(a) Requirement for assurances. (1) Each MCO, PIHP, and PAHP that is not a Federally qualified HMO (as defined in section 1310 of the Public Health Service Act) must provide assurances satisfactory to the State showing that its provision against the risk of insolvency is adequate to ensure that its Medicaid enrollees will not be liable for the MCO's, PIHP's, or PAHP's debts if the entity becomes insolvent.
(2) Federally qualified HMOs, as defined in section 1310 of the Public Health Service Act, are exempt from this requirement.
(b) Other requirements—(1) General rule. Except as provided in paragraph (b)(2) of this section, an MCO or PIHP, must meet the solvency standards established by the State for private health maintenance organizations, or be licensed or certified by the State as a risk-bearing entity.
(2) Exception. Paragraph (b)(1) of this section does not apply to an MCO or PIHP that meets any of the following conditions:
(i) Does not provide both inpatient hospital services and physician services.
(ii) Is a public entity.
(iii) Is (or is controlled by) one or more Federally qualified health centers and meets the solvency standards established by the State for those centers.
(iv) Has its solvency guaranteed by the State.
Notes of Decisions
Cited in
3
cases (
1 in the last 5 years), 2011–2025 · leading case:
AlohaCare v. Ito, 271 P.3d 621 (Haw. 2012).
AlohaCare v. Ito, 271 P.3d 621 (Haw. 2012).
· cites it 6× “any public or private entity that meets the advance directives requirements and meets the following conditions: (a) makes the service it provides to its Medicaid members as accessible (in terms of timeliness, amount, duration, and scope) as those services that are available to…”
G. Ex Rel. K. v. Hawaii, 794 F. Supp. 2d 1119 (D. Haw. 2011).
“any public or private entity that meets the advance directives requirements and meets the following conditions: (a) makes the service it provides to its Medicaid members as accessible (in terms of timeliness, amount, duration, and scope) as those services that are available to…”
Cecile Erwin Young, in Her Off. Capacity as the Exec. Comm'r of the Texas Health & Human Servs. Comm'n; Molina Healthcare of Texas, Inc.; & Aetna Better Health of Texas, Inc. v. Cook Child.'s Health Plan, Texas Child.'s Health Plan, Superior Health Plan, Inc., & Wellpoint Ins. Co., No. 15-24-00114-CV (Tex. App.—15th Dist. Sept. 29, 2025).
“5 (Required Financial Information) will be reviewed to establish that Respondent provided satisfactory assurances regarding its financial solvency in accordance with the requirements under 42 C.F.R. § 438.116 , Solvency Standards and this Solicitation.”
42 C.F.R. § 438.116(b)(1): 1 case
AlohaCare v. Ito, 271 P.3d 621 (Haw. 2012).
“any public or private entity that meets the advance directives requirements and meets the following conditions: (a) makes the service it provides to its Medicaid members as accessible (in terms of timeliness, amount, duration, and scope) as those services that are available to…”
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