona Administrative Code › Title 20 - COMMERCE, FINANCIAL INSTITUTIONS, AND INSURANCE › Chapter 06 - DEPARTMENT OF INSURANCE AND FINANCIAL INSTITUTIONS - INSURANCE DIVISION › Article 19 - HEALTH CARE SERVICES ORGANIZATIONS OVERSIGHT › Section R20-6-1905 - Geographic Area

Current through Register Vol. 30, No. 28, July 12, 2024
A. An applicant
				shall describe the proposed geographic area in at least one of the following
				ways:
1. Legal description,
2. Local governmental jurisdiction such as
				city or county,
3. Census
				tracts,
4. Street boundaries,
				or
5. Area within a specified
				radius of a specified intersection or a specified primary care
				center.
Arizona Administrative Code › Title 20 - COMMERCE, FINANCIAL INSTITUTIONS, AND INSURANCE › Chapter 06 - DEPARTMENT OF INSURANCE AND FINANCIAL INSTITUTIONS - INSURANCE DIVISION › Article 19 - HEALTH CARE SERVICES ORGANIZATIONS OVERSIGHT › Section R20-6-1906 - Chief Executive Officer

Current through Register Vol. 30, No. 28, July 12, 2024
A.
				The governing authority shall appoint a CEO who has appropriate education and
				experience to manage the HCSO. The governing authority shall define the
				authority and duties of the CEO in writing. The CEO is the appointed
				representative of the governing authority and is the executive officer of the
				HCSO.
B. The CEO shall have at
				least the following duties and responsibilities:
1. Manage the HCSO;
2. Establish and implement policies,
				procedures, and effective processes of the HCSO;
3. Act as liaison between the governing
				authority and the providers of healthcare and other services to the HCSO;
				and
4. Establish a written plan of
				authority that will be in place in the CEO's absence.
Arizona Administrative Code › Title 20 - COMMERCE, FINANCIAL INSTITUTIONS, AND INSURANCE › Chapter 06 - DEPARTMENT OF INSURANCE AND FINANCIAL INSTITUTIONS - INSURANCE DIVISION › Article 19 - HEALTH CARE SERVICES ORGANIZATIONS OVERSIGHT › Section R20-6-1907 - Medical Director

Current through Register Vol. 30, No. 28, July 12, 2024
A. The
				HCSO shall designate a physician as medical director.
B. The medical director shall be responsible
				for planning and implementing the method for the continuing review and
				evaluation of health care provided by the HCSO and the continuing education of
				its providers of health care services. The medical director may also serve as
				the CEO if the medical director has appropriate education and experience to
				manage the HCSO.
C. The medical
				director responsibilities include:
1.
				Supervising medical staff;
2.
				Performance planning and evaluating medical staff;
3. Coordinating medical staff activities;
				and
4. Developing medical care
				policies.
Arizona Administrative Code › Title 20 - COMMERCE, FINANCIAL INSTITUTIONS, AND INSURANCE › Chapter 06 - DEPARTMENT OF INSURANCE AND FINANCIAL INSTITUTIONS - INSURANCE DIVISION › Article 19 - HEALTH CARE SERVICES ORGANIZATIONS OVERSIGHT › Section R20-6-1908 - Quality Assurance

Current through Register Vol. 30, No. 28, July 12, 2024
A. The
				HCSO shall provide an effective process for a continuing review and evaluation
				of the covered services it provides to enrollees to ensure that:
1. Treatment and level of covered services
				are appropriate and adequate and
2.
				The quality of covered services is acceptable to the HCSO.
Arizona Administrative Code › Title 20 - COMMERCE, FINANCIAL INSTITUTIONS, AND INSURANCE › Chapter 06 - DEPARTMENT OF INSURANCE AND FINANCIAL INSTITUTIONS - INSURANCE DIVISION › Article 19 - HEALTH CARE SERVICES ORGANIZATIONS OVERSIGHT › Section R20-6-1909 - Evaluation of Network

