Title 58, INSURANCE

A health maintenance organization shall be entitled to claim any statutory privileges against such disclosure which the provider who furnished such information to the health maintenance organization is entitled to claim. Source: SL 1974, ch 321 , § 36 (5).

Any data or information pertaining to the diagnosis, treatment, or health of any enrollee, or any application obtained from any person, shall be confidential and shall not be disclosed to any person except: (1) To the extent that it may be necessary to carry out the purposes of t…

The director may issue an order directing a health maintenance organization or a representative of a health maintenance organization to cease and desist from engaging in any act or practice in violation of the provision of this chapter. Source: SL 1974, ch 321 , § 47.

Within twenty days after service of the order to cease and desist, the respondent may request a hearing on the question of whether acts or practices in violation of this chapter have occurred. Such hearings shall be conducted pursuant to, and judicial review shall be available as…

Each application for a certificate of authority shall include: (1) A copy of the form of each evidence of coverage to be issued to the enrollees; (2) A copy of the form of each individual or group health maintenance contract which is to be issued to enrollees or their representat…

In the event of any violation of the provisions of this chapter, if the director elects not to issue a cease and desist order, or in the event of noncompliance with a cease and desist order pursuant to § 58-41-79 , the director may institute a proceeding to obtain injunctive reli…

The director may suspend or revoke any certificate of authority issued to a health maintenance organization under this chapter if the director finds that any of the following conditions exists: (1) The health maintenance organization is operating significantly in contravention of…

The director may suspend or revoke any certificate of authority issued to a health maintenance organization under this chapter if: (1) The health maintenance organization does not meet the requirements of § 58-41-12 ; or (2) The health maintenance organization is unable to fulfil…

If the director, for any reason, has cause to believe that any violation of this chapter has occurred or is threatened, the director may, before commencing action under § 58-41-81 , 58-41-82 , 58-41-85 , or 58-41-87 , give notice to the health maintenance organization and to the …

Proceedings under § 58-41-83 are not governed by any formal procedural requirements, and may be conducted in such manner as the director finds appropriate under the circumstances. Source: SL 1974, ch 321 , § 46; SL 2013, ch 256 , § 30.

The director may, in lieu of suspension or revocation of a certificate of authority under 58-41-81 or 58-41-82 , levy a money penalty pursuant to § 58-4-28.1 . Source: SL 1974, ch 321 , § 44; SL 2000, ch 235 , § 4.

A certificate of authority shall be suspended or revoked only after compliance with the requirements of §§ 58-41-87 to 58-41-91 , inclusive. Source: SL 1974, ch 321 , § 37.

The director of the Division of Insurance may, without advance notice or a hearing thereon, immediately suspend the certificate of authority of a health maintenance organization as to which proceedings for receivership, conservatorship, rehabilitation, or other delinquency procee…

If the director has cause to believe that grounds for the denial of an application for a certificate of authority exist, or that grounds for the suspension or revocation of a certificate of authority exist, the director shall notify the health maintenance organization in writing …

The provisions of chapter 1-26 , including the right of judicial review, apply to proceedings under §§ 58-41-85 to 58-41-91 , inclusive, to the extent those provisions are not in conflict with other provisions of such sections. Source: SL 1974, ch 321 , § 39 (4); SL 2000, ch 235 …

Each application for a certificate of authority shall include a description of the proposed method of marketing the plan, a schedule of proposed charges, and a financial plan which includes a three - year projection of the expenses and income and other sources of future capital. …

After hearing pursuant to §§ 58-41-87 and 58-41-88 , or upon the failure of the health maintenance organization to appear at such hearing, the director shall take action as is deemed advisable on written findings which shall be mailed to the health maintenance organization. Sourc…

The action of the director is subject to the court of primary jurisdiction for claims of the nature and magnitude described. The court may, in disposing of the issue before it, modify, affirm, or reverse the order of the director in whole or in part. Source: SL 1974, ch 321 , § 3…

When the certificate of authority of a health maintenance organization is suspended, the health maintenance organization may not, during the period of such suspension, enroll any additional enrollees except newborn children or other newly acquired dependents of existing enrollees…

When the certificate of authority of a health maintenance organization is revoked, the organization shall proceed, immediately following the effective date of the order of revocation, to wind up its affairs, and shall conduct no further business except as may be essential to the …

The director may apply for an order directing him to rehabilitate, liquidate, or conserve a health maintenance organization upon any one or more of the grounds set out in chapter 58-29B , or when in his opinion the continued operation of the health maintenance organization would …

Any rehabilitation, liquidation, or conservation of a health maintenance organization shall be deemed to be the rehabilitation, liquidation, or conservation of an insurance company and shall be conducted under the supervision of the director pursuant to chapter 58-29B , except to…

If a part of this chapter is invalid, all valid parts that are severable from the invalid part remain in effect. If a part of this chapter is invalid in one or more of its applications, the part remains in effect in all valid applications that are severable from the invalid appli…

This chapter may be cited as the "Health Maintenance Organization Act of 1974." Source: SL 1974, ch 321 , § 1.

