R590. Insurance,
Administration.
(Effective 12-29-04)
R590-232. Authorization for a Health
Maintenance Organization to Provide Services as Third Party Administrator of
Health Care Benefits.
R590-232-1. Authority.
This rule is promulgated and adopted pursuant to Subsection 31A-8-103(2)
allowing the commissioner to waive provisions of Title 31A that he considers
inapplicable to health maintenance organizations, and Section 31A-2-201 giving
the commissioner authority to implement the provisions of Title 31A.
R590-232-2. Purpose.
The purpose of this rule is to authorize a health maintenance
organization to provide services as a third party administrator of health care
benefits.
R590-232-3. Definitions.
All definitions in Sections 31A-1-301 and 31A-8-101 are hereby adopted
by reference.
Rule R590-232-4.
Findings.
A. The term “organization” includes a health maintenance organization
by definition.
B. Subsection 31A-8-106 provides, “No organization may engage, directly
or indirectly, in any business other than that of an organization and business
reasonably incidental to that business.”
C. For some time, there has been a question as to whether providing
services by a health maintenance organization as a “third party administrator”
of health care benefits could be deemed to be the “business . . . of an
organization” or at least be deemed to be “business reasonably incidental to
that business.”
D. The Commissioner finds that when a health maintenance organization
provides services as a third party administrator of health care benefits, that
business is, at the very least, “business reasonably incidental to [the]
business” of a health maintenance organization.
E. In addition, Subsection 31A-8-103(2) provides, “The commissioner may
by rule waive other specific provisions of this title that the commissioner
considers inapplicable to health maintenance organizations or limited health
plans, upon a finding that the waiver will not endanger the interests of: (a)
enrollees; (b) investors; or (c) the public.”
E. To the extent the definition of “third party administrator” in
Section 31A-1-301 can be read as prohibiting a health maintenance organization
from providing services as a third party administrator of health care benefits,
and to the extent Chapter 25 of Title 31A can be read as requiring that a health
maintenance organization apply for a separate license to provide services as a
third party administrator of health care benefits, the commissioner finds that
waiving those provisions with respect to health maintenance organizations will
not endanger the interests of (a) enrollees, (b) investors, or (c) the public,
and therefore the commissioner hereby waives those provisions with respect to a
health maintenance organization providing third party administrator services of
health care benefits.
R590-232-5. Rule.
A health maintenance organization may provide services as a third party
administrator of health care benefits, and may do so without acquiring a third
party administrator license under Chapter 25 of Title 31A.
R590-232-6.
Severability.
If any provision of this rule or the application thereof to any person
or circumstance is for any reason held to be invalid, the remainder of the rule
and the application of such provision to other persons or circumstances shall
not be affected thereby.
KEY: health
maintenance organizations
2004
31A-2-201
31A-2-202
31A-21-312
31A-26-301
31A-26-303
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