Current through Register Vol. 30, No. 28, July 12, 2024
Each HCSO shall have an effective process to evaluate the
				  adequacy of its network to provide an enrollee with timely covered
				  services.
Arizona Administrative Code › Title 20 - COMMERCE, FINANCIAL INSTITUTIONS, AND INSURANCE › Chapter 06 - DEPARTMENT OF INSURANCE AND FINANCIAL INSTITUTIONS - INSURANCE DIVISION › Article 19 - HEALTH CARE SERVICES ORGANIZATIONS OVERSIGHT › Section R20-6-1910 - Process for Referral, Prior Authorization, Pre-certification, or Network Exception

Current through Register Vol. 30, No. 28, July 12, 2024
A. An HCSO
				shall have an effective process for assisting an enrollee to obtain timely
				covered services when the enrollee or enrollee's referring provider cannot find
				a contracted provider who is timely accessible or available.
B. An HCSO shall have an effective process
				during normal business hours for handling referrals, prior authorizations,
				pre-certifications, or network exceptions necessary for timely routine care.
				This process may include the HCSO's procedure for standing referrals required
				in A.R.S. §
									20-1057.01.
C. Each HCSO shall have an effective process
				to handle referrals or network exceptions necessary for timely urgent care
				seven days a week.
D. An HCSO that
				requires prior authorization or precertification for urgent care shall have an
				effective process to handle requests for prior authorization or
				precertification 24 hours a day, seven days a week.
E. An HCSO shall have an effective process
				for handling network exceptions that ensures the HCSO reimburses an enrollee
				for any out-of-network cost the enrollee incurs that the enrollee would not
				have incurred if the enrollee had received the services in-network.
Arizona Administrative Code › Title 20 - COMMERCE, FINANCIAL INSTITUTIONS, AND INSURANCE › Chapter 06 - DEPARTMENT OF INSURANCE AND FINANCIAL INSTITUTIONS - INSURANCE DIVISION › Article 19 - HEALTH CARE SERVICES ORGANIZATIONS OVERSIGHT › Section R20-6-1911 - HCSO Communication with Providers

Current through Register Vol. 30, No. 28, July 12, 2024
An HCSO shall have an effective process for communicating
				  with contracted providers regarding the following:
1. The providers in the network,
2. Contractual or administrative changes
				relating to enrollee access or provider availability, and
3. Procedures for handling claims and
				grievances submitted by providers.
Arizona Administrative Code › Title 20 - COMMERCE, FINANCIAL INSTITUTIONS, AND INSURANCE › Chapter 06 - DEPARTMENT OF INSURANCE AND FINANCIAL INSTITUTIONS - INSURANCE DIVISION › Article 19 - HEALTH CARE SERVICES ORGANIZATIONS OVERSIGHT › Section R20-6-1912 - Network Directories

Current through Register Vol. 30, No. 28, July 12, 2024
A. An HCSO
				shall publish a provider network directory as follows:
1. An HCSO shall list the name, address,
				telephone number, specialty, and hospital affiliation for all in-area
				contracted physicians or practitioners.
2. An HCSO may list ancillary providers by
				corporate or group name and is not required to list individual physicians or
				practitioners.
3. An HCSO is not
				required to list physicians or practitioners in the following areas of
				specialties or areas of practice:
a.
				Emergency medicine;
b.
				Anesthesiology, except anesthesiologists who provide pain management
				services;
c. Hospital-based
				pathology;
d. Hospital-based
				radiology; and
e.
				Hospitalists.
4. An HCSO
				that lists any of the physicians or practitioners in subsections
				R20-6-1912(A)(3)(a)
				through (A)(3)(e) may list by corporate or
				group name and is not required to list individual physicians or
				practitioners.
5. An HCSO that uses
				hospitalists is not required to list the hospital affiliations of PCPs who do
				not admit or attend hospitalized members.
6. An HCSO shall publish a provider network
				directory that lists all its contracted facilities and contains:
a. The name, address, and telephone number of
				each facility;
b. For each hospital
				at which the HCSO uses hospitalists, if any, a statement that the HCSO uses
				hospitalists at that hospital;
c.
				For an HCSO that uses hospitalists and does not list them in the directory,
				information on how an enrollee can find out what hospitalists or group of
				hospitalists it uses at each hospital;
Arizona Administrative Code › Title 20 - COMMERCE, FINANCIAL INSTITUTIONS, AND INSURANCE › Chapter 06 - DEPARTMENT OF INSURANCE AND FINANCIAL INSTITUTIONS - INSURANCE DIVISION › Article 19 - HEALTH CARE SERVICES ORGANIZATIONS OVERSIGHT › Section R20-6-1913 - Demographic Information Reports

