D.C. Mun. Regs. tit. 26, r. 26-A3517

Current through Register Vol. 71, No. 49, December 6, 2024

Rule 26-A3517 - DENIAL, SUSPENSION OR REVOCATION OF THE CERTIFICATE OF AUTHORITY

3517.1

The Commissioner may deny an application for a certificate of authority, and suspend or revoke a certificate of authority issued under the Act and these rules, for the following reasons:

(a) The HMO is operating in a manner that is significantly inconsistent with its basic organizational documentation;

(b) The HMO fails to comply with section 8 of the Act, D.C. Code § 35-4507 (requirements for group contract, individual contract, and evidence of coverage) and section 16 of the Act, D.C. Code § 35-4515 (filing requirements for rating information);

(c) The HMO does not provide or arrange for basic health care services;

(d) The Commissioner certifies that the HMO does not meet the requirements for issuance of a certificate of authority under section 3501.5, or it is unable to meet its obligations to provide health care services;

(e) The HMO is no longer financially sound;

(f) The HMO does not correct any deficiency occurring due to the HMO's prescribed minimum net worth being impaired;

(g) The HMO has failed to implement the grievance procedure as required under section 11 of the Act, D.C. Code § 35-4510, in reasonable manner to resolve legitimate complaints;

(h) The HMO or any person authorized to act on its behalf, has advertised or merchandised its services in an untrue, misrepresentative, misleading, deceptive, or unfair manner;

(i) The HMO's continued operation would be dangerous to its enrollees; or

(j) The HMO has otherwise failed substantially to comply with the Act and these rules.

3517.2

In addition to, or in lieu of suspension or revocation of a certificate of authority, the applicant or HMO may be subject to an administrative penalty up to $ 1,000 a day for each cause for suspension or revocation.

D.C. Mun. Regs. tit. 26, r. 26-A3517

Final Rulemaking published at 46 DCR 7291(September 17, 1999)