A primary HMO that enters into a contract with an ANHC in which
the ANHC agrees to arrange for or provide health care services other
than medical care or services ancillary to the practice of medicine,
or with a provider HMO in which the provider HMO agrees to arrange
for or provide health care services on a risk-sharing or capitated
risk arrangement on behalf of the primary HMO as part of the primary
HMO delivery network must:
(1) submit a monitoring plan to the department setting
out:
(A) how the primary HMO will ensure that the ANHC or
provider HMO has an effective administrative system for providing
timely and accurate reimbursement to all physicians and providers
under contract with the ANHC or provider HMO; and
(B) how the primary HMO will ensure that all HMO functions
delegated or assigned under contract with the ANHC or provider HMO
are consistent with full compliance by the primary HMO with all department
regulatory requirements;
(2) file with the department a copy of the form of
the written contract with an ANHC or provider HMO, in accordance with §11.301(5)
of this title (relating to Filing Requirements), that:
(A) requires that the ANHC or provider HMO cannot terminate
the contract without 90-days written notice;
(B) contains a hold-harmless provision that prohibits
the ANHC or provider HMO and its contracted physicians and providers
from billing for or attempting to collect from HMO members, except
for authorized copayments and deductibles, charges for covered services
under any circumstance, including the insolvency of the primary HMO,
ANHC, or provider HMO;
(C) contains a provision stating that nothing in the
contract will be construed to in any way limit the HMO's authority
or responsibility to comply with all of the department's regulatory
requirements;
(D) includes the ANHC's or provider HMO's acknowledgment
and agreement that:
(i) the primary HMO is required to establish, operate,
and maintain a health care delivery system, quality assurance system,
physician and provider credentialing system, and other systems and
programs meeting department standards and is directly accountable
for compliance with the standards;
(ii) the role of the ANHC or provider HMO in contracting
with the primary HMO is limited to implementing certain systems of
the primary HMO, utilizing standards approved by the primary HMO,
and subject to the primary HMO's oversight and monitoring of the ANHC's
or provider HMO's performance; and
(iii) the primary HMO may take necessary action to
ensure that all HMO systems and functions that are delegated or assigned
under the contract with the ANHC or provider HMO are in full compliance
with all department regulatory requirements;
(E) requires the ANHC to make available to the primary
HMO the ANHC's contracts with physicians and providers to ensure compliance
with contractual requirements set out in subparagraphs (B) and (C)
of this paragraph;
(F) requires the ANHC to provide the primary HMO with
evidence of both financial solvency and financial ability to perform,
such as a certified financial audit of the ANHC conducted by an independent
certified public accountant, using generally accepted accounting and
auditing principles; and
(G) requires the ANHC or provider HMO to provide the
primary HMO, on at least a monthly basis and in a usable form necessary
for audit purposes, the data necessary for the HMO to comply with
department reporting requirements with respect to any services provided
under the HMO-ANHC or HMO-provider HMO agreement, including the following
data:
(i) number of primary HMO enrollees served or assigned
to the ANHC or primary HMO to receive services, including the number
added and terminated since the last reporting period;
(ii) form of the contracts and subcontracts between
the ANHC and physicians and providers who will be providing services
to enrollees of the primary HMO and any material changes to the contracts
and subcontracts;
(iii) copayments received by the ANHC or provider HMO;
(iv) summary of the amounts paid by the ANHC or provider
HMO to physicians and providers;
(v) methods by which physicians and providers were
paid by the ANHC or provider HMO, for example, capitation, fee-for-services,
or other risk-sharing arrangements;
(vi) utilization data;
(vii) summary of the amounts paid by the ANHC or provider
HMO for administrative services relating to the primary HMOs;
(viii) the time that claims and debts related to claims
owed by the ANHC or provider HMO have been pending;
(ix) information required for the primary HMO to be
able to file claims for reinsurance, coordination of benefits, and
subrogation;
(x) physician and provider and enrollee satisfaction
data;
(xi) complaint data;
(xii) documentation of any inquiry or investigation
of the ANHC or provider HMO, or any individual subcontracting physician
or provider, made by regulatory agencies, and documentation of the
final resolution of the inquiry or investigation; and
(xiii) any other data necessary to ensure proper monitoring
and control of the primary HMO delivery network by the primary HMO;
(3) conduct an on-site audit of the ANHC or provider
HMO at least annually, or more frequently on indication of material
noncompliance, to obtain information necessary to verify compliance
with all of the department's regulatory requirements, and provide
written documentation of each audit to the department on request;
and
(4) take prompt action to correct any failure by the
ANHC or provider HMO to comply with the department's regulatory requirements
relating to any matters delegated by the primary HMO to the ANHC or
provider HMO and necessary to ensure the primary HMO's compliance
with the regulatory requirements.
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