Current through Register Vol. 30, No. 28, July 12, 2024
A.
				An HCSO shall report the following data to the Department:
1. For each enrollee, report annually:
a. Street address,
b. Zip code,
c. Gender, and
d. Year of birth.
Arizona Administrative Code › Title 20 - COMMERCE, FINANCIAL INSTITUTIONS, AND INSURANCE › Chapter 06 - DEPARTMENT OF INSURANCE AND FINANCIAL INSTITUTIONS - INSURANCE DIVISION › Article 19 - HEALTH CARE SERVICES ORGANIZATIONS OVERSIGHT › Section R20-6-1914 - Access

Current through Register Vol. 30, No. 28, July 12, 2024
An HCSO shall provide to or arrange for its enrollees
				  services or appointments for services as follows:
1. For preventive care services from a
				contracted PCP, an appointment date within 60 days of the enrollee's request,
				or sooner if necessary, for the enrollee to be immunized on schedule.
2. For routine-care services from a
				contracted PCP, an appointment date within 15 days of the enrollee's request to
				the PCP or sooner if medically necessary.
3. For specialty care services from a
				contracted SCP, an appointment date within 60 days of the enrollee's request or
				sooner if medically necessary.
4.
				In-area urgent care services from a contracted provider seven days per
				week.
5. Timely non-emergency
				inpatient care services from a contracted facility.
6. Timely services from a contracted
				physician or practitioner in a contracted facility including inpatient
				emergency care.
7. Services from a
				contracted ancillary provider during normal business hours, or sooner if
				medically necessary.
Arizona Administrative Code › Title 20 - COMMERCE, FINANCIAL INSTITUTIONS, AND INSURANCE › Chapter 06 - DEPARTMENT OF INSURANCE AND FINANCIAL INSTITUTIONS - INSURANCE DIVISION › Article 19 - HEALTH CARE SERVICES ORGANIZATIONS OVERSIGHT › Section R20-6-1915 - Alternative Access

Current through Register Vol. 30, No. 28, July 12, 2024
A. As an
				alternative to providing access to covered services from a physician, an HCSO
				may provide access to covered services from an appropriately licensed
				practitioner.
B. As an alternative
				to providing access to covered services at a hospital under
				R20-6-1914, an
				HCSO may provide access to covered services at another appropriately licensed
				facility.
C. As an alternative to
				providing access to covered services from a physician or practitioner who sees
				an enrollee in person under
				R20-6-1914, an
				HCSO may provide access to necessary covered services through:
1. Telephone calls and messages,
2. Electronic mail,
3. Communication with the physician's or
				practitioner's staff,
4. Coverage
				by another physician or practitioner, or
5. Telemedicine,
Arizona Administrative Code › Title 20 - COMMERCE, FINANCIAL INSTITUTIONS, AND INSURANCE › Chapter 06 - DEPARTMENT OF INSURANCE AND FINANCIAL INSTITUTIONS - INSURANCE DIVISION › Article 19 - HEALTH CARE SERVICES ORGANIZATIONS OVERSIGHT › Section R20-6-1916 - Availability Ratios

Current through Register Vol. 30, No. 28, July 12, 2024
A. An HCSO
				shall maintain a ratio of contracted adult PCPs to adults that is adequate to
				provide those adults with covered services. An HCSO with a Medicare Advantage
				(MA) plan may have one ratio that applies to both its insured and MA
				populations, or a separate ratio for each.
B. An HCSO shall maintain a ratio of
				contracted pediatric PCPs to children that is adequate to provide those
				children enrollees with covered services.
C. An HCSO shall maintain a ratio of
				contracted high profile SCPs to enrollees that is adequate to provide those
				enrollees with covered services that include services at contracted facilities.
				An HCSO with a MA plan may have one ratio that applies to both its insured and
				MA populations, or a separate ratio for each.
Arizona Administrative Code › Title 20 - COMMERCE, FINANCIAL INSTITUTIONS, AND INSURANCE › Chapter 06 - DEPARTMENT OF INSURANCE AND FINANCIAL INSTITUTIONS - INSURANCE DIVISION › Article 19 - HEALTH CARE SERVICES ORGANIZATIONS OVERSIGHT › Section R20-6-1917 - Geographic Availability in an Urban Area

