(1) The maintenance of a valid and current health care provider certificate issued pursuant to part III of this chapter is a condition of the maintenance of a valid and current certificate of authority issued by the office to operate a health maintenance organization. Denial or revocation of a health care provider certificate shall be deemed to be an automatic and immediate cancellation of a health maintenance organization’s certificate of authority. At the discretion of the office, nonrenewal of a health care provider certificate may be deemed to be an automatic and immediate cancellation of a health maintenance organization’s certificate of authority if the Agency for Health Care Administration notifies the office, in writing, that the health care provider certificate will not be renewed.
(2) The office may suspend the authority of a health maintenance organization to enroll new subscribers or revoke any certificate issued to a health maintenance organization, or order compliance within 30 days, if it finds that any of the following conditions exists:(a) The organization is not operating in compliance with this part;
(b) The plan is no longer actuarially sound or the organization does not have the minimum surplus as required by this part;
(c) The existing contract rates are excessive, inadequate, or unfairly discriminatory;
(d) The organization has advertised, merchandised, or attempted to merchandise its services in such a manner as to misrepresent its services or capacity for service or has engaged in deceptive, misleading, or unfair practices with respect to advertising or merchandising; or
(e) The organization is insolvent.
(3) Whenever the financial condition of the health maintenance organization is such that, if not modified or corrected, its continued operation would result in impairment or insolvency, the office may order the health maintenance organization to file with the office and implement a corrective action plan designed to do one or more of the following:(a) Reduce the total amount of present potential liability for benefits by reinsurance or other means.
(b) Reduce the volume of new business being accepted.
(c) Reduce the expenses of the health maintenance organization by specified methods.
(d) Suspend or limit the writing of new business for a period of time.
(e) Require an increase in the health maintenance organization’s net worth.
If the health maintenance organization fails to submit a plan within 30 days of the office’s order or submits a plan which is insufficient to correct the health maintenance organization’s financial condition, the office may order the health maintenance organization to implement one or more of the corrective actions listed in this subsection.
(4) The office shall, in its order suspending the authority of a health maintenance organization to enroll new subscribers, specify the period during which the suspension is to be in effect and the conditions, if any, which must be met by the health maintenance organization prior to reinstatement of its authority to enroll new subscribers. The order of suspension is subject to rescission or modification by further order of the office prior to the expiration of the suspension period. Reinstatement shall not be made unless requested by the health maintenance organization; however, the office shall not grant reinstatement if it finds that the circumstances for which the suspension occurred still exist or are likely to recur.
(5) The commission shall adopt rules establishing an actuarially sound medical loss ratio for Medicaid. In determining the appropriate medical loss ratio, the commission shall consider factors, including but not limited to, plan age, plan structure, geographic service area, product mix, provider network, medical inflation, provider services, other professional services, out of network referrals and expenditures, in and out of network emergency room expenditures, inpatient expenditures, other medical expenditures, incentive pool adjustments, copayments, coordination of benefits, subrogation, and any other expenses associated with the delivery of medical benefits. The commission shall utilize assistance from the Agency for Health Care Administration, the State University System, an independent actuary, and representatives from health maintenance organizations in developing the rule for appropriate medical loss ratios.
(6) The office shall calculate and publish at least annually the medical loss ratios of all licensed health maintenance organizations. The publication shall include an explanation of what the medical loss ratio means and shall disclose that the medical loss ratio is not a direct reflection of quality, but must be looked at along with patient satisfaction and other standards that define quality.
