Title 24, Insurance

§432D-5 Annual and quarterly reports. (a) Every health maintenance organization shall file annually, on or before March 1, a report verified by at least two principal officers covering the preceding calendar year. Each health maintenance organization shall file quarterly with the…

[§432D-6] Information to enrollees or subscribers. (a) The health maintenance organization shall provide to its subscribers a list of providers and participating providers, upon enrollment and reenrollment. (b) Every health maintenance organization shall provide to its subscriber…

§432D-7 Investments. All investments permitted under section 432D-3(a)(1) may be considered admitted assets in determination of net worth; provided that these investments are in compliance with article 6 of chapter 431. [L 1995, c 179, pt of §1; am L 2000, c 74, §5; am L 2003, c …

§432D-8 Protection against insolvency. (a) Net worth requirements are as follows: (b) Deposit requirements are as follows: (c) Every health maintenance organization, when determining liabilities, shall include an amount estimated in the aggregate to provide for any unearned premi…

§432D-9 Uncovered expenditures insolvency deposit. (a) If, at any time, uncovered expenditures exceed ten per cent of total health care expenditures, a health maintenance organization shall place with the commissioner or with any organization or trustee acceptable to the commissi…

[§432D-9.5] Reserve credit for reinsurance. Any health maintenance organization that takes credit for reserves on risks ceded to a reinsurer shall be subject to provisions of chapter 431 related to credit for reinsurance. [L 2000, c 74, §2]

PART I. GENERAL PROVISIONS §432E-1 Definitions. As used in this chapter, unless the context otherwise requires: "Adverse action" means an adverse determination or a final adverse determination. "Adverse determination" means a determination by a health carrier or its designated ut…

§432E-1.4 Medical necessity. (a) For contractual purposes, a health intervention shall be covered if it is an otherwise covered category of service, not specifically excluded, recommended by the treating licensed health care provider, and determined by the health plan's medical d…

§432E-1.5 Licensure of managed care plan medical directors. The medical director of any managed care plan providing services in the State shall hold an unlimited license to practice medicine or osteopathic medicine in the State pursuant to chapter 453. [L 1999, c 273, §1; am L 20…

§432E-10 Managed care plan performance measurement and data reporting standards. (a) It is the policy of this State that all managed care plans shall adopt and comply with nationally developed and promulgated standards for measuring quality, outcomes, access, satisfaction, and ut…

§432E-11 Accreditation of managed care plans. (a) Beginning January 1, 1999, the commissioner shall contract with one or more certified vendors of the consumer assessment health plan survey to conduct a survey of all managed care plans actively offering managed care plans in this…

[§432E-12] Rules. The commissioner shall adopt rules pursuant to chapter 91 necessary for the purposes of this chapter. [L 1999, c 137, pt of §2]

[§432E-13] Annual report. The commissioner shall submit annually to the legislature a report that shall contain the number of external review hearing cases reviewed, the type of cases reviewed, a summary of the nature of the cases reviewed, and the disposition of the cases review…

[§432E-2] Conflict with other laws. If there is a conflict with any other law, this chapter shall prevail to the extent that this chapter offers greater protection or rights to the enrollee. [L 1998, c 178, pt of §2]

[PART IV.] EXTERNAL REVIEW OF HEALTH INSURANCE DETERMINATIONS [§432E-31] Applicability and scope. (a) Except as provided in subsection (b), this part shall apply to all health carriers. (b) This part shall not apply to a policy or certificate that provides coverage only for a spe…

[§432E-32] Notice of right to external review. Notice of the right to external review issued pursuant to this part shall set forth the options available to the enrollee under this part. The commissioner may specify the form and content of notice of external review. [L 2011, c 230…

[§432E-33] Request for external review. (a) All requests for external review of a health carrier's adverse action shall be made in writing to the commissioner and shall include: The commissioner shall waive the filing fee required by this subsection if the commissioner determines…

§432E-34 Standard external review. (a) An enrollee or the enrollee's appointed representative may file a request for an external review with the commissioner within one hundred thirty days of receipt of notice of an adverse action. Within three business days after the receipt of …

§432E-35 Expedited external review. (a) Except as provided in subsection (i), an enrollee or the enrollee's appointed representative may request an expedited external review with the commissioner if the enrollee receives: (b) Upon receipt of a request for an expedited external re…

§432E-36 External review of experimental or investigational treatment adverse determinations. (a) An enrollee or an enrollee's appointed representative may file a request for an external review with the commissioner within one hundred thirty days of receipt of notice of an advers…

[§432E-37] Binding nature of external review decision. (a) An external review decision shall be binding on the health carrier and the enrollee except to the extent that the health carrier or the enrollee has other remedies available under applicable federal or state law. (b) An e…

[§432E-38] Approval of independent review organizations. (a) An independent review organization shall be approved by the commissioner in order to be eligible to be assigned to conduct external reviews under this part. (b) To be eligible for approval by the commissioner to conduct…

[§432E-39] Minimum qualifications for independent review organizations. (a) To be eligible for approval under this part to conduct external reviews, an independent review organization shall have and maintain written policies and procedures that govern all aspects of both the stan…

