§ 58-67-1 – Short title.
58-67-1. Short title. This Article may be cited as the Health Maintenance Organization Act of 1979. (1977, c. 580, s. 1; 1979, c. 876, s. 1.)
§ 58-67-10 – Establishment of health maintenance organizations.
58-67-10. Establishment of health maintenance organizations. (a) Notwithstanding any law of this State to the contrary, any person may apply to the Commissioner for a license to establish and operate a health maintenance organization in compliance with this Article. No person shall establish or operate a health maintenance organization in this State, nor sell or […]
§ 58-67-100 – Examinations.
58-67-100. Examinations. (a) The Commissioner may make an examination of the affairs of any health maintenance organization and the contracts, agreements or other arrangements pursuant to its health care plan as often as the Commissioner deems it necessary for the protection of the interests of the people of this State but not less frequently than […]
§ 58-67-105 – Hazardous financial condition.
58-67-105. Hazardous financial condition. (a) Whenever the financial condition of any health maintenance organization indicates a condition such that the continued operation of the health maintenance organization might be hazardous to its enrollees, creditors, or the general public, then the Commissioner may order the health maintenance organization to take such action as may be reasonably […]
§ 58-67-11 – Additional HMO application information.
58-67-11. Additional HMO application information. (a) In addition to the information filed under G.S. 58-67-10(c), each application shall include a description of the following: (1) The program to be used to evaluate whether the applicant’s provider network is sufficient, in numbers and types of providers, to assure that all health care services will be accessible […]
§ 58-67-110 – Protection against insolvency.
58-67-110. Protection against insolvency. (a) The Commissioner shall require deposits in accordance with the provisions of G.S. 58-67-25. (b) Each full service health maintenance organization shall maintain a minimum net worth equal to the greater of one million dollars ($1,000,000) or the amount required pursuant to the risk-based capital provisions of Article 12 of this […]
§ 58-67-115 – Hold harmless agreements or special deposit.
58-67-115. Hold harmless agreements or special deposit. (a) Unless the HMO maintains a special deposit in accordance with subsection (b) of this section, each contract between every HMO and a participating provider of health care services shall be in writing and shall set forth that in the event the HMO fails to pay for health […]
§ 58-67-12 – Commissioner use of consultants and other professionals.
58-67-12. Commissioner use of consultants and other professionals. (a) The Commissioner may contract with consultants and other professionals to expedite and complete the application process, examinations, and other regulatory activities required under this Article. Costs of contracts entered into under this section shall be reimbursed by the applicant or licensee. (b) Contracts under this section […]
§ 58-67-120 – Continuation of benefits.
58-67-120. Continuation of benefits. (a) The Commissioner shall require that each HMO have a plan for handling insolvency, which plan allows for continuation of benefits for the duration of the contract period for which premiums have been paid and continuation of benefits to enrollees who are confined in an inpatient facility until their discharge or […]
§ 58-67-125 – Enrollment period.
58-67-125. Enrollment period. (a) In the event of an insolvency of an HMO upon order of the Commissioner, all other carriers that participated in the enrollment process with the insolvent HMO at a group’s last regular enrollment period shall offer such group’s enrollees of the insolvent HMO a 30-day enrollment period commencing upon the date […]
§ 58-67-130 – Replacement coverage.
58-67-130. Replacement coverage. (a) Any carrier providing replacement coverage with respect to group hospital, medical, or surgical expense or service benefits, within a period of 60 days from the date of discontinuance of a prior HMO contract or policy providing such hospital, medical or surgical expense or service benefits, shall immediately cover all enrollees who […]
§ 58-67-135 – Incurred but not reported claims.
58-67-135. Incurred but not reported claims. (a) Every HMO shall, when determining liability, include an amount estimated in the aggregate to provide for any unearned premium and for the payment of all claims for health care expenditures that have been incurred, whether reported or unreported, that are unpaid and for which such HMO is or […]
§ 58-67-140 – Suspension or revocation of license.
58-67-140. Suspension or revocation of license. (a) The Commissioner may suspend or revoke an HMO license if the Commissioner finds that the HMO: (1) Is operating significantly in contravention of its basic organizational document, or in a manner contrary to that described in and reasonably inferred from any other information submitted under G.S. 58-67-10, unless […]
§ 58-67-145 – Rehabilitation, liquidation, or conservation of health maintenance organization.
58-67-145. Rehabilitation, liquidation, or conservation of health maintenance organization. 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 Commissioner pursuant to the law governing the rehabilitation, liquidation, or conservation of insurance […]
§ 58-67-15 – Health maintenance organization of bordering states may be admitted to do business; reciprocity.
58-67-15. Health maintenance organization of bordering states may be admitted to do business; reciprocity. A federally qualified health maintenance organization approved and regulated under the laws of a state bordering this State may be admitted to do business in this State by satisfying the Commissioner that it is fully and legally organized under the laws […]
§ 58-67-150 – Regulations.
58-67-150. Regulations. The Commissioner may, after notice and hearing, promulgate reasonable rules and regulations as are necessary or proper to carry out the provisions of this Article. Such rules and regulations shall be subject to review in accordance with G.S. 58-67-155. (1977, c. 580, s. 1; 1979, c. 876, s. 1.)
§ 58-67-155 – Administrative procedures.
58-67-155. Administrative procedures. (a) When the Commissioner 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, he shall notify the health maintenance organization in writing specifically stating the grounds for denial, suspension, […]
§ 58-67-160 – Fees.
58-67-160. Fees. Every health maintenance organization subject to this Article shall pay to the Commissioner a fee of five hundred dollars ($500.00) for filing an application for a license and an annual license continuation fee of two thousand dollars ($2,000) for each license. The license shall continue in full force and effect, subject to timely […]
§ 58-67-165 – Penalties and enforcement.
58-67-165. Penalties and enforcement. (a) The Commissioner may, in addition to or in lieu of suspending or revoking a license under G.S. 58-67-140, proceed under G.S. 58-2-70, provided that the health maintenance organization has a reasonable time within which to remedy the defect in its operations that gave rise to the procedure under G.S. 58-2-70. […]
§ 58-67-170 – Statutory construction and relationship to other laws.
58-67-170. Statutory construction and relationship to other laws. (a) Except as otherwise provided in this Chapter, provisions of the insurance laws and service corporation laws do not apply to any health maintenance organization licensed under this Article. This subsection does not apply to an insurer or service corporation licensed and regulated under the insurance laws […]