CODE OF VIRGINIA

CERTIFICATION OF QUALITY ASSURANCE; APPLICATION; ISSUANCE; DENIAL; RENEWAL (§
32.1-137.2)

A. Every managed care health insurance plan licensee shall request a certificate
of quality assurance with reference to its managed care health insurance plans
simultaneously with filing an initial application to the Bureau of Insurance for
licensure. If already licensed by the Bureau of Insurance, every managed care
health insurance plan licensee may file an application for quality assurance
certification with the Department of Health by December 1, 1998, and shall file
an application for quality assurance certification with the Department of Health
by December 1, 1999, in order to obtain its certificate of quality assurance by
July 1, 2000.On or before July 1, 2000, the State Health Commissioner shall
certify to the Bureau of Insurance that a managed care health insurance plan
licensee has been issued a certificate of quality assurance by providing the
Bureau of Insurance with a copy of each certificate at the time of
issuance.Application for a certificate of quality assurance shall be made on a
form prescribed by the Board and shall be accompanied by a fee based upon a
percentage, not to exceed one-tenth of one percent, of the proportion of direct
gross premium income on business done in this Commonwealth attributable to the
operation of managed care health insurance plans in the preceding biennium,
sufficient to cover reasonable costs for the administration of the quality
assurance program. Such fee shall not exceed $ 10,000 per licensee. Whenever the
account of the program shows expenses for the past biennium to be more than ten
percent greater or lesser than the funds collected, the Board shall revise the
fees levied by it for certification so that the fees are sufficient, but not
excessive, to cover expenses; provided that such fees shall not exceed the
limits set forth in this section. Until July 1, 2014, the Department may utilize
such certification funds as are needed in fulfilling its responsibilities
pursuant to subsection B of § 32.1-16.All applications, including those for
renewal, shall require (i) a description of the geographic area to be served,
with a map clearly delineating the boundaries of the service area or areas, (ii)
a description of the complaint system required under § 32.1-137.6, (iii) a
description of the procedures and programs established by the licensee to assure
both availability and accessibility of adequate personnel and facilities and to
assess the quality of health care services provided, and (iv) a list of the
licensee’s managed care health insurance plans.

B. Every managed care health insurance plan licensee certified under this
article shall renew its certificate of quality assurance with the Commissioner
biennially by July 1, subject to payment of the fee.

C. The Commissioner shall periodically examine or review each applicant for
certificate of quality assurance or for renewal thereof.No certificate of
quality assurance may be issued or renewed unless a managed care health
insurance plan licensee has filed a completed application and made payment of a
fee pursuant to subsection A of this section and the Commissioner is satisfied,
based upon his examination, that, to the extent appropriate for the type of
managed care health insurance plan under examination, the managed care health
insurance plan licensee has in place and complies with: (i) a complaint system
for reasonable and adequate procedures for the timely resolution of written
complaints pursuant to § 32.1-137.6; (ii) a reasonable and adequate system for
assessing the satisfaction of its covered persons; (iii) a system to provide for
reasonable and adequate availability of and accessibility to health care
services for its covered persons; (iv) reasonable and adequate policies and
procedures to encourage the appropriate provision and use of preventive services
for its covered persons; (v) reasonable and adequate standards and procedures
for credentialing and recredentialing the providers with whom it contracts; (vi)
reasonable and adequate procedures to inform its covered persons and providers
of the managed care health insurance plan licensee’s policies and
procedures; (vii) reasonable and adequate systems to assess, measure, and
improve the health status of covered persons, including outcome measures, (viii)
reasonable and adequate policies and procedures to ensure confidentiality of
medical records and patient information to permit effective and confidential
patient care and quality review; (ix) reasonable, timely and adequate
requirements and standards pursuant to § 32.1-137.9; and (x) such other
requirements as the Board may establish by regulation consistent with this
article.Upon the issuance or reissuance of a certificate, the Commissioner shall
provide a copy of such certificate to the Bureau of Insurance.

D. Upon determining to deny a certificate, the Commissioner shall notify such
applicant in writing stating the reasons for the denial of a certificate. A copy
of such notification of denial shall be provided to the Bureau of Insurance.
Appeals from a notification of denial shall be brought by a certificate
applicant pursuant to the process set forth in § 32.1-137.5.

E. The State Corporation Commission shall give notice to the Commissioner of its
intention to issue an order based upon a finding of insolvency, hazardous
financial condition, or impairment of net worth or surplus to policyholders or
an order suspending or revoking the license of a managed care health insurance
plan licensee; and the Commissioner shall notify the Bureau of Insurance when he
has reasonable cause to believe that a recommendation for the suspension or
revocation of a certificate of quality assurance or the denial or nonrenewal of
such a certificate may be made pursuant to this article. Such notifications
shall be privileged and confidential and shall not be subject to subpoena.

F. No certificate of quality assurance issued pursuant to this article may be
transferred or assigned without approval of the Commissioner.

HISTORY: 1998, c. 891; 2013, cc. 670, 679.