23-76-109. Powers — Definition.

23-76-109. Powers — Definition. (a) The powers of a health maintenance organization include, but are not limited to, the following: (1) The purchase, lease, construction, renovation, operation, or maintenance of hospitals, medical facilities, or both, and their ancillary equipment, and the property as may reasonably be required for its principal office or for other purposes as may be necessary in the transaction of the business of the health maintenance organization; (2) The making of loans to a medical group under contract with it in furtherance of its program or the making of loans to a corporation or corporations under its control for the purpose of acquiring or constructing medical facilities and hospitals or in furtherance of a program providing healthcare services to enrollees; (3) The furnishing of healthcare services through providers which are under contract with the health maintenance organization; (4) The contracting with any person for the performance on its behalf of certain functions such as marketing, enrollment, and administration; (5) 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 healthcare services provided by the health maintenance organization; (6) The offering, in addition to basic healthcare services, of: (A) Additional healthcare services; (B) Indemnity benefits covering out-of-area or emergency services, and special services not provided on a direct service basis; and (C)(i) Indemnity benefits on a point-of-service basis within such limits as may be prescribed by the Insurance Commissioner. (ii) As used in this section, the term “point-of-service” means indemnifying or paying on behalf of an enrollee for covered healthcare services on a nonemergency, self-referred basis obtained from providers who are not employed by, under contract with, or otherwise affiliated with, the health maintenance organization, or services obtained from providers affiliated with the health maintenance organization without proper referrals; and (7) The contracting with providers located out of state who are properly licensed to render medical care in the jurisdiction in which such a provider is located. (b)(1)(A) A health maintenance organization shall file notice, with adequate supporting information, with the commissioner prior to each exercise of any power granted in subdivision (a)(1) or subdivision (a)(2) of this section. (B) The commissioner shall disapprove the exercise of power if in his or her opinion it would substantially and adversely affect the financial soundness of the health maintenance organization and endanger its ability to meet its obligations. (C) If the commissioner does not disapprove within sixty (60) days of the filing, the exercise of power shall be deemed approved. (2) The commissioner may promulgate rules exempting from the filing requirement of subdivision (b)(1) of this section those activities having a de minimis effect.