Hospital and Medical Service Associations and Contracts

Miss. Code Ann. tit. 83, ch. 41
in effect

Miss. Code Ann. § 83-41-1 Repealed.

Repealed by Laws, 1997, ch. 307, § 1, eff from and after July 1, 1997. § 83-41-1 through § 83-41-19 . [Codes, 1942, §§ 5606-5615; Laws, 1936, ch. 177] Editor’s Notes — Former §§ 83-41-1 through 83-41-19 provided for the organization and regulation of hospital and medical service associations by the Commissioner of Insurance.

Miss. Code Ann. § 83-41-101 Repealed.

Repealed by Laws, 1997, ch. 307, § 2, eff from and after July 1, 1997. § 83-41-101 through § 83-41-123 . [Codes, 1942, §§ 5615-01-5615-12; Laws, 1948, ch. 349, §§ 1-12] § 83-41-125 . [Codes, 1942, § 5615-13; Laws, 1948, ch. 349, § 13; Laws, 1994, ch. 422, § 4] § 83-41-127 . [Codes, 1942, § 5615-14; Laws, 1948, ch. 349, § 14; Laws, 1956, ch. 341; Laws, 1978, ch. 441, § 8] § 83-41-129 . [Codes, 1942, § 5615-15; Laws, 1948, ch. 349, § 15] § 83-41-131 . [Codes, 1942, § 5615-16; Laws, 1948, ch. 349, § 16; Laws, 1994, ch. 422, § 5] Editor’s Notes — Former §§ 83-41-101 through 83-41-123 provided for the organization and regulation of nonprofit hospital, medical and surgical service corporations by the Commissioner of Insurance. Former § 83-41-125 directed that any dissolution, liquidation supervision or rehabilitation of a corporation be conducted by the Commissioner of Insurance. Former § 83-41-127 provided that charitable and benevolent corporations be exempt from taxation. Former § 83-41-129 provided for the conversion of existing service corporations into nonprofit corporations. Former § 83-41-131 provided for the conversion of nonprofit hospital, medical and surgical corporations to mutual insurance companies.

Miss. Code Ann. § 83-41-201 Notice to insured required for cancellation.

Whenever any policy of hospital, medical, or surgical insurance issued or renewed after June 11, 1964, shall have been in continuous full force and effect for at least four (4) years with all premiums paid thereon, no insurance company chartered or authorized to do business in the State of Mississippi, or doing business herein, shall be permitted to cancel or refuse to renew its policy of hospital, medical, or surgical insurance issued after said date to a resident citizen of the State of Mississippi without first giving written notice to the insured; and the cancellation or refusal to renew shall not be effective until one (1) year from and after the date of the receipt of such written notice as shown by certified mail sent with return receipt requested. Any effort to cancel a policy of hospital, medical, or surgical insurance or any refusal to accept premiums on such a policy contrary to the provisions of this section shall be ineffective if the policyholder makes an offer to pay the premium as and when due, or within the grace period, and one (1) offer shall be all that is necessary if that offer is refused by the company. The provisions of this section shall not apply to group and blanket insurance, nor to any policy in which the insurer does not reserve the right to refuse renewal on an individual basis. The provisions of this section shall not prevent cancellation of any hospital, medical, or surgical insurance policy because of duplicate coverage providing for payment of benefits in excess of hospital, medical, nursing, or drug expenses actually incurred.

Miss. Code Ann. § 83-41-203 Beneficiaries’ freedom of choice of practitioner in performance of visual service; optometrists.

Whenever any policy of insurance or any medical service plan or hospital service contract or hospital and medical service contract issued in this state provides for reimbursement for any visual service which is within the lawful scope of practice of a duly licensed optometrist as defined in Section 73-19-1, Mississippi Code of 1972, the insured or other person entitled to benefits under such policy shall be entitled to reimbursement for such services, whether such services are performed by a duly licensed physician or by a duly licensed optometrist, notwithstanding any provision to the contrary in any statute or in such policy, plan or contract. Duly licensed optometrists shall be entitled to participate in such policies, plans, or contracts providing for visual services, as authorized by Sections 73-19-1 and 43-3-67, Mississippi Code of 1972, to the same extent as duly licensed physicians.

Miss. Code Ann. § 83-41-205 Individual hospital and medical expense contracts and policies shall provide for continuation of coverage for persons having an intellectual or physical disability.

Any individual hospital or medical service plan contract or any individual hospital or medical expense insurance policy delivered or issued for delivery in this state after September 12, 1972, which provides that coverage of a dependent child shall terminate upon attainment of the limiting age for dependent children specified in the contract or policy, shall also provide in substance that attainment of such limiting age shall not operate to terminate the coverage of such child while the child is and continues to be both (a) incapable of self-sustaining employment by reason of having an intellectual disability or a physical disability, and (b) chiefly dependent upon the subscriber or policyholder for support and maintenance, provided proof of such incapacity and dependency is furnished to the hospital or medical service plan corporation or insurer by the subscriber or policyholder within thirty-one (31) days of the child’s attainment of the limiting age and subsequently as may be required by the corporation or insurer, but not more frequently than annually after the two-year period following the child’s attainment of the limiting age. Any insurer or hospital service plan corporation continuing dependent coverage beyond the limiting age for dependent children as prescribed by this section, shall have the right to charge the standard adult premium for such coverage.

Miss. Code Ann. § 83-41-207 Group hospital and medical expense contracts and policies shall provide for continuation of coverage for persons having an intellectual or physical disability.

Any group hospital or medical service plan contract or any group hospital or medical expense insurance policy delivered or issued for delivery in this state after September 12, 1972, which provides that coverage of a dependent child of an employee, insured party, or other member of the covered group shall terminate upon attainment of the limiting age for dependent children specified in the contract or policy, shall also provide in substance that attainment of such limiting age shall not operate to terminate the coverage of such child while the child is and continues to be both (a) incapable of self-sustaining employment by reason of having an intellectual disability or a physical disability, and (b) chiefly dependent upon the employee, insured party, or member for support and maintenance, provided proof of such incapacity and dependency is furnished to the hospital or medical service plan corporation or insurer by the employee, insured party, or member within thirty-one (31) days of the child’s attainment of the limiting age and subsequently as may be required by the corporation or insurer, but not more frequently than annually after the two-year period following the child’s attainment of the limiting age. Any insurer or hospital service plan corporation continuing dependent coverage beyond the limiting age for dependent children as prescribed by this section, shall have the right to charge the standard adult premium for such coverage.

Miss. Code Ann. § 83-41-209 Beneficiaries’ freedom of choice of practitioner in performance of dental services.

Whenever any policy of insurance or any medical service plan or hospital service contract or hospital and medical service contract issued in this state provides for reimbursement for any service which is within the lawful scope of practice of a duly licensed dentist, as defined by the laws of the State of Mississippi, the insured, or other person entitled to benefits under such policy, shall be entitled to reimbursement for such services, whether such services are performed by a duly licensed physician or by a duly licensed dentist, notwithstanding any provision to the contrary in any statute or in such policy, plan or contract; duly licensed dentists shall be entitled to participate in such policies, plans or contracts providing for dental services, as authorized by the laws of the State of Mississippi.

Miss. Code Ann. § 83-41-211 Beneficiaries’ freedom of choice of practitioner in treatment of mental, nervous or emotional disorders; psychologist, professional counselor or clinical social worker.

Whenever any policy of insurance or any medical service plan or hospital service contract or hospital and medical service contract issued in this state provides for reimbursement for any diagnosis and treatment of mental, nervous or emotional disorders only which are within the lawful scope of practice of a duly licensed psychologist as defined in Section 73-31-3, within the lawful scope of practice of a duly licensed professional counselor as defined in Section 73-30-3, within the lawful scope of practice of a duly licensed clinical social worker as defined in Section 73-53-3, or within the lawful scope of practice of a duly licensed marriage and family therapist as defined in Section 73-54-5, the insured or other person entitled to benefits under such policy shall be entitled to reimbursement for such services, whether such services are performed by a duly licensed physician or by a duly licensed psychologist, by a duly licensed professional counselor, by a duly licensed clinical social worker or by a duly licensed marriage and family therapist, notwithstanding any provision to the contrary in any statute or in such policy, plan or contract. Duly licensed psychologists shall be entitled to participate in such policies, plans or contracts providing for the diagnosis and treatment of mental, nervous or emotional disorders only as authorized by Section 73-31-3. A duly licensed professional counselor shall be entitled to participate in such policies, plans or contracts providing for the diagnosis and treatment of mental, nervous or emotional disorders only as authorized by Section 73-30-3. A duly licensed clinical social worker shall be entitled to participate in such policies, plans or contracts providing for the diagnosis and treatment of mental, nervous or emotional disorders only as authorized by Section 73-53-3. A duly licensed marriage and family therapist shall be entitled to participate in such policies, plans or contracts providing for the diagnosis and treatment of mental, nervous or emotional disorders only as authorized by Section 73-54-5 et seq. The addition of marriage and family therapists as providers herein is intended to only allow them to treat mental, nervous or emotional disorders as treated by other providers, to the extent that marriage and family therapists are qualified to treat such disorders. Notwithstanding anything in this section to the contrary, the scope or definition of mental, nervous or emotional disorders shall remain the same and shall not be expanded by the addition of marriage and family therapists as allowable providers.