Current through Register Vol. 30, No. 28, July 12, 2024
An HCSO shall provide each enrollee living in an urban area
				  of the HCSO's service area the following:
1. Primary care services from a contracted
				PCP located within 10 miles or 30 minutes of the enrollee's home;
2. High profile specialty care services from
				a contracted SCP located within 15 miles or 45 minutes of the enrollee's home;
				and
3. Inpatient care in a
				contracted general hospital, or contracted special hospital, within 25 miles or
				75 minutes of the enrollee's home.
Arizona Administrative Code › Title 20 - COMMERCE, FINANCIAL INSTITUTIONS, AND INSURANCE › Chapter 06 - DEPARTMENT OF INSURANCE AND FINANCIAL INSTITUTIONS - INSURANCE DIVISION › Article 19 - HEALTH CARE SERVICES ORGANIZATIONS OVERSIGHT › Section R20-6-1918 - Geographic Availability in a Suburban Area

Current through Register Vol. 30, No. 28, July 12, 2024
Each HCSO shall provide each enrollee member living in a
				  suburban area within the HCSO's service area the following:
1. Primary care from a contracted PCP located
				within 15 miles or 45 minutes of the enrollee's home;
2. High profile specialty care services from
				a contracted SPC within 20 miles or 60 minutes of the enrollee's home;
				and
3. Inpatient care in a
				contracted hospital, or a contracted special hospital within 30 miles or 90
				minutes of the enrollee's home.
Arizona Administrative Code › Title 20 - COMMERCE, FINANCIAL INSTITUTIONS, AND INSURANCE › Chapter 06 - DEPARTMENT OF INSURANCE AND FINANCIAL INSTITUTIONS - INSURANCE DIVISION › Article 19 - HEALTH CARE SERVICES ORGANIZATIONS OVERSIGHT › Section R20-6-1919 - Geographic Availability in a Rural Area

Current through Register Vol. 30, No. 28, July 12, 2024
An HCSO shall provide each enrollee living in a rural area
				  with primary care services from a contracted physician or practitioner within
				  30 miles or 90 minutes of the enrollee's home.
Arizona Administrative Code › Title 20 - COMMERCE, FINANCIAL INSTITUTIONS, AND INSURANCE › Chapter 06 - DEPARTMENT OF INSURANCE AND FINANCIAL INSTITUTIONS - INSURANCE DIVISION › Article 19 - HEALTH CARE SERVICES ORGANIZATIONS OVERSIGHT › Section R20-6-1920 - Travel Requirements

Current through Register Vol. 30, No. 28, July 12, 2024
A. An HCSO
				may require an enrollee to travel a greater distance in-area to obtain covered
				services from a contracted provider than the enrollee would have to travel to
				obtain equivalent services from a non-contracted provider, except where a
				network exception is medically necessary. Nothing in this Section creates an
				exception to
				R20-6-1918
				through
				R20-6-1920.
B. If the HCSO prior-authorizes services that
				require an enrollee to travel outside the HCSO service area because the
				services are not available in the area, the HCSO shall reimburse the enrollee
				for travel expenses. Except as provided under
				R20-6-1904(E)(6),
				an HCSO is not required to reimburse an enrollee for travel expenses the
				enrollee incurs to obtain covered services in-area.
Arizona Administrative Code › Title 20 - COMMERCE, FINANCIAL INSTITUTIONS, AND INSURANCE › Chapter 06 - DEPARTMENT OF INSURANCE AND FINANCIAL INSTITUTIONS - INSURANCE DIVISION › Article 19 - HEALTH CARE SERVICES ORGANIZATIONS OVERSIGHT › Section R20-6-1921 - Enforcement Consideration

