Effective 28 Aug 1997

354.470. Suspension or revocation, when — effect. — 1. The director may suspend, revoke or place conditions or restrictions on any certificate of authority issued to a health maintenance organization pursuant to sections 354.400 to 354.636 if the director finds that any of the following conditions exist:

(1) 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 pursuant to section 354.405, unless amendments to such submissions have been filed with and approved by the director;

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

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

(4) The health maintenance organization is no longer financially responsible and may reasonably be expected to be unable to meet its obligations to enrollees or prospective enrollees;

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

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

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

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

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

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

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

3. 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.

4. When the certificate of authority of a health maintenance organization is revoked, such health maintenance 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. It shall engage in no further advertising or solicitation whatsoever. The director may, by written order, permit such further operation of the health maintenance organization as the director 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.

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