Miss. Code Ann. § 83-41-213 Right of insureds or other beneficiaries to be reimbursed for services performed by physicians or nurse practitioners within lawful scope of their practice.

From and after January 1, 1999, whenever any policy of insurance or any medical service plan or hospital service contract or hospital and medical service contract issued, delivered, administered, continued or renewed in this state provides for reimbursement for any service which is within the lawful scope of practice of a duly certified nurse practitioner as provided for by rules and regulations implemented by the Mississippi Board of Nursing under Section 73-15-5(2), the insured or other person entitled to benefits under such policy shall be entitled to reimbursement for such services, whether such services are performed by a duly licensed physician or by a duly certified nurse practitioner, notwithstanding any provision to the contrary in any statute or in such policy, plan or contract. Duly certified nurse practitioners shall be entitled to participate in such policies, plans or contracts providing for the services of nurse practitioners, as authorized by the rules and regulations implemented by the Mississippi Board of Nursing under Section 73-15-5(2). Reimbursement shall be based on services rendered by a duly certified nurse practitioner. It is the intent of the Legislature by this section to provide for increased access of health delivery services to the underserved.

Miss. Code Ann. § 83-41-214 Payment by third parties of certified nurse practitioners.

A policy or contract providing for third-party payment or prepayment of health or medical expenses shall include a provision for the payment of necessary medical or surgical care and treatment provided by a duly certified nurse practitioner and performed within the scope of the license of the certified nurse practitioner if the policy or contract would pay for the care and treatment if the care and treatment were provided by a person engaged in the practice of medicine and surgery or osteopathic medicine and surgery. The policy or contract shall provide that policyholders and subscribers under the policy or contract may reject the coverage for services which may be provided by a certified nurse practitioner if the coverage is rejected for all providers of similar services. A policy or contract subject to this section shall not impose a practice or supervision restriction which is inconsistent with or more restrictive than the restriction already imposed by law. This section applies to services provided under a policy or contract delivered, issued for delivery, continued, or renewed in this on or after July 1, 1999, and to an existing policy or contract, on the policy’s or contract’s anniversary or renewal date, whichever is later. This section does not apply to policyholders or subscribers eligible for coverage under Title XVIII of the federal Social Security Act or any similar coverage under a state or federal government plan. For the purposes of this section, third-party payment or prepayment includes an individual or group health care service contract, an individual or group health maintenance organization contract, or a preferred provider organization contract. Nothing in this section shall be interpreted to require an individual or group health maintenance organization, or a preferred provider organization to provide payment or prepayment for services provided by a certified nurse practitioner unless the certified nurse practitioner or the certified nurse practitioner’s collaborating physician has entered into a contract or other agreement to provide services with the individual or group health maintenance organization or the preferred provider organization or arrangement.

Miss. Code Ann. § 83-41-215 Right of beneficiary or insured to reimbursement for services performed by chiropractor; freedom of choice of practitioner and place of services.

Whenever any policy of insurance or any medical service plan or hospital service contract or hospital and medical service contract issued in this state provides for reimbursement for any service which is within the lawful scope of practice of a duly licensed chiropractor as defined in Section 73-6-1, Mississippi Code of 1972, then such service may be performed by a duly licensed chiropractor, and the insured or other person entitled to benefits under such policy, plan or contract shall be entitled to reimbursement for such services. The insured shall have the right to choose the place where the service is to be performed as well as the chiropractor to perform such service, provided that such service shall be performed in the chiropractor’s office, clinic or regular place of business.

Miss. Code Ann. § 83-41-217 Direct access to obstetricians/gynecologists to be allowed; status as primary care physicians.

Any health care service plan contract that provides hospital, outpatient, medical or surgical coverage that is issued, amended, delivered or renewed in this state shall include obstetricians/gynecologists as primary care physicians and allow direct access to obstetricians/gynecologists by female patients if the obstetrician/gynecologist otherwise meets the policy or contract requirements.

Miss. Code Ann. § 83-41-219 Reciprocal time limitations on health insurance claim filing and claim audits; applicability [See Editor’s Note for effective date and applicability].

If any health insurance issuer or other health insurance benefit payer limits the time in which a health care provider or other person is required to submit a claim for payment, the health insurance issuer or other health insurance benefit payer shall have the same time limit following payment of the claim to perform any review or audit for reconsidering the validity of the claim and requesting reimbursement for payment of an invalid claim or overpayment of a claim. If any health insurance issuer or other health insurance benefit payer does not limit the time in which a health care provider or other person is required to submit a claim for payment, the health insurance issuer or other health insurance benefit payer may not request reimbursement or offset another claim payment for reimbursement of an invalid claim or overpayment of a claim more than twelve (12) months after the payment of an invalid or overpaid claim. Nothing in this section shall apply to: Audits that were opened before July 1, 2012; Audits of pharmacies as provided in Section 73-21-175 et seq.; Claims submitted by providers for reimbursement under the Mississippi Medicaid Program, except that all audits of claims and payments made by or on behalf of the Division of Medicaid are limited to a maximum of five (5) years after final filing of the claim; and Claims submitted in the context of misrepresentation, omission, concealment, or fraud by the health care provider or other person.

Miss. Code Ann. § 83-41-301 Short title.

This article may be cited as the Health Maintenance Organization, Preferred Provider Organization and Other Prepaid Health Benefit Plans Protection Act.

Miss. Code Ann. § 83-41-303 Definitions.

“Basic health care services” means the following medically necessary services: preventive care, emergency care, inpatient and outpatient hospital and physician care, diagnostic laboratory and diagnostic and therapeutic radiological services and includes but is not limited to mental health services or services for alcohol or drug abuse, dental or vision services or long-term rehabilitation treatment for the purpose of preventing, alleviating, curing or healing human illness or physical disability. “Capitated basis” means fixed per member per month payment or percentage of premium payment wherein the provider assumes the full risk for the cost of contracted services without regard to the type, value or frequency of services provided. Capitated basis includes the cost associated with operating staff model facilities. “Carrier” means a health maintenance organization, an insurer, a nonprofit hospital and medical service corporation, fraternal societies, preferred provider organizations or any other entity responsible for the payment of benefits or provision for services under a group contract or individual contract on a prepayment basis. “Commissioner” means the Commissioner of Insurance. “Copayment” means an amount an enrollee must pay in order to receive a specific service which is not fully prepaid. “Deductible” means the amount an enrollee is responsible to pay out-of-pocket before the carrier begins to be responsible for the costs associated with treatment. “Enrollee” means an individual who is covered for the benefits offered by the carrier. “Evidence of coverage” means a statement of the essential features and services of the health care provider which is given to the subscriber by the carrier or by the group contract holder. “Extension of benefits” means the continuation of coverage under a particular benefit provided under a contract following termination with respect to an enrollee or subscriber who is totally disabled on the date of termination. “Financing” means the prepayment of premium or premium equivalences for services to be received by the enrollee in the future together with acceptance and assumption of the risk, including capitation fee. “Grievance” means a written complaint submitted in accordance with the provider’s formal grievance procedure by or on behalf of the enrollee regarding any aspect of the carrier or provider to the enrolled. “Group contract” means a contract for health care services which by its terms limits eligibility to members of a specified group and may include coverage for dependents. “Group contract holder” means a person having a group contract. “Health maintenance organization” means any person that undertakes to provide or arrange for the delivery of basic health care services through an organized system which combines the delivery and financing of health care to enrollees on a prepaid or other financial basis (except for enrolled responsibility for copayment or deductibles) through an organized system which combines the delivery and financing of health care. When an organization accepts and assumes risks and accepts payments, fees, premiums or premium equivalences for that risk it is deemed to be a health maintenance organization. “Health maintenance organization producer” means a person who holds a life, health and accident insurance license and a certificate of authority to represent the health maintenance organization who solicits, negotiates, effects, procures, delivers, renews or continues a policy or contract for health maintenance organization membership, or who takes or transmits a membership fee or premium for such a policy or contract, other than for himself, or a person who advertises or otherwise holds himself out to the public as such. “Individual contract” means a contract for health care services issued to and covering an individual may include dependents of the subscriber. “Insolvent” or “Insolvency” means that the organization has been declared insolvent and placed under an order of rehabilitation or liquidation by a court of competent jurisdiction. “Managed hospital payment basis” means agreements wherein the financial risk is primarily related to the degree of utilization rather than to the cost of services. “Net worth” means the excess of total admitted assets over total liabilities, but the liabilities shall not include fully subordinated debt. “Participating provider” means a provider as defined in paragraph (v) who, under an express or implied contract with the health maintenance organization or with its contractor or subcontractor, has agreed to provide health care services to enrollees with an expectation of receiving payment, other than copayment or deductible, directly or indirectly from the health maintenance organization. “Person” means any natural or artificial person including but not limited to individuals, partnerships, associations, trusts, fraternal societies, or corporations. “Provider” means any physician, hospital or other person licensed or otherwise authorized to furnish health care services. “Replacement coverage” means the benefits provided by a succeeding carrier. “Subscriber” means an individual whose employment or other status, except family dependency, is the basis for eligibility for enrollment in the health maintenance organization, or in the case of an individual contract, the person in whose name the contract is issued. “Uncovered expenditures” means the costs to the health maintenance organization for health care services that are the obligation of the health maintenance organization, for which an enrollee may also be liable if the health maintenance organization is insolvent and for which no alternative arrangements have been made that are acceptable to the commissioner.