Current through Register Vol. 30, No. 28, July 12, 2024
In determining the appropriate enforcement action or
				  penalties for failure to comply with these rules, the Department shall consider
				  any documentation the HCSO provides regarding:
1. Whether seasonal shifts in demand affect
				access and availability of covered services;
2. Whether the HCSO's demographic information
				has changed significantly since the HCSO's most recent report;
3. Whether an enrollee has refused to accept
				covered services the HCSO has offered in the time-frames or locations required
				of the HCSO by this Article;
4.
				Whether an enrollee has requested and obtained covered services from a
				contracted provider whose location, or appointment availability, or capacity
				result in the HCSO's non-compliance; and
5. Whether market factors indicate that on a
				short-term basis, compliance is not possible. Market factors include shortage
				of providers, enrollee or provider location, and provider practice or
				contracting patterns.
Arizona Administrative Code › Title 20 - COMMERCE, FINANCIAL INSTITUTIONS, AND INSURANCE › Chapter 06 - DEPARTMENT OF INSURANCE AND FINANCIAL INSTITUTIONS - INSURANCE DIVISION › Article 20 - CAPTIVE INSURERS › Section R20-6-2002 - Fees; Examination Costs

Current through Register Vol. 30, No. 28, July 12, 2024
A. A corporation
				applying for a license to do business as a captive insurer shall pay a
				nonrefundable fee of $1,000.00 to the Department for issuance of the license
				under A.R.S. §
									20-1098.01(J). A
				captive insurer that is a protected cell captive insurer, as defined in A.R.S.
				§
									20-1098, also shall pay to the
				Department a nonrefundable fee of $1,000 for each participant contract
				application that establishes a protected cell under A.R.S. §
									20-1098.05(B)(9).
				The fee is payable in full at the time the applicant submits the application
				for license to the Department under A.R.S. §
									20-1098.01.
B. A captive insurer shall pay a
				nonrefundable annual renewal fee of $5,500.00 to the Department at the time of
				filing its annual report under A.R.S. §
									20-1098.07. Under A.R.S. §
									20-1098.01(J), a
				captive insurer that is a protected cell captive insurer also shall pay to the
				Department a nonrefundable annual renewal fee of $2,500.00 for each protected
				cell at the time of filing its annual report under A.R.S. §
									20-1098.07.
C. A captive insurer shall pay a
				nonrefundable fee of $200.00 to the Department at the time of filing for
				issuance of an amended certificate of authority.
D. In addition to the fees prescribed in
				subsections (A), (B), and (C), an applicant for a captive insurer license or a
				licensed captive insurer shall pay the costs of any examination the Director
				conducts, under A.R.S. §
									20-1098.08.
Arizona Administrative Code › Title 20 - COMMERCE, FINANCIAL INSTITUTIONS, AND INSURANCE › Chapter 06 - DEPARTMENT OF INSURANCE AND FINANCIAL INSTITUTIONS - INSURANCE DIVISION › Article 21 - CUSTOMER INFORMATION SECURITY PROGRAM › Section R20-6-2101 - Definitions

Current through Register Vol. 30, No. 28, July 12, 2024
The following definitions apply in this Article:
1. "Consumer" means an individual, or the individual's legal
				  representative, who seeks to obtain, obtains, or has obtained an insurance
				  product or service from a licensee that is to be used primarily for personal,
				  family, or household purposes, and about whom the licensee has nonpublic
				  personal information. Consumer can include a prospective applicant,
				  policyholder, certificateholder, insured, or claimant.
2. "Customer" means a consumer who has a continuing
				  relationship with a licensee under which the licensee provides one or more
				  insurance products or services to the consumer that are used primarily for
				  personal, family, or household purposes.
3. "Customer information" means nonpublic personal
				  information and privileged information about a customer whether in paper,
				  electronic, or other form, that is maintained by or on behalf of an insurance
				  institution, insurance producer, or insurance support organization.
4. "Customer information systems" means the electronic, or
				  physical methods used to access, collect, store, use, transmit, protect, or
				  dispose of customer information.
5. "Insurance institution" has the meaning prescribed in
				  A.R.S. §
									20-2102(10).
6. "Insurance producer" means a person required to be
				  licensed under A.R.S. Title 20, Chapter 2, Article 3 to sell, solicit, or
				  negotiate insurance and includes a managing general agent as defined in A.R.S.
				  §
									20-311.
7. "Insurance support organization" has the meaning
				  prescribed in A.R.S. §
									20-2102(13).
8. "Licensee" means an insurance institution, insurance
				  producer, or insurance support organization, but does not include a purchasing
				  group or an unauthorized insurer in regard to the excess line business
				  conducted under Title 20, Chapter 2, Article 5.
9. "Personal information" has the meaning prescribed in
				  A.R.S. §
									20-2102(19).
10. "Privileged information" has the meaning prescribed in
				  A.R.S. §
									20-2102(22).
11. "Service provider" means a person that maintains,
				  processes, or otherwise is permitted access to customer information through its
				  provision of services directly to a licensee.
Arizona Administrative Code › Title 20 - COMMERCE, FINANCIAL INSTITUTIONS, AND INSURANCE › Chapter 06 - DEPARTMENT OF INSURANCE AND FINANCIAL INSTITUTIONS - INSURANCE DIVISION › Article 21 - CUSTOMER INFORMATION SECURITY PROGRAM › Section R20-6-2102 - Customer Information Security Program

