1751.05 Issuance or denial of certificate of authority.

(A) The superintendent of insurance shall issue or deny a certificate of authority to health insuring corporations within the deadlines specified as follows:

(1) For a health insuring corporation filing an application pursuant to section 1751.03 of the Revised Code, forty-five days from the superintendent’s receipt of the certification from the director of health under division (C) of section 1751.04 of the Revised Code;

(2) One hundred thirty-five days from the superintendent’s receipt of a complete application and accompanying documents if the health insuring corporation is to cover solely the following:

(a) Medicaid recipients;

(b) Medicare beneficiaries;

(d) Participants of the children’s buy-in program;

(e) Medicaid recipients and participants of the children’s buy-in program;

(f) Medicaid recipients, medicare beneficiaries, and participants of the children’s buy-in program.

(B) A certificate of authority shall be issued upon payment of the application fee prescribed in section 1751.44 of the Revised Code if the superintendent is satisfied that the following conditions are met:

(1) The persons responsible for the conduct of the affairs of the applicant are competent, trustworthy, and possess good reputations.

(2) The director certifies, in accordance with division (C) of section 1751.04 of the Revised Code, that the organization’s proposed plan of operation meets the requirements of division (B) of that section and sections 3702.51 to 3702.62 of the Revised Code. If, after the director has certified compliance, the application is amended in a manner that affects its approval under section 1751.04 of the Revised Code, the superintendent shall request the director to review and recertify the amended plan of operation. Within forty-five days of receipt of the amended plan from the superintendent, the director shall certify to the superintendent, pursuant to section 1751.04 of the Revised Code, whether or not the amended plan meets the requirements of section 1751.04 of the Revised Code. The superintendent’s forty-five-day review period shall cease to run as of the date on which the amended plan is transmitted to the director and shall remain suspended until the superintendent receives a new certification from the director.

(3) The applicant constitutes an appropriate mechanism to effectively provide or arrange for the provision of the basic health care services, supplemental health care services, or specialty health care services to be provided to enrollees.

(4) The applicant is financially responsible, complies with section 1751.28 of the Revised Code, and may reasonably be expected to meet its obligations to enrollees and prospective enrollees. In making this determination, the superintendent may consider:

(a) The financial soundness of the applicant’s arrangements for health care services, including the applicant’s proposed contractual periodic prepayments or premiums and the use of copayments and deductibles;

(b) The adequacy of working capital;

(c) Any agreement with an insurer, a government, or any other person for insuring the payment of the cost of health care services or providing for automatic applicability of an alternative coverage in the event of discontinuance of the health insuring corporation’s operations;

(d) Any agreement with providers or health care facilities for the provision of health care services;

(e) Any deposit of securities submitted in accordance with section 1751.27 of the Revised Code as a guarantee that the obligations will be performed.

(5) The applicant has submitted documentation of an arrangement to provide health care services to its enrollees until the expiration of the enrollees’ contracts with the applicant if a health care plan or the operations of the health insuring corporation are discontinued prior to the expiration of the enrollees’ contracts. An arrangement to provide health care services may be made by using any one, or any combination, of the following methods:

(a) The maintenance of insolvency insurance;

(b) A provision in contracts with providers and health care facilities, but no health insuring corporation shall rely solely on such a provision for more than thirty days;

(c) An agreement with other health insuring corporations or insurers, providing enrollees with automatic conversion rights upon the discontinuation of a health care plan or the health insuring corporation’s operations;

(d) Such other methods as approved by the superintendent.

(6) Nothing in the applicant’s proposed method of operation, as shown by the information submitted pursuant to section 1751.03 of the Revised Code or by independent investigation, will cause harm to an enrollee or to the public at large, as determined by the superintendent.

(7) Any deficiencies certified by the director have been corrected.

(8) The applicant has deposited securities as set forth in section 1751.27 of the Revised Code.

(C) If an applicant elects to fulfill the requirements of division (A)(5) of this section through an agreement with other health insuring corporations or insurers, the agreement shall require those health insuring corporations or insurers to give thirty days’ notice to the superintendent prior to cancellation or discontinuation of the agreement for any reason.

(D) A certificate of authority shall be denied only after compliance with the requirements of section 1751.36 of the Revised Code.

Effective Date: 09-26-2003; 09-29-2005; 2008 HB562 09-22-2008