Miss. Code Ann. § 83-41-305 Requirement of certificate of authority for establishment and operation of health maintenance organization; filing, form and contents of application for certificate and attachments; qualification of foreign health maintenance organizations; effect of denial of certificate; rules and regulations.

Notwithstanding any law of this state to the contrary, any person may apply to the commissioner for a certificate of authority to establish and operate a health maintenance organization in compliance with this article. No person shall establish or operate a health maintenance organization in this state, without obtaining a certificate of authority under this article. A foreign health maintenance organization may qualify under this article, subject to its registration to do business in this state as a foreign health maintenance organization under Section 79-4-15.01, Mississippi Code of 1972, and compliance with all provisions of this article and other applicable state laws. Any health maintenance organization which has not previously received a certificate of authority to operate as a health maintenance organization as of July 1, 1995, shall submit an application for a certificate of authority under subsection (3) within sixty (60) days. Each applicant may continue to operate until the commissioner acts upon the application. If an application is denied under Section 83-41-307, the applicant shall thereafter be treated as a health maintenance organization whose certificate of authority has been revoked. Each application for a certificate of authority shall be verified by an officer or authorized representative of the applicant, shall be in a form prescribed by the commissioner, and shall set forth or be accompanied by the following: A copy of the organizational documents of the applicant, such as the articles of incorporation, articles of association, partnership agreement, trust agreement, or other applicable documents, and all amendments thereto; A copy of the bylaws, rules and regulations, or similar document, if any, regulating the conduct of the internal affairs of the applicant; A list of the names, addresses and official positions and biographical information on forms acceptable to the commissioner of the persons who are to be responsible for the conduct of the affairs and day to day operations of the applicant, including all members of the board of directors, board of trustees, executive committee or other governing board or committee and the principal officers in the case of a corporation, or the partners or members in the case of a partnership or association; A copy of any contract form made or to be made between any class of providers and the health maintenance organization and a copy of any contract made or to be made between third party administrators, marketing consultants or persons listed in paragraph (c) and the health maintenance organization; A copy of the form of evidence of coverage to be issued to the enrollees; A copy of the form of group contract, if any, which is to be issued to employers, unions, trustees or other organizations; Financial statements showing the applicant’s assets, liabilities and sources of financial support. Include both a copy of the applicant’s most recent (regular) certified financial statement and an unaudited current financial statement; A financial feasibility plan which includes detailed enrollment projections, the methodology for determining premium rates to be charged during the first twelve months of operations certified by an actuary or other qualified person, a projection of balance sheets, cash flow statements showing any capital expenditures, purchase and sale of investments and deposits with the state, and income and expense statements anticipated from the start of operations until the organization has had net income for at least one (1) year, and a statement as to the sources of working capital as well as any other sources of funding; A power of attorney duly executed by the applicant, if not domiciled in this state, appointing the commissioner and his successors in office, and duly authorized deputies, as the true and lawful attorney of the applicant in and for this state upon whom all lawful process in any legal action or proceeding against the health maintenance organization on a cause of action arising in this state may be served; A statement or map reasonably describing the geographic area or areas to be served; A description of the internal grievance procedures to be utilized for the investigation and resolution of enrollee complaints and grievances; A description of the proposed quality assurance program, including the formal organizational structure, methods for developing criteria, procedures for comprehensive evaluation of the quality of care rendered to enrollees, and processes to initiate corrective action and reevaluation when deficiencies in provider or organizational performance are identified; A description of the procedures to be implemented to meet the protection against insolvency requirements in Section 83-41-325; A list of the names, addresses, and license numbers of all providers with which the health maintenance organization has agreements and this list must be updated at the end of each calendar quarter. Any other information as the commissioner may require to make the determinations required in Section 83-41-307. The commissioner may promulgate rules and regulations as he deems necessary to the proper administration of this article to require a health maintenance organization and other entities subsequent to receiving its certificate of authority to submit the information, modifications or amendments to the items described in subsection (3) of this section to the commissioner, either for his approval or for information only, prior to the effectuation of the modification or amendment, or to require the health maintenance organization to indicate the modifications to both State Health Officer and commissioner at the time of the next succeeding site visit or examination. Any modification or amendment for which the commissioner’s approval is required shall be deemed approved unless disapproved within thirty (30) days. The commissioner may postpone the action for a time, not exceeding an additional thirty (30) days, as necessary for proper consideration.

Miss. Code Ann. § 83-41-307 Transmission of copies of application for certificate of authority to State Health Officer; duties of State Health Officer; grant or denial of certificate of authority.

Upon receipt of an application for issuance of a certificate of authority, the commissioner shall forthwith transmit copies of the application and accompanying documents to the State Health Officer. The State Health Officer shall determine whether the applicant for a certificate of authority, with respect to health care services to be furnished has complied with Section 83-41-313. Within forty-five (45) days of receipt of the application for issuance of a certificate of authority, the State Health Officer shall certify to the commissioner that the proposed health maintenance organization meets the requirements of Section 83-41-313 or notify the commissioner that the health maintenance organization does not meet the requirements and specify deficiencies. The commissioner shall within forty-five (45) days of receipt of certification or notice of deficiencies from the State Health Officer issue a certificate of authority to any person filing a completed application upon receiving the prescribed fees and upon the commissioner being satisfied that: The persons responsible for the conduct of the affairs of the applicant are competent, trustworthy and possess good reputations; Any deficiencies identified by the State Health Officer have been corrected and the State Health Officer has certified to the commissioner that the health maintenance organization’s proposed plan of operation meets the requirements of Section 83-41-313 and other related regulations; The health maintenance organization will effectively provide or arrange for the provision of basic health care services on a prepaid basis, through insurance or otherwise, except to the extent of reasonable requirements for copayments and/or deductibles; and The health maintenance organization is in compliance with Sections 83-41-325 and 83-41-329. A certificate of authority shall be denied only after the commissioner complies with the requirements of Section 83-41-339.

Miss. Code Ann. § 83-41-309 Powers of health maintenance organization generally; notice of exercise of powers affecting financial condition of organization.

The powers of a health maintenance organization include, but are not limited to, the following: The purchase, lease, construction, renovation, operation or maintenance of hospitals, medical facilities, or both, and their ancillary equipment, and any property as may reasonably be required for its principal office or for those purposes as may be necessary in the transaction of the business of the organization; Transactions between affiliated entities, including loans and the transfer of responsibility under all contracts between affiliates loans from the health maintenance organization to a parent are prohibited without prior approval in writing from the commissioner; The furnishing of health care services through providers, provider associations or agents for providers which are under contract with or employed by the health maintenance organization; The contracting with any person for the performance on its behalf of certain functions such as marketing, enrollment and administration provided all entities are qualified under this article; The contracting with an insurance company licensed in this state, or with a hospital or medical service corporation authorized to do business in this state, for the provision of insurance, indemnity or reimbursement against the cost of health care services provided by the health maintenance organization; The offering of other health care services, in addition to basic health care services. Non-basic health care services may be offered by a health maintenance organization on a prepaid basis without offering basic health care services to any group or individual; The joint marketing of products with an insurance company licensed in this state or with a hospital or medical service corporation authorized to do business in this state as long as the company that is offering each product is clearly identified. A health maintenance organization shall file notice, with adequate supporting information, with the commissioner prior to the exercise of any power granted in subsection 1(a), (b) or (d) which may affect the financial condition of the health maintenance organization. The commissioner shall disapprove an exercise of power only if in his opinion it would substantially and adversely affect the financial condition of the health maintenance organization and endanger its ability to meet its obligations. The commissioner may promulgate rules and regulations exempting from the filing requirement of paragraph (a) those activities having a de minimis effect.

Miss. Code Ann. § 83-41-311 Bonds or insurance for directors, officers, employees, partners and contractors.

Any director, officer, employee, contractor or partner of a health maintenance organization who receives, collects, disburses or invests funds in connection with the activities of such organization shall be responsible for the funds in a fiduciary relationship to the organization. A health maintenance organization shall maintain in force a fidelity bond or fidelity insurance on employees and officers, directors and partners in an amount not less than Two Hundred Fifty Thousand Dollars ($250,000.00) for each health maintenance organization or a maximum of Five Million Dollars ($5,000,000.00) in aggregate maintained on behalf of health maintenance organizations owned by a common parent corporation, or such sum as may be prescribed by the commissioner.

Miss. Code Ann. § 83-41-313 Quality assurance procedures, programs and activities; maintenance and examination of patient records.

