Kentucky Statutes 304.38-130 – Revocation or suspension of certificate of authority
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(1) The commissioner may suspend or revoke any certificate of authority issued to a health maintenance organization under this subtitle if the commissioner finds that any of the conditions exist for which the commissioner could suspend or revoke a certificate of authority as provided in Subtitles 2 and 3 of this chapter or if the commissioner finds that any of the following conditions exist:
(a) The health maintenance organization is operating significantly in contravention of its basic organizational document or in a manner contrary to that described in and reasonably inferred from any other information submitted under KRS § 304.38-040, unless amendments to such submissions have been filed with and approved by the commissioner;
(b) The health maintenance organization issues evidence of coverage or uses a schedule of charges for health care services which do not comply with the requirements of KRS § 304.38-050 or Subtitle 17A of this chapter;
(c) The health maintenance organization does not provide or arrange for health care services as approved by the commissioner in KRS § 304.38-050(1)(a);
(d) The certificate of need and licensure board certifies to the commissioner that the health maintenance organization fails to meet the requirements of the board or that the health maintenance organization is unable to fulfill its obligations to furnish health care services;
(e) The health maintenance organization is no longer financially responsible and may reasonably be expected to be unable to meet its obligations to enrollees or prospective enrollees;
(f) The health maintenance organization, or any person on its behalf, has advertised or merchandised its services in an untrue, misrepresentative, misleading, deceptive, or unfair manner;
(g) The continued operation of the health maintenance organization would be hazardous to its enrollees;
(h) The health maintenance organization has otherwise failed to substantially comply with this subtitle; or
(i) The health maintenance organization has contracted with the Department for Medicaid Services to act as a managed care organization providing Medicaid benefits pursuant to KRS Chapter 205 and has exhibited willful or frequent and repeated failure to comply with KRS § 304.17A-700 to KRS § 304.17A-730,
205.593, and 304.14-135 and KRS § 205.522, 205.532 to 205.536, and
304.17A-515.
(2) If the certificate of authority of a health maintenance organization is suspended, the health maintenance organization shall not, during the period of the suspension, enroll any additional enrollees except newborn children or other newly acquired dependents of existing enrollees, and shall not engage in any advertising or solicitation whatsoever.
(3) If the certificate of authority of a health maintenance organization is revoked, the organization shall proceed, immediately following the effective date of the order of
revocation, to wind up its affairs, and shall conduct no further business except as may be essential to the orderly conclusion of the affairs of the organization. It shall engage in no further advertising or solicitation whatsoever. The commissioner may, by written order, permit the further operation of the organization as the commissioner may find to be in the best interest of enrollees, to the end that enrollees will be afforded the greatest practical opportunity to obtain continuing health care coverage. If the commissioner permits such further operation the health maintenance organization will continue to collect the periodic prepayments required of enrollees.
Effective: July 14, 2018
History: Amended 2018 Ky. Acts ch. 106, sec. 12, effective July 14, 2018. — Amended
2010 Ky. Acts ch. 24, sec. 1509, effective July 15, 2010. — Amended 2004 Ky. Acts ch. 24, sec. 43, effective July 13, 2004. — Created 1974 Ky. Acts ch. 357, subtit. 38, sec. 13, effective June 21, 1974.
(a) The health maintenance organization is operating significantly in contravention of its basic organizational document or in a manner contrary to that described in and reasonably inferred from any other information submitted under KRS § 304.38-040, unless amendments to such submissions have been filed with and approved by the commissioner;
Terms Used In Kentucky Statutes 304.38-130
- Commissioner: means the commissioner of the Department of Insurance. See Kentucky Statutes 304.38-030
- Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.
- Health maintenance organization: means any person who undertakes to provide, directly or through arrangements with others, health care services to individuals enrolled with such an organization on a per capita or a predetermined, fixed prepayment basis. See Kentucky Statutes 304.38-030
- Person: includes but is not limited to any individual, partnership, association, trust, or corporation. See Kentucky Statutes 304.38-030
(b) The health maintenance organization issues evidence of coverage or uses a schedule of charges for health care services which do not comply with the requirements of KRS § 304.38-050 or Subtitle 17A of this chapter;
(c) The health maintenance organization does not provide or arrange for health care services as approved by the commissioner in KRS § 304.38-050(1)(a);
(d) The certificate of need and licensure board certifies to the commissioner that the health maintenance organization fails to meet the requirements of the board or that the health maintenance organization is unable to fulfill its obligations to furnish health care services;
(e) The health maintenance organization is no longer financially responsible and may reasonably be expected to be unable to meet its obligations to enrollees or prospective enrollees;
(f) The health maintenance organization, or any person on its behalf, has advertised or merchandised its services in an untrue, misrepresentative, misleading, deceptive, or unfair manner;
(g) The continued operation of the health maintenance organization would be hazardous to its enrollees;
(h) The health maintenance organization has otherwise failed to substantially comply with this subtitle; or
(i) The health maintenance organization has contracted with the Department for Medicaid Services to act as a managed care organization providing Medicaid benefits pursuant to KRS Chapter 205 and has exhibited willful or frequent and repeated failure to comply with KRS § 304.17A-700 to KRS § 304.17A-730,
205.593, and 304.14-135 and KRS § 205.522, 205.532 to 205.536, and
304.17A-515.
(2) If the certificate of authority of a health maintenance organization is suspended, the health maintenance organization shall not, during the period of the suspension, enroll any additional enrollees except newborn children or other newly acquired dependents of existing enrollees, and shall not engage in any advertising or solicitation whatsoever.
(3) If the certificate of authority of a health maintenance organization is revoked, the organization shall proceed, immediately following the effective date of the order of
revocation, to wind up its affairs, and shall conduct no further business except as may be essential to the orderly conclusion of the affairs of the organization. It shall engage in no further advertising or solicitation whatsoever. The commissioner may, by written order, permit the further operation of the organization as the commissioner may find to be in the best interest of enrollees, to the end that enrollees will be afforded the greatest practical opportunity to obtain continuing health care coverage. If the commissioner permits such further operation the health maintenance organization will continue to collect the periodic prepayments required of enrollees.
Effective: July 14, 2018
History: Amended 2018 Ky. Acts ch. 106, sec. 12, effective July 14, 2018. — Amended
2010 Ky. Acts ch. 24, sec. 1509, effective July 15, 2010. — Amended 2004 Ky. Acts ch. 24, sec. 43, effective July 13, 2004. — Created 1974 Ky. Acts ch. 357, subtit. 38, sec. 13, effective June 21, 1974.