Current through Register Vol. 30, No. 28, July 12, 2024
A licensee shall implement a comprehensive written customer
				  information security program that includes administrative, technical, and
				  physical safeguards for the protection of customer information. The
				  administrative, technical, and physical safeguards included in the information
				  security program shall be appropriate to the size and complexity of the
				  licensee and the nature and scope of its activities.
Arizona Administrative Code › Title 20 - COMMERCE, FINANCIAL INSTITUTIONS, AND INSURANCE › Chapter 06 - DEPARTMENT OF INSURANCE AND FINANCIAL INSTITUTIONS - INSURANCE DIVISION › Article 21 - CUSTOMER INFORMATION SECURITY PROGRAM › Section R20-6-2103 - Objectives of Customer Information Security Program

Current through Register Vol. 30, No. 28, July 12, 2024
A licensee's customer information security program shall be
				  designed to:
1. Ensure the security
				and confidentiality of customer information;
2. Protect against any anticipated threats or
				hazards to the security or integrity of the information; and
3. Protect against unauthorized access to or
				use of the information.
Arizona Administrative Code › Title 20 - COMMERCE, FINANCIAL INSTITUTIONS, AND INSURANCE › Chapter 06 - DEPARTMENT OF INSURANCE AND FINANCIAL INSTITUTIONS - INSURANCE DIVISION › Article 21 - CUSTOMER INFORMATION SECURITY PROGRAM › Section R20-6-2104 - Guidelines for Methods of Development and Implementation

Current through Register Vol. 30, No. 28, July 12, 2024
A licensee may implement the requirements of
				  R20-6-2102
				  and
				  R20-6-2103
				  by the actions and procedures prescribed in this Section, which are
				  non-exclusive illustrations:
1. A
				licensee may assess risk by:
a. Identifying
				reasonably foreseeable internal or external threats that could result in
				unauthorized disclosure, misuse, alteration, or destruction of customer
				information or customer information systems;
b. Assessing the likelihood and potential
				damage of these threats, taking into consideration the sensitivity of customer
				information; and
c. Assessing the
				sufficiency of policies, procedures, customer information systems, and other
				safeguards in place to control risks.
Arizona Administrative Code › Title 20 - COMMERCE, FINANCIAL INSTITUTIONS, AND INSURANCE › Chapter 06 - DEPARTMENT OF INSURANCE AND FINANCIAL INSTITUTIONS - INSURANCE DIVISION › Article 23 - THRESHOLD RATE REVIEW - INDIVIDUAL HEALTH INSURANCE › Section R20-6-2301 - Applicability; Definitions

Current through Register Vol. 30, No. 28, July 12, 2024
A. This
				Article applies to rates charged by health insurers for individual health
				insurance. This Article does not apply to rates charged by health insurers for
				the following:
1. Health insurance that a
				health insurer issues to an employer or to any group described in either A.R.S.
				§
										20-1401 or A.R.S.
				§
										20-1404(A),
				except health insurance issued to an association or its individual members as
				described in R20-6-2301(B)(7)(b);
2. Grandfathered health plan coverage as
				defined in
				45 CFR
				147.140; or
3. Health insurance that covers excepted
				benefits as described in section 2791(c) of the PHS Act,
				42 U.S.C.
				300gg -
				91(c).
Arizona Administrative Code › Title 20 - COMMERCE, FINANCIAL INSTITUTIONS, AND INSURANCE › Chapter 06 - DEPARTMENT OF INSURANCE AND FINANCIAL INSTITUTIONS - INSURANCE DIVISION › Article 23 - THRESHOLD RATE REVIEW - INDIVIDUAL HEALTH INSURANCE › Section R20-6-2302 - Disclosure of Preliminary Justification