The health maintenance organization shall establish procedures to assure that the health care services provided to enrollees shall be rendered under reasonable standards of quality of care consistent with prevailing professionally recognized standards of medical practice. The procedures shall include mechanisms to assure availability, accessibility and continuity of care. The health maintenance organization shall have an ongoing internal quality assurance program to monitor and evaluate its health care services, including primary and specialist physician services, and ancillary and preventive health care services, across all institutional and non-institutional settings. The program shall include, at a minimum, the following: A written statement of goals and objectives which emphasizes improved health status in evaluating the quality of care rendered to enrollees; A written quality assurance plan which describes the following: The health maintenance organization’s scope and purpose in quality assurance; The organizational structure responsible for quality assurance activities; Contractual arrangements, where appropriate, for delegation of quality assurance activities; Confidentiality policies and procedures; A system of ongoing evaluation activities; A system of focused evaluation activities; A system for credentialing providers and performing peer review activities; and Duties and responsibilities of the designated physician responsible for the quality assurance activities. A written statement describing the system of ongoing quality assurance activities including: Problem assessment, identification, selection and study; Corrective action, monitoring, evaluation and reassessment; and Interpretation and analysis of patterns of care rendered to individual patients by individual providers; A written statement describing the system of focused quality assurance activities based on representative samples of the enrolled population which identifies method of topic selection, study, data collection, analysis, interpretation and report format; and Written plans for taking appropriate corrective action whenever, as determined by the quality assurance program, inappropriate or substandard services have been provided or services which should have been furnished have not been provided. The organization shall record proceedings of formal quality assurance program activities and maintain documentation in a confidential manner. Quality assurance program minutes shall be available to the State Health Officer. The organization shall ensure the use and maintenance of an adequate patient record system which will facilitate documentation and retrieval of clinical information for the purpose of the health maintenance organization evaluating continuity and coordination of patient care and assessing the quality of health and medical care provided to enrollees. Enrollee clinical records shall be available to the State Health Officer or an authorized designee for examination and review to ascertain compliance with this section, or as deemed necessary by the State Health Officer. The organization shall establish a mechanism for periodic reporting of quality assurance program activities to the governing body, providers and appropriate organization staff.

Miss. Code Ann. § 83-41-315 Filing, contents and approval of group and individual contracts and evidence of coverage.

Every group and individual contract holder is entitled to a group or individual written contract respectively. The contract shall not contain provisions or statements which are unjust, unfair, inequitable, misleading, deceptive, or which encourage misrepresentation as defined by the Unfair Trade Practices Act. The contract shall contain a clear statement of the following: Name and street address of the physical location of the home office of the health maintenance organization and telephone number; Eligibility requirements; Benefits and services within the service area; Emergency care benefits and services; Out of area benefits and services (if any); Copayments, deductibles or other out-of-pocket expenses; Limitations and exclusions; Enrollee termination; Enrollee reinstatement (if any); Claims procedures; Enrollee grievance procedures; Continuation of coverage; Conversion; Extension of benefits (if any); Coordination of benefits (if applicable); Subrogation (if any); Description of the service area; Entire contract provision; Term of coverage; Cancellation of group or individual contract holder; Renewal; Reinstatement of group or individual contract holder (if any); Grace period; and Conformity with state law, including but not limited to Section 83-9-1 et seq., Mississippi Code of 1972. In addition to those provisions required in subsection (1)(c), an individual contract shall provide for a ten-day (10-day) period to examine and return the contract and have the premium refunded. If services were received during the ten-day (10-day) period, and the person returns the contract to receive a refund of the premium paid, he or she must pay for the services. Every subscriber shall receive an evidence of coverage from the group contract holder or the health maintenance organization. The evidence of coverage shall not contain provisions or statements which are unfair, unjust, inequitable, misleading, deceptive, or which encourage misrepresentation as defined by Unfair Trade Practices Act. The evidence of coverage shall contain a clear statement of the provisions required in subsection (1)(c). The commissioner may adopt regulations establishing readability standards for individual contract, group contract, and evidence of coverage forms. No group or individual contract, evidence of coverage or amendment thereto, shall be delivered or issued for delivery in this state, unless its form has been filed and the proper fees paid with and approved by the commissioner, subject to subsections (6) and (7) of this section. If an evidence of coverage issued pursuant to and incorporated in a contract issued in this state is intended for delivery in another state and the evidence of coverage has been approved for use in the state in which it is to be delivered, the evidence of coverage need not be submitted to the commissioner of this state for approval though it cannot be offered in this state without approval of the commissioner. Every form required by this section shall be filed for approval with the commissioner. At any time, after thirty (30) days’ notice and for cause shown, the commissioner may withdraw approval of any form, effective at the end of the thirty (30) days. When a filing is disapproved or approval of a form is withdrawn, the commissioner shall give the health maintenance organization written notice of the reasons for disapproval and in the notice shall inform the health maintenance organization that within thirty (30) days of receipt of the notice the health maintenance organization may request a hearing. A hearing will be conducted within thirty (30) days after the commissioner has received the request for hearing. The commissioner may require the submission of whatever relevant information he deems necessary in determining whether to approve or disapprove a filing made pursuant to this section.

Miss. Code Ann. § 83-41-317 Filing of annual reports, financial statements, etc.

Every health maintenance organization shall annually, on or before the first day of March, file a report verified by at least two (2) principal officers with the commissioner, with a copy to the State Health Officer, covering the preceding calendar year. Such report shall be on and in accordance to the National Association of Insurance Commissioner’s Annual Statement Blanks and Instruction thereto and the NAIC Accounting Practices and Procedures Manual. The health maintenance organization shall file by the first day of March of each year, unless otherwise stated: Audited financial statements on or before June 1; A list of the providers who have executed a contract that complies with Section 83-41-325(12); and A description of the grievance procedures, and The total number of grievances handled through such procedures, a compilation of the causes underlying those grievances, and a summary of the final disposition of those grievances. The commissioner may require such additional reports as are deemed necessary and appropriate to enable the commissioner to carry out his duties and responsibilities under this article.

Miss. Code Ann. § 83-41-319 Provision of information and notices to subscribers.

The health maintenance organization shall provide to its subscribers a list of providers, upon enrollment, re-enrollment or at a minimum annually. Every health maintenance organization shall provide within thirty (30) days to its subscribers notice of any material change in the operation of the organization that will affect them directly. An enrollee must be notified in writing by the health maintenance organization of the termination of the primary care provider who provided health care services to that enrollee, if the plan operates on a formal gatekeeper concept. The health maintenance organization shall provide assistance to the enrollee in transferring to another participating primary care provider. The health maintenance organization shall provide to subscribers information on how services may be obtained, where additional information on access to services can be obtained and a number where the enrollee can contact the health maintenance organization, at no cost to the enrollee.

Miss. Code Ann. § 83-41-321 Grievance procedures.

Every health maintenance organization shall establish and maintain a grievance procedure which has been approved by the commissioner, after consultation with the State Health Officer, to provide procedures for the resolution of grievances initiated by enrollees. The health maintenance organization shall maintain records regarding grievances received since the date of its last examination of such grievances. The commissioner or the State Health Officer may examine such grievance procedures.

Miss. Code Ann. § 83-41-323 Funds.

With the exception of investments made in accordance with Section 83-41-309(1)(a), the funds of a health maintenance organization shall be invested only in accordance with investment permitted by the laws of the State of Mississippi for life insurance companies (Section 83-19-51 et seq., Mississippi Code of 1972).

Miss. Code Ann. § 83-41-325 Minimum net worth requirement; deposits generally; computation of liabilities; contracts between health maintenance organizations and participating providers of services; insolvency plans.

