420-M:9 Requirements for Participating Carriers.
I. To qualify as a participating carrier, a carrier shall demonstrate the following characteristics:
(a) That it is licensed and in good standing with the insurance department;
(b) That it has the ability to administer health coverage, to provide adequate service, and to comply with all contractual requirements of the alliance;
(c) That it has the ability to provide enrollees with access to covered services;
(d) That it has the ability to provide coverage for enrollees in any service area in which the carrier plans to participate through the alliance;
(e) That it has the ability to arrange and pay for quality health care services;
(f) That it has the ability to provide standard data required by the alliance, in a manner prescribed by the alliance, including information on:
(1) Plan performance;
(2) Enrollee satisfaction;
(3) Provider payment and incentive structures; and
(4) Such other data requirements prescribed by the alliance;
(g) That it has the ability to meet quality of care standards established by government and industry authorities; and
(h) That it is financially strong and has competent management.
II. Participating carriers that contract with or employ health care providers shall have the ability to accomplish the following in a manner satisfactory to the alliance:
(a) Review and report on the cost and quality of care covered;
(b) Review and report on the appropriateness of care covered; and
(c) Provide accessible health care services.
III. Each participating carrier shall:
(a) Meet the standards established by the alliance pursuant to this chapter;
(b) Provide data and information as required by the alliance;
(c) Comply with all laws and rules regarding underwriting, rating, claims handling, sales, solicitation, licensing, fair marketing, unfair trade practices, the provisions of this chapter, and other applicable state statutes;
(d) Enroll and terminate individuals in the manner specified by the alliance; and
(e) Comply with other requirements established by the alliance pursuant to this chapter.
IV. Nothing in this chapter shall prohibit participating carriers from contracting with particular health care providers or types, classes, or categories of health care providers, or setting reimbursement methodology.
V. In the event that the participating carrier elects to terminate its contract with the alliance, the participating carrier shall:
(a) Provide advance notice of its decision to the alliance; and
(b) Provide notice of the decision at least 180 days prior to the non-renewal of health coverage to the member employers and employee enrollees.
Source. 2010, 346:1, eff. July 20, 2010.