Subchapter E. CONTINUING SUPERVISION OF OPERATIONAL HEALTH MAINTENANCE ORGANIZATIONS
Sec.
301.81. Financial reports.
301.82. Departmental investigation.
301.83. Federally qualified HMOs.
301.84. Exceptions.§ 301.81. Financial reports.
(a) An HMO shall submit to the Department before March 1 of each year an annual financial report for the preceding calendar year in a form prescribed by the Commissioner.
(b) During the initial 5 years of operation, an HMO shall submit to the Department quarterly financial reports in a form prescribed by the Commissioner. The reports shall be submitted within 45 days following the end of a calendar quarter.
Source The provisions of this § 301.81 adopted February 20, 1987, effective February 21, 1987, 17 Pa.B. 807.
§ 301.82. Departmental investigation.
(a) The Department may investigate further information contained in or forming the basis of reports submitted according to this chapter.
(b) Investigation may include onsite inspection of the HMO’s facilities and records of the HMO.
(c) The Commissioner or an agent shall have free access to the books, records, papers and documents that relate to the business of the HMO.
(d) The Department may charge the HMO for the services of its examiners in the manner it charges insurance companies as prescribed in section 216 of The Insurance Department Act of one thousand nine hundred and twenty-one (40 P. S. § 54) and under the funding requirements set forth by the National Association of Insurance Commissioners (NAIC).
Source The provisions of this § 301.82 adopted February 20, 1987, effective February 21, 1987, 17 Pa.B. 807.
§ 301.83. Federally qualified HMOs.
(a) In applying this chapter to Federally-qualified HMOs, the Department may take into account the extent of compliance with Federal standards.
(b) If there is a conflict or potential conflict between this chapter and Federal regulations applicable to Federally-qualified HMOs, the Department will coordinate directly with the appropriate Federal authority to attempt to remove or resolve the conflict.
Source The provisions of this § 301.83 adopted February 20, 1987, effective February 21, 1987, 17 Pa.B. 807.
§ 301.84. Exceptions.
(a) The Department may, for good cause and only if financial viability of the HMO or the welfare of a citizen would not be impaired, grant exceptions to this chapter when the policy objectives and intentions of this chapter are otherwise substantially met.
(b) A request for exceptions to this chapter shall be made in writing to the Department. A request, whether approved or not, will be retained on file by the Department. An approved request shall be retained on file by the corporation during the period the exception remains in effect.
(c) An exception granted under this chapter may be revoked by the Department for good cause whenever the policy objectives and reasons for granting the exception will no longer be furthered.
(d) The Department will give written notice by certified mail, return receipt requested, revoking an exception and will state the reason for its action and a specific date upon which the exception will be terminated.
(e) The Department will provide for a reasonable time between the date of written notice of revocation and the date of termination of an exception for the HMO from compliance with this chapter.
(f) Failure of the HMO to comply by the specified date may result in action to revoke the previously approved certificate of authority.
(g) The Department’s denial or revocation of an exception is a final agency action and is appealable under 2 Pa.C.S. § § 701—704 (relating to judicial review of Commonwealth agency action).
Source The provisions of this § 301.84 adopted February 20, 1987, effective February 21, 1987, 17 Pa.B. 807.
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