Before issuing any certificate of authority, the commissioner shall require that the health maintenance organization have an initial net worth of One Million Five Hundred Thousand Dollars ($1,500,000.00) and shall thereafter maintain the minimum net worth required under subsection (2). Except as provided in subsections (3) and (4) of this section, every health maintenance organization must maintain a minimum net worth equal to the greater of: One Million Dollars ($1,000,000.00); or Two percent (2%) of annual premium revenues as reported on the most recent annual financial statement filed with the commissioner on the first One Hundred Fifty Million Dollars ($150,000,000) of premium and one percent (1%) of annual premium on the premium in excess of One Hundred Fifty Million Dollars ($150,000,000.00); or An amount equal to the sum of three (3) months uncovered health care expenditures as reported on the most recent financial statement filed with the commissioner; or For a health maintenance organization in which seventy-five percent (75%) or more of the providers are paid on a capitated basis, an amount equal to the sum of: Eight percent (8%) of annual health care expenditures except those paid on a capitated basis or managed hospital payment basis as reported on the most recent financial statement filed with the commissioner; and Four percent (4%) of annual hospital expenditures paid on a managed hospital payment basis as reported on the most recent financial statement filed with the commissioner. A health maintenance organization licensed before July 1, 1995 must maintain a minimum net worth of: Twenty-five percent (25%) of the amount required by subsection (2) by December 31, 1995; Fifty percent (50%) of the amount required by subsection (2) by December 31, 1996; Seventy-five percent (75%) of the amount required by subsection (2) by December 31, 1997; One hundred percent (100%) of the amount required by subsection (2) by December 31, 1998. In determining net worth, no debt shall be considered fully subordinated unless the subordination clause is in a form acceptable to the commissioner. Any interest obligation relating to the repayment of any subordinated debt must be similarly subordinated. The interest expenses relating to the repayment of any fully subordinated debt shall be considered covered expenses. Any debt incurred by a note meeting the requirements of this section, and otherwise acceptable to the commissioner, shall not be considered a liability and shall be recorded as equity. Unless otherwise provided below, each health maintenance organization shall deposit with the commissioner or, at the discretion of the commissioner, with any organization or trustee acceptable to him through which a custodial or controlled account is utilized, cash, securities, or any combination of these or other measures that are acceptable to him which at all times shall have a value of not less than Five Hundred Thousand Dollars ($500,000.00). A health maintenance organization that is in operation on July 1, 1995 shall make a deposit equal to Two Hundred Fifty Thousand Dollars ($250,000.00). In the second year, the amount of the additional deposit for a health maintenance organization that is in operation on July 1, 1995 shall be equal to Two Hundred Fifty Thousand Dollars ($250,000.00), for a total of Five Hundred Thousand Dollars ($500,000.00). The deposit shall be an admitted asset of the health maintenance organization in the determination of net worth. All income from deposits shall be an asset of the organization. A health maintenance organization that has made a securities deposit may withdraw that deposit or any part thereof after making a substitute deposit of cash, securities, or any combination of these or other measures of equal amount and value. Any securities shall be approved by the commissioner before being deposited or substituted. The deposit shall be used to protect the interests of the health maintenance organization’s enrollees and to assure continuation of health care services to enrollees of a health maintenance organization which is in rehabilitation or conservation. The commissioner may use the deposit for administrative costs directly attributable to a receivership or liquidation. If the health maintenance organization is placed in receivership or liquidation, the deposit shall be an asset subject to the provisions of the liquidation act. The commissioner may reduce or eliminate the deposit requirement if the health maintenance organization deposits with the state treasurer, commissioner, or other official body of the state or jurisdiction of domicile for the protection of all subscribers and enrollees, wherever located, of such health maintenance organization, cash, acceptable securities or surety, and delivers to the commissioner a certificate to such effect, duly authenticated by the appropriate state official holding the deposit. If the commissioner becomes aware of a need for additional deposits he may order a health maintenance organization to place with the State Treasurer additional deposits to meet the need to protect the securities. Every health maintenance organization shall, when determining liabilities, include an amount estimated in the aggregate to provide for any unearned premium and for the payment of all claims for health care expenditures which have been incurred, whether reported or unreported, which are unpaid and for which such organization is or may be liable, and to provide for the expense of adjustment or settlement of such claims, and guaranteed renewal reserves if applicable. The liabilities shall be computed in accordance with regulations promulgated by the commissioner upon reasonable consideration of the ascertained experience and character of the health maintenance organization. Every contract between a health maintenance organization and a participating provider of health care services shall be in writing and shall set forth that if the health maintenance organization fails to pay for health care services as set forth in the contract, the subscriber or enrollee shall not be liable to the provider for any sums owed by the health maintenance organization. If the participating provider contract has not been reduced to writing as required or that the contract fails to contain the required prohibition, the participating provider shall not collect or attempt to collect from the subscriber or enrollee sums owed by the health maintenance organization. No participating provider, or agent, trustee or assignee thereof, may maintain any action at law against a subscriber or enrollee to collect sums owed by the health maintenance organization. The commissioner shall require that each health maintenance organization have a plan for handling insolvency which allows for continuation of benefits for the duration of the contract period for which premiums have been paid and continuation of benefits to members who are confined on the date of insolvency in an inpatient facility until their discharge or expiration of benefits. The commissioner in his discretion may require: Insurance to cover the expenses to be paid for continued benefits after an insolvency; Provisions in provider contracts that obligate the provider to provide services for the duration of the period after the health maintenance organization’s insolvency for which premium payment has been made and until the enrollees’ discharge from inpatient facilities; Insolvency reserves; Acceptable letters of credit; Any other arrangements to assure that benefits are continued as specified above. An agreement to provide health care services between a provider and a health maintenance organization must require that if the provider terminates the agreement, the provider shall give the health maintenance organization at least sixty (60) days’ advance notice of termination.

Miss. Code Ann. § 83-41-327 Uncovered expenditures insolvency deposits.

If at any time uncovered expenditures exceed ten percent (10%) of total health care expenditures, a health maintenance organization shall place an uncovered expenditures insolvency deposit with the commissioner, with any organization or trustee acceptable to the commissioner through which a custodial or controlled account is maintained, cash or securities that are acceptable to the commissioner. The deposit shall at all times have a fair market value in an amount of one hundred twenty percent (120%) of the health maintenance organization’s outstanding liability for uncovered expenditures for enrollees in this state, including incurred but not reported claims, and shall be calculated as of the first day of the month and maintained for the remainder of the month. If a health maintenance organization is not otherwise required to file a quarterly report, it shall file a report within forty-five (45) days of the end of the calendar quarter with information sufficient to demonstrate compliance with this section. The deposit required under this section is in addition to the deposit required in Section 83-41-325 and is an admitted asset (as defined under insurance law) of the health maintenance organization in the determination of net worth. All income from deposits or trust accounts shall be assets of the health maintenance organization and may be withdrawn from such deposit or account quarterly with the approval of the commissioner. A health maintenance organization that has made a deposit may withdraw that deposit or any part of the deposit if: (a) a substitute deposit of cash or securities of equal amount and value is made, (b) the fair market value exceeds the amount of the required deposit, or (c) the required deposit under subsection (1) is reduced or eliminated. Deposits, substitutions or withdrawals may be made only with the prior written approval of the commissioner. The deposit required under this section is in trust and may be used only as provided under this section. The commissioner may use the deposit of an insolvent health maintenance organization for administrative costs associated with administering the deposit and payment of claims of enrollees of this state for uncovered expenditures in this state. Claims for uncovered expenditures shall be paid on a pro rata basis based on assets available to pay ultimate liability for incurred expenditures. Partial distribution may be made pending final distribution. Any amount of the deposit remaining may be paid into the liquidation or receivership of the health maintenance organization. The commissioner may by regulation prescribe the time, manner and form for filing claims under subsection (4). The commissioner may by regulation or order require health maintenance organizations to file annual, quarterly or more frequent reports as he deems necessary to demonstrate compliance with this section. The commissioner may require that the reports include liability for uncovered expenditures as well as an audit opinion.

Miss. Code Ann. § 83-41-329 Proceedings upon insolvency of health maintenance organization; terms and conditions of replacement coverage.

In the event of an insolvency of a health maintenance organization, upon order of the commissioner all other carriers that participated in the enrollment process with the insolvent health maintenance organization at a group’s last regular enrollment period shall offer such group’s enrollees of the insolvent health maintenance organization a thirty-day enrollment period commencing upon the date of insolvency. Each carrier shall offer such enrollees of the insolvent health maintenance organization the same coverages and rates that it had offered to the enrollees of the group at its last regular enrollment period. If no other carrier had been offered to some groups enrolled in the insolvent health maintenance organization, or if the commissioner determines that the other health benefit plans lack sufficient health care delivery resources to assure that health care services will be available and accessible to all of the group enrollees of the insolvent health maintenance organization, then the commissioner shall allocate equitably the insolvent health maintenance organization’s group contracts for those groups among all health maintenance organizations which operate within a portion of the insolvent health maintenance organization’s service area, taking into consideration the health care delivery resources of each health maintenance organization. Each health maintenance organization to which a group or groups are so allocated shall offer the group or groups the health maintenance organization’s existing coverage which is most similar to each group’s coverage with the insolvent health maintenance organization at rates determined in accordance with the successor health maintenance organization’s existing rating methodology. The commissioner in his sole discretion addresses reasonableness. The commissioner shall also allocate equitably the insolvent health maintenance organization’s nongroup enrollees which are unable to obtain other coverage among all health maintenance organizations which operate within a portion of the insolvent health maintenance organization’s service area, taking into consideration the health care delivery resources of each such health maintenance organization. Each health maintenance organization to which nongroup enrollees are allocated shall offer such nongroup enrollees the health maintenance organization’s existing coverage for individual or conversion coverage as determined by his type of coverage in the insolvent health maintenance organization at rates determined in accordance with the successor health maintenance organization’s existing rating methodology. Successor health maintenance organizations which do not offer direct nongroup enrollment may aggregate all of the allocated nongroup enrollees into one group for rating and coverage purposes. The commissioner in his sole discretion addresses reasonableness. “Discontinuance” means the termination of the contract between the group contract holder and a health maintenance organization due to the insolvency of the health maintenance organization, and does not refer to the termination of any agreement between any individual enrollee and the health maintenance organization. Any carrier providing replacement coverage with respect to group hospital, medical or surgical expense or service benefits within a period of sixty (60) days from the date of discontinuance of a prior health maintenance organization contract or policy providing hospital, medical or surgical expense or service benefits shall immediately cover all enrollees who were validly covered under the previous health maintenance organization contract or policy at the date of discontinuance and who would otherwise be eligible for coverage under the succeeding carrier’s contract, regardless of any provisions of the contract relating to active employment or hospital confinement or pregnancy. Except to the extent benefits for the condition would have been reduced or excluded under the prior carrier’s contract or policy, no provision in a succeeding carrier’s contract of replacement coverage which would operate to reduce or exclude benefits on the basis that the condition giving rise to benefits preexisted the effective date of the succeeding carrier’s contract shall be applied with respect to those enrollees validly covered under the prior carrier’s contract or policy on the date of discontinuance.

Miss. Code Ann. § 83-41-331 Premium rates.

No premium rate may be used until either a schedule of premium rates or methodology for determining premium rates has been filed with and approved by the commissioner. Either a specific schedule of premium rates, or a methodology for determining premium rates, shall be established in accordance with actuarial principles for various categories of enrollees, provided that the premium applicable to an enrollee shall not be individually determined based on the status of the enrollee’s health. However, the premium rates shall not be excessive, inadequate or unfairly discriminatory. A certification by a qualified actuary or other qualified person acceptable to the commissioner as to the appropriateness of the use of the methodology, based on reasonable assumptions, shall accompany the filing along with adequate supporting information. The commissioner shall approve the schedule of premium rates or methodology for determining premium rates if the requirements of subsection (2) are met. If the commissioner disapproves the filing, he shall notify the health maintenance organization. In the notice, the commissioner shall specify the reasons for his disapproval. A hearing will be conducted within thirty (30) days after a request in writing by the person filing.