Current through Register Vol. 30, No. 28, July 12, 2024
A. Preliminary Justification. For each
				threshold rate increase for each affected product, a health insurer shall
				submit to the Department and to CMS, on a form and in the manner prescribed by
				the Secretary in
				45 CFR
				154.215, a preliminary justification that
				contains all of the following:
1. Preliminary
				Justification Part I. A summary of the content of the threshold rate increase
				that includes:
a. Historical and projected
				claims experience;
b. Trend
				projections related to utilization, and service or unit cost;
c. Any claims assumptions related to benefit
				changes;
d. Allocation of the
				overall rate increase to claims and non-claims costs;
e. Per enrollee per month allocation of
				current and projected premium; and
f. Three year history of rate increases for
				the product associated with the rate increase.
Arizona Administrative Code › Title 20 - COMMERCE, FINANCIAL INSTITUTIONS, AND INSURANCE › Chapter 06 - DEPARTMENT OF INSURANCE AND FINANCIAL INSTITUTIONS - INSURANCE DIVISION › Article 23 - THRESHOLD RATE REVIEW - INDIVIDUAL HEALTH INSURANCE › Section R20-6-2303 - Timing for Submission of Preliminary Justification

Current through Register Vol. 30, No. 28, July 12, 2024
A. If
				R20-6-607
				applies to a threshold rate increase, the health insurer shall submit its
				preliminary justification to the Department and to CMS on the date on which the
				health insurer files the rate increase request under
				R20-6-607.
B. If
				R20-6-607
				does not apply to a threshold rate increase, the health insurer shall submit
				the preliminary justification to the Department and to CMS at least 60 days
				prior to the date the health insurer intends to implement the threshold rate
				increase in Arizona.
C. The
				Department shall provide access from its website to the Parts I and II of the
				Preliminary Justifications of the proposed rate increases that it reviews and
				have a mechanism for receiving public comments on those proposed rate
				increases.
Arizona Administrative Code › Title 20 - COMMERCE, FINANCIAL INSTITUTIONS, AND INSURANCE › Chapter 06 - DEPARTMENT OF INSURANCE AND FINANCIAL INSTITUTIONS - INSURANCE DIVISION › Article 23 - THRESHOLD RATE REVIEW - INDIVIDUAL HEALTH INSURANCE › Section R20-6-2304 - Response to Unreasonableness Determination

Current through Register Vol. 30, No. 28, July 12, 2024
If the health insurer receives from CMS a notice that the
				  Department has determined that the health insurer's threshold rate increase is
				  unreasonable, the health insurer shall select one of the following three
				  options:
1. Option to not implement
				the rate increase determined unreasonable. Within 30 days of receiving from CMS
				the Department's determination, the health insurer shall notify the Department
				and CMS that it will not implement the rate increase and request the Department
				to withdraw the rate increase request;
2. Option to implement a smaller rate
				increase than the rate determined unreasonable. Within 30 days of receiving
				from CMS the Department's determination, the health insurer shall notify the
				Department and CMS, on a form and in the manner prescribed by the Secretary,
				that it intends to implement a rate increase that is smaller than the one
				determined unreasonable. One of the following shall apply to this option:
a. If the health insurer selects this option
				and the smaller rate increase is not a threshold rate increase, the smaller
				rate increase is not subject to this Article;
b. If the health insurer selects this option,
				and
				R20-6-607
				applied to the rate increase the Department determined to be unreasonable, the
				health insurer shall revise the rate increase filing to reflect the smaller
				rate increase or file a new rate increase. If the smaller rate increase is a
				threshold rate increase, the health insurer shall submit a new preliminary
				justification on the date the health insurer revises the rate increase filing
				or files a new rate increase; or
c.
				If the health insurer selects this option, and
				R20-6-607
				did not apply to the rate increase the Department determined to be
				unreasonable, and the smaller increase is a threshold rate increase, the health
				insurer shall submit to the Department and to CMS a new preliminary
				justification at least 60 days prior to the date the health insurer intends to
				implement the smaller increase in Arizona.