Ala. Admin. Code r. 420-5-6-.02
Current through Register Vol. 43, No. 1, October 31, 2024
Section 420-5-6-.02 - Content Of Application For Certificate Of Authority(1) Each application for a certificate of authority under Code of Ala. 1975, §§ 27-21A-1, etseq., shall be made to the Commissioner of the Department of Insurance and to the State Health Officer. "Certificate of Authority" means the document issued by the State Insurance Commissioner permitting a person to establish, maintain and operate a health maintenance organization. The application specific to the Alabama Department of Public Health shall contain the following: (a) Copies of the basic organizational documents such as the certificate of incorporation, bylaws, rules, articles of association, partnership agreement, trust agreement or other applicable documents and agreements regulating the conduct of the internal affairs of the applicant and all amendments thereto;(b) A list and organization chart of the names and addresses and official positions of the members of the board of directors, officers, controlling persons, owners, or partners, the medical director and the administrator of the proposed health maintenance organization and any other persons responsible for the health services system of the health maintenance organization;(c) A resume of the medical director, administrator and all department managers; 1. "Administrator" means a person who demonstrates competence and experience in health maintenance organization management; who is assigned the responsibility for the interpretation, implementation, and proper application of policies and programs established by the governing body; is assigned responsibility for the establishment and maintenance of effective management, control, and operation of the services provided; and, is responsible for coordination of activities and communication between the Department, the governing body, and the health delivery systems. The administrator shall be available and accessible to the Department. In the absence of the administrator, an individual shall be designated, in writing, who shall be authorized to act on the administrator's behalf.2. "Medical Director" means a physician who oversees medical aspects of the plan, supervises the quality improvement and utilization management programs and advises the governing body on the adoption and enforcement of policies concerning medical services. A medical director must have a current license to practice medicine granted by the Medical Licensure Commission of Alabama. Alternately, an HMO may employ, for no longer than 12 months, an individual as medical director provided that the individual is eligible in all respects for licensure as an Alabama physician and the individual has a current active application for licensure on file with the Medical Licensure Commission of Alabama.(d) A detailed description of the proposed health maintenance organization's potential ability to assure both the availability and accessibility of adequate personnel and facilities to serve enrollees in a manner enhancing availability, accessibility, and continuity;(e) A description of the service area of the proposed health maintenance organization (geographic boundaries, demographic data, and identification of population groups of enrollees);(f) Information regarding proposed practice site locations and hours of operation;(g) A list of proposed providers with physical address and phone number;(h) A copy of the applicant's proposed contracts and marketing documents with enrollees and group contracts with employers, unions, trustees, or other organizations, setting forth the corporation's contractual obligation to provide a minimum of basic health services;(i) Applicant's provider contracts with physicians, groups of physicians organized on a group practice or individual practice basis, hospitals, and other providers of health care services enabling it to provide basic and frequently utilized specialty health services to an enrolled population;(j) A detailed description of the applicant's proposed complaint system whereby the complaints of the enrollees may be acted upon promptly and satisfactorily;(k) A detailed description of the applicant's arrangements for ongoing quality-of-health-care assurance program;(l) A detailed description of the applicant's capability to collect and analyze necessary data relating to the utilization of health care services;(m) Job descriptions of the medical director, administrator and department managers;(n) A procedure for referral of enrollees to nonparticipating specialists;(o) A copy of written procedures for provision and payment of emergency services;(p) A copy of the written procedures regarding the method for providing frequently utilized services required by 420-5-6-.06(11);(q) An organizational chart demonstrating the delegation of authority and control of the health services delivery system, from the highest authority (governing body) to the physician, with support documentation demonstrating that all personnel at each level of authority have the requisite expertise for their particular area of authority.(r) A detailed description of how medical records will be maintained;(s) Evidence that the proposed health maintenance organization has complied with Alabama Health Planning Laws, §§ 22-21-260etseq.;(t) Any other pertinent information; and(u) A health maintenance organization shall not materially alter, amend, modify, suspend, or delete any of the provisions of any document submitted in connection with an application for a Certificate of Authority unless in accordance with Code of Ala. 1975, § 27-21A-2(d)(1). The State Health Officer will forward in a timely manner a recommendation to the Commissioner of Insurance that the requested alteration, modification, amendment, suspension, addition or deletion be approved or disapproved in accordance with Code of Ala. 1975, § 27-21A-17(a)(1). Author: Department of Public Health
Ala. Admin. Code r. 420-5-6-.02
Filed September 1, 1982. Repealed and New Rule adopted in lieu thereof: Filed March 31, 1987. Amended: Filed January 20, 1999; effective February 24, 1999.Statutory Authority:Code of Ala. 1975, §§ 22-2-2(6), etseq., 22-21-20, etseq., 27-21A-1, etseq.