354.470. Suspension or revocation, when--effect. - Missouri Statutes

Suspension or revocation, when--effect.

354.470. 1. The director may suspend, revoke or place conditions orrestrictions on any certificate of authority issued to a health maintenanceorganization pursuant to sections 354.400 to 354.636 if the director findsthat any of the following conditions exist:

(1) The health maintenance organization is operating significantly incontravention of its basic organizational document or in a manner contraryto that described in any other information submitted pursuant to section354.405, unless amendments to such submissions have been filed with andapproved by the director;

(2) The health maintenance organization issues evidence of coverageor uses a schedule of charges for health care services which do not complywith the requirements of section 354.430;

(3) The health maintenance organization does not provide nor arrangefor basic health care services;

(4) The health maintenance organization is no longer financiallyresponsible and may reasonably be expected to be unable to meet itsobligations to enrollees or prospective enrollees;

(5) The health maintenance organization has failed to implement amechanism affording the enrollees an opportunity to participate in mattersof policy and operation as required pursuant to section 354.420;

(6) The health maintenance organization has failed to implement thecomplaint system required by section 354.450 in a manner designed toreasonably resolve valid complaints;

(7) The health maintenance organization has advertised ormerchandised its services in an untrue, misrepresentative, misleading,deceptive, or unfair manner;

(8) The continued operation of the health maintenance organizationwould be hazardous to its enrollees;

(9) The person operating the health maintenance organization is inviolation of the provisions of sections 375.930 to 375.948, RSMo, except tothe extent that the director has determined that the nature of healthmaintenance organizations renders the application of such sections clearlyinappropriate; notwithstanding the foregoing, paragraph (b) of subdivision(11) of section 375.936, RSMo, shall not apply to health maintenanceorganizations;

(10) The health maintenance organization has otherwise failed tosubstantially comply with sections 354.400 to 354.636.

2. A certificate of authority shall be suspended, revoked, or besubject to conditions or restrictions only after compliance with therequirements of section 354.490.

3. When the certificate of authority of a health maintenanceorganization is suspended, the health maintenance organization shall not,during the period of such suspension, enroll any additional enrolleesexcept newborn children or other newly acquired dependents of existingenrollees, and shall not engage in any advertising or solicitationwhatsoever.

4. When the certificate of authority of a health maintenanceorganization is revoked, such health maintenance organization shallproceed, immediately following the effective date of the order ofrevocation, to wind up its affairs, and shall conduct no further businessexcept as may be essential to the orderly conclusion of the affairs of suchorganization. It shall engage in no further advertising or solicitationwhatsoever. The director may, by written order, permit such furtheroperation of the health maintenance organization as the director may findto be in the best interest of enrollees, to the end that enrollees will beafforded the greatest practical opportunity to obtain continuing healthcare coverage.

(L. 1983 H.B. 127, A.L. 1997 H.B. 335)