Miss. Code Ann. § 83-41-333 Rules and regulations generally; exemptions from certification requirement.

The commissioner may, after notice and hearing, promulgate rules and regulations as are necessary to provide for the licensing of health maintenance organization producers. The rules shall establish: The requirements for licensure of resident health maintenance organization producers; The conditions for entering into reciprocal agreements with other jurisdictions for the licensure of nonresident health maintenance organization producers; Any examination, prelicensing or continuing education requirements; The requirements for registering and terminating the appointment of health maintenance organization producers; Any requirements for registering any assumed names or office locations in which an health maintenance organization producer does business; The conditions for health maintenance organization producer license renewal; The grounds for denial, refusal, suspension or revocation of an health maintenance organization producer’s license; Any required fees for the licensing activities of health maintenance organization producers; and Any other requirement or procedure and any form as may be reasonably necessary to provide for the effective administration of the licensing of health maintenance organization producers under this section. The commissioner may by rule exempt certain classes of persons from the requirement of obtaining a license: If the functions they perform do not require special competence, trustworthiness or the regulatory surveillance made possible by licensing; or If other existing safeguards make regulation unnecessary.

Miss. Code Ann. § 83-41-335 Operation of health maintenance organizations by insurance companies and medical service corporations.

An insurance company licensed in this state, or a hospital or medical service corporation authorized to do business in this state, may either directly or through a subsidiary or affiliate organize and operate a health maintenance organization under the provisions of this article. Any two (2) or more insurance companies, hospital or medical service corporations, or subsidiaries or affiliates, may jointly organize and operate a health maintenance organization. The business of insurance is deemed to include the providing of health care by a health maintenance organization owned or operated by an insurer or a subsidiary thereof, which health maintenance organization shall be subject to the provisions of this article. Notwithstanding any provision of insurance and hospital or medical service corporation laws, an insurer or a hospital or medical service corporation may contract with a health maintenance organization to provide insurance or similar protection against the cost of care provided through health maintenance organizations and to provide coverage if the health maintenance organization fails to meet its obligations. The enrollees of a health maintenance organization constitute a permissible group under such laws. Among other things, under the contracts, the insurer or hospital or medical service corporation may make benefit payments to health maintenance organizations for health care services rendered by providers.

Miss. Code Ann. § 83-41-337 Examination of health maintenance organizations and providers; acceptance of reports in lieu of examinations.

The commissioner shall make an examination of the affairs of any health maintenance organization and providers with whom such organization has contracts, agreements or other arrangements as often as is reasonably necessary for the protection of the interests of the people of this state but not less frequently than once every five (5) years at the expense of the health maintenance organization and provider with whom the health maintenance organization has contracted according to relevant statutes which govern examinations of insurance companies under the insurance laws of this state. The State Health Officer may make an examination concerning the quality assurance program of the health maintenance organization and of any providers with whom such organization has contracts, agreements or other arrangements as often as is reasonably necessary for the protection of the interests of the people of this state but not less frequently than once every five (5) years. Every health maintenance organization and provider shall submit its books and records for such examinations and in every way facilitate the completion of the examination. For the purpose of examinations, the commissioner and the State Health Officer may administer oaths to, and examine the officers and agents of, the health maintenance organization and the principals of providers concerning their business as per existing insurance laws, rules and regulations. The expenses of examinations under this section shall be assessed against the health maintenance organization being examined as per existing laws for examination of insurance companies or the State Health Officer for whom the examination is being conducted. In lieu of such examination, the commissioner or State Health Officer may accept the report of an examination made by the Commissioner of Insurance or the State Health Officer of another state.

Miss. Code Ann. § 83-41-339 Grounds and procedure for revocation, suspension or denial of certificate of authority; administrative penalty generally; correction of deficiencies in net worth; proceedings upon suspension or revocation of certificate of authority; appeals.

Any certificate of authority issued under this article may be suspended or revoked, and any application for a certificate of authority may be denied, if the commissioner after a hearing finds that any of the conditions listed below exist: The health maintenance organization is operating significantly in contravention of its basic organizational document or in a manner contrary to that described in any other information submitted under Section 83-41-305, unless amendments to the submissions have been filed with and approved by the commissioner; The health maintenance organization issues an evidence of coverage or uses a schedule of charges for health care services which do not comply with the requirements of Sections 83-41-315 and 83-41-331; The health maintenance organization does not provide or arrange for basic health care services; The State Health Officer certifies to the commissioner that: The health maintenance organization does not meet the requirements of Section 83-41-307(1)(b); or The health maintenance organization is unable to fulfill its obligations to furnish health care services; The health maintenance organization operating in a “hazardous condition”, and is no longer financially responsible and may reasonably be expected to be unable to meet its obligations to enrollees or prospective enrollees; The health maintenance organization has failed to correct, within the time prescribed by subsection (3), any deficiency occurring due to such health maintenance organization’s prescribed minimum net worth being impaired; The health maintenance organization has failed to implement the grievance procedures required by Section 83-41-321 in a reasonable manner to resolve valid complaints; 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; The continued operation of the health maintenance organization would be hazardous to its enrollees; or The health maintenance organization has otherwise failed substantially to comply with this article. In addition to or in lieu of suspension or revocation of a certificate of authority pursuant to this section, the applicant or health maintenance organization may be subjected to an administrative penalty of up to One Thousand Dollars ($1,000.00) for each violation. The following shall pertain when insufficient net worth is maintained: Whenever the commissioner finds that the net worth maintained by any health maintenance organization subject to the provisions of this article is less than the minimum net worth required to be maintained by Section 83-41-325, he shall give written notice to the health maintenance organization of the amount of the deficiency and require: (i) filing with the commissioner a plan for correction of the deficiency acceptable to the commissioner and (ii) correction of the deficiency within a reasonable time, not to exceed sixty (60) days, unless an extension of time, not to exceed sixty (60) additional days, is granted by the commissioner. The deficiency shall be deemed an impairment, and failure to correct the impairment in the prescribed time shall be grounds for suspension or revocation of the certificate of authority or for placing the health maintenance organization in administrative supervision, rehabilitation or liquidation as per the insurance laws of this State. Unless allowed by the commissioner no health maintenance organization or person acting on its behalf may, directly or indirectly, renew, issue or deliver any certificate, agreement or contract of coverage in this state, for which a premium is charged or collected, when the health maintenance organization writing such coverage is impaired, and the fact of such impairment is known to the health maintenance organization or to such person. However, the existence of an impairment shall not prevent the issuance or renewal of a certificate, agreement or contract when the enrollee exercises an option granted under the plan to obtain a new, renewed or converted coverage. A certificate of authority shall be suspended or revoked or an application or a certificate of authority denied or an administrative penalty imposed only after compliance with the requirements of this section. Suspension or revocation of a certificate of authority or the denial of an application or the imposition of an administrative penalty pursuant to this section shall be by written order and shall be sent to the health maintenance organization or applicant by certified or registered mail and to the State Health Officer. The written order shall state the grounds, charges or conduct on which suspension, revocation or denial or administrative penalty is based. The health maintenance organization or applicant may in writing request a hearing within twenty-day (20) days from the date of mailing of the order. The said request must be filed with the commissioner within the twenty-day (20-day) period. If no written request is made, such order shall be final upon the expiration of said twenty (20) days. If the health maintenance organization or applicant requests a hearing pursuant to this section, the commissioner shall issue a written notice of hearing and send it to the health maintenance organization or applicant by certified or registered mail and to the State Health Officer stating: A specific time for the hearing, which may not be less than twenty (20) days after mailing of the notice of hearing; and A specific place for the hearing which shall be at the discretion of the commissioner and which may be either in Jackson, Hinds County, Mississippi or in the county where the health maintenance organization’s or applicant’s principal place of business is located. If a hearing is requested, the State Health Officer or his designated representative shall be in attendance and shall participate in the proceedings. The recommendations and findings of the State Health Officer with respect to matters relating to the quality of health care services provided in connection with any decision regarding denial, suspension or revocation of a certificate of authority, shall be conclusive and binding upon the commissioner. After the hearing, or upon failure of the health maintenance organization to appear at the hearing, the commissioner shall take whatever action he deems necessary based on written findings and shall mail his decision to the health maintenance organization or applicant with a copy to the State Health Officer. The action of the commissioner and the recommendation and findings of the State Health Officer shall be subject to review under the Administrative Rules of Practice and Procedure Act. When the certificate of authority of a health maintenance organization is suspended, the health maintenance organization shall not, during the period of such 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. When the certificate of authority of a health maintenance organization is revoked, such 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 such organization under supervision of the commissioner. It shall engage in no further advertising or solicitation whatsoever. The commissioner may, by written order, permit such further operation of the organization as he 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. Any appeal from a decision of the commissioner under this section shall be to the Chancery Court of the First Judicial District of Hinds County, Mississippi within thirty days (30) from the final Order of the commissioner.

