§ 4403. Health maintenance organizations; issuance of certificate of\nauthority. 1. The commissioner shall not issue a certificate of\nauthority to an applicant therefor unless the applicant demonstrates\nthat:\n (a) it has defined a proposed enrolled population to which the health\nmaintenance organization proposes to provide comprehensive health\nservices and has established a mechanism by which that population may\nadvise in determining the policies of the organization;\n (b) it has the capability of organizing, marketing, managing,\npromoting and operating a comprehensive health services plan;\n (c) it is financially responsible and may be expected to meet its\nobligations to its enrolled members. For the purpose of this paragraph,\n"financially responsible" means that the applicant shall assume full\nfinancial risk on a prospective basis for the provision of comprehensive\nhealth services, including hospital care and emergency medical services\nwithin the area served by the plan, except that it may require providers\nto share financial risk under the terms of their contract, it may have\nfinancial incentive arrangements with providers or it may obtain\ninsurance or make other arrangements for the cost of providing\ncomprehensive health services to enrollees; any insurance or other\narrangement required by this paragraph shall be approved as to adequacy\nby the superintendent as a prerequisite to the issuance of any\ncertificate of authority by the commissioner;\n (d) the character, competence, and standing in the community of the\nproposed incorporators, directors, sponsors or stockholders, are\nsatisfactory to the commissioner;\n (e) the prepayment mechanism of its comprehensive health services\nplan, the bases upon which providers of health care are compensated, and\nthe anticipated use of allied health personnel are conducive to the use\nof ambulatory care and the efficient use of hospital services;\n (f) acceptable procedures have been established to monitor the quality\nof care provided by the plan, which, in the case of services provided by\nnon-participating providers, shall be limited to the provision of\nreports to the primary care practitioner responsible for supervising and\ncoordinating the care of the enrollee;\n (g) approved mechanisms exist to resolve complaints and grievances\ninitiated by any enrolled member; and\n (h) the contract between the enrollee and the organization meet the\nrequirements of the superintendent as set forth in section forty-four\nhundred six of this article, as to the provisions contained therein for\nhealth services, the procedures for offering, renewing, converting and\nterminating contracts to enrollees, and the rates for such contracts\nincluding but not limited to, compliance with the provisions of section\none thousand one hundred nine of the insurance law.\n 2. The commissioner may adopt and amend rules and regulations pursuant\nto the state administrative procedure act to effectuate the purposes and\nprovisions of this article. Such regulations may include rules and\nprocedures addressing the provision of emergency services, including\npatient notification, obtaining authorization for treatment, transfer of\npatients from one facility to another and emergency transportation\narrangements.\n 3. Nothing contained in this section shall preclude any person or\npersons in developing a health maintenance organization from contacting\npotential participants to discuss the health care services such\norganization would offer, prior to the granting of a certificate of\nauthority.\n 4. Nothing in this article shall preclude any health maintenance\norganization from meeting the requirements of any federal law which\nwould authorize such health maintenance organization to receive federal\nfinancial assistance or which would authorize enrollees to receive\nassistance from federal funds.\n 5. (a) The commissioner, at the time of initial licensure, at least\nevery three years th
‹ Prev All New York sections Next ›
Lexace provides legal information, not legal advice, and no attorney–client relationship is created. Statute text is provided for general information and may not reflect the most recent amendments; verify against the official state code.