§432E-4 Enrollee participation in treatment decisions. (a) An enrollee shall have the right to be informed fully prior to making any decision about any treatment, benefit, or nontreatment. (b) In order to inform enrollees fully, the provider shall: (c) The provider shall discuss …

[§432E-40] Hold harmless for independent review organizations. No independent review organization or clinical reviewer working on behalf of an independent review organization or an employee, agent, or contractor of an independent review organization shall be liable in damages to …

[§432E-41] External review reporting requirements. (a) An independent review organization assigned pursuant to this part to conduct an external review shall maintain written records in the aggregate by state and by health carrier on all requests for external review for which it c…

[§432E-42] Funding of external review. The health carrier against which a request for a standard external review or an expedited external review is filed shall pay the cost of the independent review organization for conducting the external review. There shall be no recourse again…

[§432E-43] Disclosure requirements. (a) Each health carrier shall include a description of the external review procedures in or attached to the policy, certificate, membership booklet, outline of coverage, or other evidence of coverage it provides to enrollees. (b) Disclosure sha…

[§432E-44] Rules. The insurance commissioner shall adopt rules pursuant to chapter 91 to effectuate the purpose of this part including requirements for forms to request external review and expedited external review, to request approval by independent review organizations, and for…

§432E-5 Complaints and appeals procedure for enrollees. (a) A health carrier with enrollees in this State shall establish and maintain a procedure to provide for the resolution of an enrollee's complaints and internal appeals. The procedure shall provide for expedited internal ap…

§432E-6.5 Expedited internal appeal, when authorized; standard for decision. (a) An enrollee may request that the internal appeal under section 432E-5 be conducted as an expedited appeal. If a request for expedited appeal is approved by the health carrier, the appropriate interna…

§432E-7 Information to enrollees. (a) The managed care plan shall provide to its enrollees upon enrollment and thereafter upon request the following information: This information shall be provided to prospective enrollees upon request. (b) Every managed care plan shall provide to…

[§432E-8] Enforcement. All remedies, penalties, and proceedings in articles 2 and 13 of chapter 431 made applicable hereby to managed care plans shall be invoked and enforced solely and exclusively by the commissioner. [L 1998, c 178, pt of §2]

PART III. REPORTING AND OTHER PROVISIONS [§432E-9] Utilization review. (a) Every managed care plan shall establish procedures for continuous review of quality of care, performance of providers, utilization of health services, facilities, and costs. (b) Notwithstanding any other p…

§432G-1 Definitions. As used in this chapter: "Capitated basis" means fixed per member per month payment or percentage of premium payment wherein the provider assumes the full risk for the cost of contracted services without regard to the type, value, or frequency of services pro…

[§432G-10] Powers of insurers and hospital and medical service corporations. (a) An insurance company licensed in this State, or a hospital or medical service corporation authorized to do business in this State, either directly or through a subsidiary or affiliate, may organize a…

[§432G-11] Examinations. (a) The commissioner may examine the affairs of any dental insurer or of any providers with whom a dental insurer has contracts, agreements, or other arrangements as often as is reasonably necessary for the protection of the interests of the people of thi…

§432G-12 Fees. (a) The commissioner shall collect, in advance, the following fees: The commissioner may, upon showing of good cause, waive or modify, in whole or part, all fees in this subsection by order. (b) No certificate of authority shall contain an expiration date, but all …

[§432G-13] Suspension, revocation, or denial of certificate of authority. (a) The commissioner may suspend, revoke, or refuse to extend any certificate of authority issued under this chapter and may deny any application for a certificate of authority if the commissioner finds tha…

[§432G-14] Summary orders and supervision. (a) Whenever the commissioner determines that the financial condition of any dental insurer is such that its continued operation might be hazardous to its enrollees, creditors, or the general public, or that it has violated any provision…

[§432G-15] Administrative fines and enforcement. (a) The commissioner, in addition to or in lieu of suspension or revocation of a certificate of authority pursuant to section 432G‑13, may levy an administrative fine upon a dental insurer in an amount not less than $500 and not mo…

[§432G-16] Statutory construction and relationship to other laws. (a) Except as provided in subsection (c) and otherwise provided in this chapter, the insurance laws shall not apply to the activities authorized and regulated under this chapter of any dental insurer granted a cert…

[§432G-17] Acquisition of control of or merger of a dental insurer. No person may make a tender for or a request or invitation for tenders of, enter into an agreement to exchange securities for, or acquire in the open market or otherwise, any voting security of a dental insurer o…

[§432G-18] Federally funded programs; exemption. Requirements provided in this chapter relating to mandated coverages or essential health benefits shall not be applicable to any dental insurer offering dental insurance under a federally funded program under the Social Security Ac…

[§432G-19] Coordination of benefits. (a) Dental insurers are required to adopt provisions for coordination of benefits to avoid overinsurance and to provide for the orderly payment of claims when a person is covered by two or more group health insurance or health care plans. (b) …

[§432G-2] Establishment of a dental insurer; certificate of authority. (a) Any person may apply to the commissioner for a certificate of authority to establish and operate a dental insurer in compliance with this chapter and chapter 423. No person shall establish or operate a den…