Alabama Administrative Code › Title 420 - ALABAMA STATE BOARD OF HEALTH › Chapter 420-5-6 - HEALTH MAINTENANCE ORGANIZATIONS › Section 420-5-6-.02 - Content Of Application For Certificate Of Authority

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Each application for a certificate of
			 authority under
Code of Ala. 1975
, §§
								27-21A-1,
et
seq
., shall be made to the
			 Commissioner of the Department of Insurance and to the State Health Officer.
			 "Certificate of Authority" means the document issued by the State Insurance
			 Commissioner permitting a person to establish, maintain and operate a health
			 maintenance organization. The application specific to the Alabama Department of
			 Public Health shall contain the following:
(a) Copies of the basic organizational
			 documents such as the certificate of incorporation, bylaws, rules, articles of
			 association, partnership agreement, trust agreement or other applicable
			 documents and agreements regulating the conduct of the internal affairs of the
			 applicant and all amendments thereto;
(b) A list and organization chart of the
			 names and addresses and official positions of the members of the board of
			 directors, officers, controlling persons, owners, or partners, the medical
			 director and the administrator of the proposed health maintenance organization
			 and any other persons responsible for the health services system of the health
			 maintenance organization;
(c) A
			 resume of the medical director, administrator and all department managers;
1. "Administrator" means a person who
			 demonstrates competence and experience in health maintenance organization
			 management; who is assigned the responsibility for the interpretation,
			 implementation, and proper application of policies and programs established by
			 the governing body; is assigned responsibility for the establishment and
			 maintenance of effective management, control, and operation of the services
			 provided; and, is responsible for coordination of activities and communication
			 between the Department, the governing body, and the health delivery systems.
			 The administrator shall be available and accessible to the Department. In the
			 absence of the administrator, an individual shall be designated, in writing,
			 who shall be authorized to act on the administrator's behalf.
2. "Medical Director" means a physician who
			 oversees medical aspects of the plan, supervises the quality improvement and
			 utilization management programs and advises the governing body on the adoption
			 and enforcement of policies concerning medical services. A medical director
			 must have a current license to practice medicine granted by the Medical
			 Licensure Commission of Alabama. Alternately, an HMO may employ, for no longer
			 than 12 months, an individual as medical director provided that the individual
			 is eligible in all respects for licensure as an Alabama physician and the
			 individual has a current active application for licensure on file with the
			 Medical Licensure Commission of Alabama.
(d) A detailed description of the proposed
			 health maintenance organization's potential ability to assure both the
			 availability and accessibility of adequate personnel and facilities to serve
			 enrollees in a manner enhancing availability, accessibility, and
			 continuity;
(e) A description of
			 the service area of the proposed health maintenance organization (geographic
			 boundaries, demographic data, and identification of population groups of
			 enrollees);
(f) Information
			 regarding proposed practice site locations and hours of operation;
(g) A list of proposed providers with
			 physical address and phone number;
(h) A copy of the applicant's proposed
			 contracts and marketing documents with enrollees and group contracts with
			 employers, unions, trustees, or other organizations, setting forth the
			 corporation's contractual obligation to provide a minimum of basic health
			 services;
(i) Applicant's provider
			 contracts with physicians, groups of physicians organized on a group practice
			 or individual practice basis, hospitals, and other providers of health care
			 services enabling it to provide basic and frequently utilized specialty health
			 services to an enrolled population;
(j) A detailed description of the applicant's
			 proposed complaint system whereby the complaints of the enrollees may be acted
			 upon promptly and satisfactorily;
(k) A detailed description of the applicant's
			 arrangements for ongoing quality-of-health-care assurance program;
(l) A detailed description of the applicant's
			 capability to collect and analyze necessary data relating to the utilization of
			 health care services;
(m) Job
			 descriptions of the medical director, administrator and department
			 managers;
(n) A procedure for
			 referral of enrollees to nonparticipating specialists;
(o) A copy of written procedures for
			 provision and payment of emergency services;
(p) A copy of the written procedures
			 regarding the method for providing frequently utilized services required by
			 420-5-6-.06(11);
(q) An organizational chart demonstrating the
			 delegation of authority and control of the health services delivery system,
			 from the highest authority (governing body) to the physician, with support
			 documentation demonstrating that all personnel at each level of authority have
			 the requisite expertise for their particular area of authority.
(r) A detailed description of how medical
			 records will be maintained;
(s)
			 Evidence that the proposed health maintenance organization has complied with
			 Alabama Health Planning Laws, §§
									22-21-260
et
seq
.;
(t) Any other pertinent information;
			 and
(u) A health maintenance
			 organization shall not materially alter, amend, modify, suspend, or delete any
			 of the provisions of any document submitted in connection with an application
			 for a Certificate of Authority unless in accordance with
Code of
			 Ala. 1975
, §
									27-21A-2(d)(1).
			 The State Health Officer will forward in a timely manner a recommendation to
			 the Commissioner of Insurance that the requested alteration, modification,
			 amendment, suspension, addition or deletion be approved or disapproved in
			 accordance with
Code of Ala. 1975
, §
									27-21A-17(a)(1).
Author:
Department of Public
				Health