Miss. Code Ann. § 83-41-341 Rehabilitation, liquidation or administrative supervision of health maintenance organizations.

Any rehabilitation, liquidation or administrative supervision of a health maintenance organization shall be deemed to be the same as the rehabilitation, liquidation or administrative supervision of an insurance company and shall be conducted under the supervision of the commissioner pursuant to the law governing the rehabilitation, liquidation, and administrative supervision of insurance companies. The commissioner may apply for an order directing him to rehabilitate or liquidate a health maintenance organization upon any one or more grounds set out in Section 83-41-325 or when in his opinion the continued operation of the health maintenance organization would be hazardous either to the enrollees or to the people of this state. Enrollees shall have the same priority in the event of liquidation or rehabilitation as the law provides to policyholders of an insurer. For purpose of determining the priority of distribution of general assets, claims of enrollees and enrollees’ beneficiaries shall have the same priority as established by the Rehabilitation and Liquidation Act (Section 83-24-1 et seq., Mississippi Code of 1972) for policyholders and beneficiaries of insureds of insurance companies. If an enrollee is liable to any provider for services provided pursuant to and covered by the health care plan, that liability shall have the status of an enrollee claim for distribution of general assets. Any provider who is obligated by statute or agreement to hold enrollees harmless from liability for services provided pursuant to and covered by a health care plan shall have a priority of distribution of the general assets immediately following that of enrollees and enrollees’ beneficiaries as described herein, and immediately preceding the priority of distribution described in Section 83-24-1 et seq., Mississippi Code of 1972.

Miss. Code Ann. § 83-41-343 Remedies for correction of financial conditions of health maintenance organizations deemed hazardous to enrollees, creditors, or general public and violations of article.

Whenever the commissioner determines that the financial condition of any health maintenance organization is such that its continued operation might be hazardous to its enrollees, creditors, or the general public, or that it has violated any provision of this article, he may, after notice and hearing, order the health maintenance organization to take such action as may be reasonably necessary to rectify such condition or violation, including but not limited to one or more of the following: Reduce the total amount of present and potential liability for benefits by reinsurance or other method acceptable to the commissioner; Reduce the volume of new business being accepted; Reduce expenses by specified methods; Suspend or limit the writing of new business for a period of time; Increase the health maintenance organization’s capital and surplus by contribution; or Take such other steps as the commissioner may deem appropriate under the circumstances. For purposes of this section, the violation by a health maintenance organization of any law of this state to which such health maintenance organization is subject shall be deemed a violation of this article. The commissioner is authorized, by rules and regulations, to set uniform standards and criteria for early warning that the continued operation of any health maintenance organization might be hazardous to its enrollees, creditors, or the general public and to set standards for evaluating the financial condition of any health maintenance organization, which standards shall be consistent with the purposes expressed in subsection (1) of this section. The remedies and measures available to the commissioner under this section shall be in addition to, and not in lieu of, the remedies and measures available to the commissioner under the provisions of the insurance laws of the State of Mississippi.

Miss. Code Ann. § 83-41-345 Adoption of rules and regulations.

The commissioner may, after notice and hearing, promulgate reasonable rules and regulations, as are necessary or proper to carry out the provisions of this article.

Miss. Code Ann. § 83-41-347 Fees.

Every health maintenance organization subject to this article shall pay to the commissioner the following fees: For filing an application for a certificate of authority for a healthmaintenance organization and amendment thereto . . . . . . . . $5,000.00; For filing an amendment to the organizationdocuments that requires approval . . . . . $ 50.00; For filing an amendment “for information only” . . . . . $ 25.00; For filing each annual report . . . . . $ 500.00; Annual renewal of Certificate of Authority . . . . . $ 500.00; Policy forms, certificates, endorsements, riders,applications and rates . . . . . $ 15.00; The State Health Officer may utilize state employees or he may contract with other persons, companies, corporations and entities to carry out the duties and responsibilities under this article. If it is necessary to contract for the performance of the duties and responsibilities required under this article, the expense for the services shall be charged to the carrier and paid directly to the contracting party. The charge shall be approved by the State Health Officer prior to the services being rendered when sufficient information is available to the State Health Officer, though the carrier is responsible for all charges expended when additional services are necessary to carry out the duties and responsibilities for finalization of the licensing process. The method and procedure for the payment of the expenses may be addressed in the regulations promulgated under this article.

Miss. Code Ann. § 83-41-349 Imposition of administrative penalties; informal proceedings for investigation and correction or prevention of violations; cease and desist orders.

The commissioner may, in lieu of suspension or revocation of a certificate of authority under Section 83-41-339, levy an administrative penalty in an amount not less than One Hundred Dollars ($100.00) per violation, nor more than One Thousand Dollars ($1,000.00) per violation, if reasonable; notice in writing is given of the intent to levy the penalty and the health maintenance organization has a reasonable time within which to remedy the defect in its operations which gave rise to the penalty citation. The commissioner may augment this penalty by an amount equal to the sum that he calculates to be the damages suffered by enrollees or other members of the public. If the commissioner or the State Health Officer shall for any reason have cause to believe that any violation of this article has occurred or is threatened, the commissioner or State Health Officer may give notice to the health maintenance organization and to the representatives, or other persons who appear to be involved in the suspected violation, to arrange a hearing with the alleged violators or their authorized representatives for the purpose of attempting to ascertain the facts relating to the suspected violation; and, if it appears that any violation has occurred or is threatened, to arrive at an adequate and effective means of correcting or preventing the violation. Proceedings under this subsection shall not be governed by any formal procedural requirements, and may be conducted in such manner as the commissioner or the State Health Officer may deem appropriate under the circumstances. However, unless consented to by the health maintenance organization, no rule or order may result from a conference until the requirements of this section of this article are satisfied. The commissioner may issue an order directing a health maintenance organization or a representative of a health maintenance organization to cease and desist from engaging in any act or practice in violation of the provisions of this article. Within ten (10) days after service of the cease and desist order, the respondent may request a hearing on the question of whether acts or practices in violation of this article have occurred. The hearings shall be conducted pursuant to rules of practice and procedure before the Mississippi Insurance Department and judicial review shall be available as provided by Section 83-41-339. In the case of any violation of the provisions of this article, if the commissioner elects not to issue a cease and desist order, or in the event of noncompliance with a cease and desist order issued pursuant to subsection (3), the commissioner may institute a proceeding to obtain injunctive or other appropriate relief in the Chancery Court of the First Judicial District of Hinds County, Jackson, Mississippi. Notwithstanding any other provisions of this article, if a health maintenance organization fails to comply with the net worth requirement of this article, the commissioner is authorized to take appropriate action to assure that the continued operation of the health maintenance organization will not be hazardous to its enrollees.

Miss. Code Ann. § 83-41-351 Solicitation of enrollees.

This provision shall not apply to an insurer or hospital or medical service corporation licensed and regulated pursuant to the insurance law or the hospital or medical service corporation laws of this state except with respect to its health maintenance organization activities authorized and regulated pursuant to this article. Solicitation of enrollees by a health maintenance organization granted a certificate of authority, or its representatives, shall not be construed to violate any provision of law relating to solicitation or advertising by health professionals.

Miss. Code Ann. § 83-41-353 Documents deemed public documents.

All applications, filings and reports required under this article shall be treated as public documents, except those which are trade secrets or privileged or confidential quality assurance, commercial or financial information, other than any annual financial statement that may be required under Section 83-41-317.

Miss. Code Ann. § 83-41-355 Confidentiality of data or information; claims of privilege; civil liability of members of health review committees; discovery of information considered by and records of health review committees; access to treatment records, etc., of enrollees.

Any data or information pertaining to the diagnosis, treatment or health of any enrollee or applicant obtained from the person or from any provider by any health maintenance organization shall be held in confidence and shall not be disclosed to any person except to the extent that it may be necessary to carry out the purposes of this article; or upon the express consent of the enrollee or applicant; or pursuant to statute or court order for the production of evidence or the discovery thereof; or in the event of claim or litigation between the person and the health maintenance organization wherein the data or information is pertinent. A health maintenance organization shall be entitled to claim any statutory privileges against disclosure which the provider who furnished information to the health maintenance organization is entitled to claim. A person who, in good faith and without malice, takes any action or makes any decision or recommendation as a member, agent or employee of a health care review committee or who furnishes any records, information or assistance to a committee shall not be subject to liability for civil damages or any legal action in consequence of the action, nor shall the health maintenance organization which established a committee or the officers, directors, employees or agents of the health maintenance organization be liable for the activities of the person. This section shall not be construed to relieve any person of liability arising from treatment of a patient. The information considered by a health care review committee and the records of their actions and proceedings shall be confidential and not subject to subpoena or order to produce except in proceedings before the appropriate state licensing or certifying agency, or in an appeal, if permitted, from the committee’s findings or recommendations. No member of a health care review committee, or officer, director or other member of a health maintenance organization or its staff engaged in assisting a committee, or any person assisting or furnishing information to a committee may be subpoenaed to testify in any judicial or quasi-judicial proceeding if the subpoena is based solely on such activities. Information considered by a health care review committee and the records of its actions and proceedings which are used pursuant to subsection (3)(a) by a state licensing or certifying agency or in an appeal shall be kept confidential and shall be subject to the same provision concerning discovery and use in legal actions as are the original information and records in the possession and control of a health care review committee. To fulfill its obligations under Section 83-41-313, the health maintenance organization shall have access to treatment records and other information pertaining to the diagnosis, treatment or health status of any enrollee.

