53-6-703. Managed care community network. (1) A managed care community network shall comply with:
     (a) the requirements of Title 33, chapter 31, but the commissioner may by rule reduce or eliminate a requirement of Title 33, chapter 31, if the requirement is demonstrated to be unnecessary for the operation of the managed care community network; and
     (b) the federal requirements for prepaid health plans as provided in 42 CFR, part 434.
     (2) A managed care community network may contract with the department to provide any combination of medicaid-covered health care services that is acceptable to the department.
     (3) A managed care community network shall demonstrate its ability to bear the financial risk of servicing enrollees under the program. The commissioner shall by rule adopt criteria for assessing the financial soundness of a network. The rules must consider the extent to which a network is composed of providers who directly render health care and are located within the community in which they seek to contract rather than solely arrange or finance the delivery of health care. The rules must consider risk-bearing and management techniques, as determined appropriate by the commissioner. The rules must also consider whether a network has sufficiently demonstrated its financial solvency and net worth. The commissioner's criteria must be based on sound actuarial, financial, and accounting principles. The commissioner is responsible for monitoring compliance with the rules.
     (4) A managed care community network may not begin operation before the effective date of rules adopted by the commissioner under this part, the approval of any necessary federal waivers, and the completion of the review of an application submitted to the commissioner. The commissioner may charge the applicant an application review fee for the commissioner's actual cost of review of the application. The fees must be adopted by rule by the commissioner. Fees collected by the commissioner must be deposited in an account in the special revenue fund and are statutorily appropriated, as provided in 17-7-502, to the commissioner to defray the cost of application review.
     (5) A health care delivery system that contracts with the department under the program may not be required to provide or arrange for any health care or medical service, procedure, or product that violates religious or moral teachings and beliefs if that health care delivery system is owned, controlled, or sponsored by or affiliated with a religious institution or religious organization but must comply with the notice requirements of 53-6-705(4)(c).
     (6) The commissioner shall adopt rules to protect managed care community networks against financial insolvency. Managed care community networks are subject to health maintenance protections against financial insolvency contained in 33-31-216 in the event that a managed care community network is declared insolvent or bankrupt.

     History: En. Sec. 3, Ch. 502, L. 1995.