Every health maintenance contract that is delivered, issued for delivery, or renewed in this state, except for policies that provide coverage for specified disease or other limited benefit coverage, shall offer coverage for testing, diagnosis, and treatment of phenylketonuria inc…

Notwithstanding the provisions of chapter 47-34A and §§ 47-15-2 and 47-22-4 , any organization may form for the purposes of purchasing group health insurance on a voluntary basis. For purposes of §§ 58-41-99 to 58-41-109 , inclusive, an organization means any nonprofit organizati…

Terms used in this chapter mean: (1) "Accountant," an independent certified public accountant or accounting firm in good standing with the American Institute of Certified Public Accountants and in all states in which the accountant or firm is licensed to practice. For Canadian an…

The lead or coordinating audit partner, having primary responsibility for the audit pursuant to this chapter, may not act in that capacity for more than five consecutive years. The person shall be disqualified from acting in that or a similar capacity for the same company or its …

The director may not recognize as an accountant, nor accept any annual audited financial report, prepared in whole or in part by, any natural person who: (1) Has been convicted of fraud, bribery, a violation of the Racketeer Influenced and Corrupt Organizations Act, 18 U.S.C. §§ …

An accountant which has been disqualified or any firm which has had an accountant disqualified by the director may request a hearing on the disqualification. The director may, as a result of the hearing, require the insurer to replace the accountant with another qualified account…

An insurer may make written application to the director for approval to file audited consolidated or combined financial statements in lieu of separate annual audited financial statements if the insurer is part of a group of insurance companies which utilizes a pooling or one hund…

An insurer shall require the accountant to report, in writing, within five business days to the board of directors or its audit committee any determination by the accountant that the insurer has materially misstated its financial condition as reported to the director as of the ba…

If the accountant, subsequent to the date of the audited financial report filed pursuant to this chapter becomes aware of facts which might affect his report, the accountant shall take the action prescribed in volume 1, section AU 561 of the professional standards of the American…

In addition to the annual audited financial report, each insurer shall furnish the director with a written communication as to any unremediated material weaknesses in the insurer's internal controls over financial reporting noted during the audit. The communication shall be prepa…

The provisions of §§ 58-43-16.2 to 58-43-16.9 , inclusive, do not apply to any foreign or alien insurer licensed in this state or any insurer that is a SOX compliant entity or a direct or indirect wholly-owned subsidiary of a SOX compliant entity. Source: SL 2009, ch 271 , § 16.

58-43-16.25 Internal audit function requirements. 58-43-16.26 Internal audit function to be organizationally independent. 58-43-16.27 Report of head of internal audit function to audit committee. 58-43-16.28 Member of insurance holding company system or group of insurers. 58-43-1…

No director or officer of an insurer shall, directly or indirectly: (1) Make or cause to be made a materially false or misleading statement to an accountant in connection with any audit, review, or communication required under this chapter; or (2) Omit to state, or cause another …

No officer or director of an insurer, or any other person acting under the direction thereof, shall directly or indirectly take any action to coerce, manipulate, mislead, or fraudulently influence any accountant engaged in the performance of an audit pursuant to this chapter if t…

Each insurer required to file an audited financial report pursuant to this chapter that has annual direct written and assumed premiums, excluding premiums reinsured with the Federal Crop Insurance Corporation and Federal Flood Program, of five hundred million dollars or more shal…

Notwithstanding the premium threshold in § 58-43-16.13, the director may require an insurer to file a Management's Report of Internal Control over Financial Reporting if the insurer is in any risk based capital (RBC) level event, or meets any one or more of the standards of an in…

An insurer or a group of insurers that is: (1) Directly subject to Section 404; (2) Part of a holding company system whose parent is directly subject to Section 404; (3) Not directly subject to Section 404 but is a SOX compliant entity; or (4) A member of a holding company system…

A Management's Report of Internal Control over Financial Reporting shall include: (1) A statement that management is responsible for establishing and maintaining adequate internal control over financial reporting; (2) A statement that management has established internal control o…

Management shall document and make available at the time of a financial condition examination the basis upon which its assertions, required in § 58-43-16.16 , are made. Management may base its assertions, in part, upon its review, monitoring, and testing of internal controls unde…

Management has discretion as to the nature of the internal control framework used, and the nature and extent of documentation, in order to make its assertion in a cost effective manner and, as such, may include assembly of or reference to existing documentation. Source: SL 2009, …

The Management's Report of Internal Control over Financial Reporting, required by § 58-43-16.13 , and any documentation provided in support thereof during the course of a financial condition examination, shall be kept confidential by the Division of Insurance. Source: SL 2009, ch…

The audit committee shall be directly responsible for the appointment, compensation, and oversight of the work of any accountant, including resolution of disagreements between management and the accountant regarding financial reporting, for the purpose of preparing or issuing the…