Miss. Code Ann. § 83-41-357 Contracting authority of State Health Officer.

The State Health Officer in carrying out his obligations under this article, may contract with qualified persons to make recommendations concerning the determinations required to be made by him. The recommendations may be accepted in full or in part by the State Health Officer.

Miss. Code Ann. § 83-41-359 Acquisitions, mergers and consolidations of health maintenance organizations.

No person may make a tender for or a request or invitation for tenders of, or enter into an agreement to exchange securities for or acquire in the open market or otherwise, any voting security of a health maintenance organization or enter into any other agreement if, after the consummation thereof, that person would, directly or indirectly, (or by conversion or by exercise of any right to acquire) be in control of the health maintenance organization, and no person may enter into an agreement to merge or consolidate with or otherwise to acquire control of a health maintenance organization, unless, at the time any offer, request or invitation is made or any agreement is entered into, or prior to the acquisition of the securities if no offer or agreement is involved, the person has filed with the commissioner and has sent to the health maintenance organization, information required by the commissioner substantially similar to the information required pursuant to Section 83-6-1 et seq., Mississippi Code of 1972, and the offer, request, invitation, agreement or acquisition has been approved by the commissioner.

Miss. Code Ann. § 83-41-361 Adoption of coordination of benefits provisions.

Health maintenance organizations are permitted, but not required, to adopt coordination of benefits provisions to avoid overinsurance and to provide for the orderly payment of claims when a person is covered by two (2) or more group health insurance or health care plans. To the extent necessary for health maintenance organizations to meet their obligations as secondary carriers under the rules for coordination, health maintenance organizations shall make payments for services that are covered under the terms of their group contracts or evidence of coverage.

Miss. Code Ann. § 83-41-363 Proceedings upon insolvency of health maintenance organization.

When a health maintenance organization in this state is declared insolvent by a court of competent jurisdiction, the commissioner may levy an assessment on health maintenance organizations doing business in this state to pay claims for uncovered expenditures for enrollees who are residents of this state and to provide continuation of coverage for subscribers or enrollees not covered under Section 83-41-329. The commissioner may not assess in any one (1) calendar year more than two percent (2%) of the aggregate premium written by each health maintenance organization in this state the prior calendar year. The commissioner may use funds obtained under subsection (1) to pay claims for uncovered expenditures for subscribers or enrollees of an insolvent health maintenance organization who are residents of this state, provide for continuation of coverage for subscribers or enrollees who are residents of this state and are not covered under Section 83-41-329, and administrative costs. The commissioner may by regulation prescribe the time, manner and form for filing claims under this section or may require claims to be allowed by an ancillary receiver or the domestic liquidator or receiver. The Commissioner may not use funds obtained under subsection (1) to pay claims by participating providers for services rendered to subscribers or enrollees prior to insolvency of the health maintenance organization. A receiver or liquidator of an insolvent health maintenance organization shall allow a claim in the proceeding in an amount equal to administrative and uncovered expenditures paid under this section. Any person receiving benefits under this section for uncovered expenditures is deemed to have assigned the rights under the covered health care plan certificates to the commissioner to the extent of the benefits received. The commissioner may require an assignment to it of such rights by any payee, enrollee, or beneficiary as a condition precedent to the receipt of any rights or benefits conferred by this section upon such person. The commissioner is subrogated to these rights against the assets of any insolvent health maintenance organization held by a receiver or liquidator of another jurisdiction. The assignment or subrogation rights of the commissioner and allowed claim under this subsection have the same priority against the assets of the insolvent health maintenance organization as those possessed by the person entitled to receive benefits under this section or for similar expenses in the receivership or liquidation. When assessed funds are unused following the completion of the liquidation of a health maintenance organization, the commissioner will distribute on a pro rata basis any amounts received under subsection (1) which are not de minimis to the health maintenance organizations which have been assessed under this section. The aggregate coverage of uncovered expenditures under this section shall not exceed Three Hundred Thousand Dollars ($300,000.00) with respect to any one (1) individual. Continuation of coverage shall not continue for more than the lesser of one (1) year after the health maintenance organization coverage is terminated by insolvency or the remaining term of the contract. The commissioner may provide continuation of coverage on any reasonable basis; including, but not limited to, continuation of the health maintenance organization contract or substitution of indemnity coverage in a form determined by the commissioner. The commissioner may waive an assessment of any health maintenance organization if it would be or is impaired or placed in financially hazardous condition. A health maintenance organization which fails to pay an assessment within thirty (30) days after notice is subject to a civil forfeiture of not more than One Thousand Dollars ($1,000.00) per day or suspension or revocation of its certificate of authority or both fine and suspension. Any action taken by the commissioner in enforcing the provisions of this section may be appealed by the health maintenance organization in accordance with the Chancery Court of the First Judicial District of Hinds County, Mississippi.

Miss. Code Ann. § 83-41-365 Contracting authority of commissioner.

The commissioner may contract with the necessary personnel to carry out the duties and responsibilities created by this article and make assessments for the expenses incurred in carrying out the duties and responsibilities of this article.

Miss. Code Ann. § 83-41-403 Definitions.

As used in this article: “Department” means the Mississippi Department of Insurance. “Managed care plan” means a plan operated by a managed care entity as described in subparagraph (c) that provides for the financing and delivery of health care services to persons enrolled in such plan through: Arrangements with selected providers to furnish health care services; Explicit standards for the selection of participating providers; Organizational arrangements for ongoing quality assurance, utilization review programs and dispute resolution; and Financial incentives for persons enrolled in the plan to use the participating providers, products and procedures provided for by the plan. “Managed care entity” includes a licensed insurance company, hospital or medical service plan, health maintenance organization (HMO), an employer or employee organization, or a managed care contractor as described in subparagraph (d) that operates a managed care plan. “Managed care contractor” means a person or corporation that: Establishes, operates or maintains a network of participating providers; Conducts or arranges for utilization review activities; and Contracts with an insurance company, a hospital or medical service plan, an employer or employee organization, or any other entity providing coverage for health care services to operate a managed care plan. “Participating provider” means a physician, hospital, pharmacy, pharmacist, dentist, nurse, chiropractor, optometrist, or other provider of health care services licensed or certified by the state, that has entered into an agreement with a managed care entity to provide services, products or supplies to a patient enrolled in a managed care plan.

Miss. Code Ann. § 83-41-405 Requirement of certification of managed care plans offered or provided to persons residing in Mississippi; termination of plans.

The department shall establish a process for the certification of managed care plans offered or provided to persons residing in Mississippi. No such plan shall be offered or provided to persons residing in this state unless it has been certified by the department. Any managed care plan certified by the department must be recertified annually, and the department shall establish procedures to ensure the continued compliance with the requirements of Section 83-41-409 through the recertification process. The department shall terminate the certificate of any managed care plan if such plan no longer meets the applicable requirements for certification. The department shall provide any such plan with an opportunity for a hearing on the proposed termination.

Miss. Code Ann. § 83-41-407 Fees.

The department shall establish a fee to cover the costs of issuing and renewing the certifications authorized by this article and the fees shall be used solely for the administration of this article.

Miss. Code Ann. § 83-41-409 Conditions for certification or recertification.

In order to be certified and recertified under this article, a managed care plan shall: Provide enrollees or other applicants with written information on the terms and conditions of coverage in easily understandable language including, but not limited to, information on the following: Coverage provisions, benefits, limitations, exclusions and restrictions on the use of any providers of care; Summary of utilization review and quality assurance policies; and Enrollee financial responsibility for copayments, deductibles and payments for out-of-plan services or supplies; Demonstrate that its provider network has providers of sufficient number throughout the service area to assure reasonable access to care with minimum inconvenience by plan enrollees; File a summary of the plan credentialing criteria and process and policies with the State Department of Insurance to be available upon request; Provide a participating provider with a copy of his/her individual profile if economic or practice profiles, or both, are used in the credentialing process upon request; When any provider application for participation is denied or contract is terminated, the reasons for denial or termination shall be reviewed by the managed care plan upon the request of the provider; and Establish procedures to ensure that all applicable state and federal laws designed to protect the confidentiality of medical records are followed.

Miss. Code Ann. § 83-41-411 Compliance with article by health maintenance organizations.

Health maintenance organizations must comply with the certification requirements in this article in addition to such other laws as might relate thereto.

Miss. Code Ann. § 83-41-413 Regulations.

The department shall adopt regulations to implement the provisions of this article and may obtain any information from managed care plans that is necessary to determine if such plan should be certified or recertified.

Miss. Code Ann. § 83-41-415 Applicability of Articles 7 and 9 to Division of Medicaid in Office of Governor.

Articles 7 and 9 do not apply to the Division of Medicaid in the Office of the Governor.

Miss. Code Ann. § 83-41-417 Geographic areas served; opportunity to apply for participation.

A health maintenance organization as defined in Section 83-41-303, and a managed care entity as defined in Section 83-41-403, shall establish procedures to give interested health care providers located in the geographic area served an opportunity to apply for participation.
Source: Public.Resource.Org MS CodeURL: https://unicourt.github.io/cic-code-ms/transforms/ms/ocms/r78/gov.ms.code.title.83.htmlFetched: 6/10/2026

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