South Carolina Code 38-33-40. Issuance of certificate of authority; criteria and considerations; arrangements for participation of providers in each geographic area served
(1) The persons responsible for the conduct of the affairs of the applicant are competent, trustworthy, and possess good reputations.
Terms Used In South Carolina Code 38-33-40
- Basic health care services: means emergency care, inpatient hospital and physician care, and outpatient medical services. See South Carolina Code 38-33-20
- Director: means the person who is appointed by the Governor upon the advice and consent of the Senate and who is responsible for the operation and management of the Department of Insurance, including all of its divisions. See South Carolina Code 38-33-20
- Health care services: means services included in furnishing an individual medical or dental care or hospitalization or incident to the furnishing of care or hospitalization, and other services to prevent, alleviate, cure, or heal human illness, injury, or physical disability. See South Carolina Code 38-33-20
- Health maintenance organization: means a person who undertakes to provide or arrange for basic health care services to enrollees for a fixed prepaid premium. See South Carolina Code 38-33-20
- Insurer: includes a corporation, fraternal organization, burial association, other association, partnership, society, order, individual, or aggregation of individuals engaging or proposing or attempting to engage as principals in any kind of insurance or surety business, including the exchanging of reciprocal or interinsurance contracts between individuals, partnerships, and corporations. See South Carolina Code 38-1-20
- Person: means a natural or an artificial person including, but not limited to, individuals, partnerships, associations, trusts, or corporations. See South Carolina Code 38-33-20
- Policy: means a contract of insurance. See South Carolina Code 38-1-20
- Premium: means payment given in consideration of a contract of insurance. See South Carolina Code 38-1-20
(2) The health maintenance organization‘s proposed plan of operation has arrangements for an on-going quality assurance program.
(3) The health maintenance organization effectively provides or arranges for the provision of basic health care services for a fixed prepaid premium, except to the extent of reasonable requirements for deductibles or co-payments.
(4) The health maintenance organization is financially responsible, is able to meet its obligations to enrollees and prospective enrollees, and otherwise meets the requirements of this chapter. In making this determination, considerations by the director or his designee may include, but are not limited to:
(a) the financial soundness of the arrangements for health care services and the schedule of charges used in connection with them;
(b) the adequacy of working capital;
(c) an agreement with an insurer, a government, or other organization for insuring the payment of the cost of health care services or the provision for automatic applicability of an alternative coverage if the health maintenance organization is discontinued;
(d) an agreement with providers for the provision of health care services;
(e) a deposit of cash or securities submitted in accordance with § 38-33-130.
(5) The enrollees are afforded an opportunity to participate in matters of policy and operation pursuant to § 38-33-60.
(6) Nothing in the proposed method of operation, pursuant to § 38-33-30 or by independent investigation, is contrary to the public interest.
(B) No health maintenance organization may be licensed unless it has employed or contracted with or made arrangements satisfactory to the director or his designee with both physicians and hospitals to participate as providers in each geographic area to be served, as identified by the health maintenance organization under § 38-33-30.