Formed, Owned, or Operated
(1)The director will not certify an MCO formed, owned, or operated by a non-qualifying employer.
(2) For purposes of this rule, “staff” means any individual who is an employee of a non-qualifying employer or of any parent or subsidiary entity of a non-qualifying employer.
(3) A non-qualifying employer or any of its staff, or their immediate family, may not:
(a) Directly participate in the formation, certification, or incorporation of the MCO;
(b) Nominate, assume a position as, or act in the role of, a director, officer, agent, or employee of the MCO;
(c) Arrange for, lend, guarantee, or otherwise provide financing for any organizational costs of the MCO;
(d) Arrange for, lend, guarantee, or otherwise provide financial support to the MCO (financial support does not include contracted fees for services rendered by an MCO);
(e) Have any ownership or similar financial interest in or right to payment from the MCO;
(f) Make or exercise any control over business, operational, or policy decisions of the MCO;
(g) Possess or control the ownership of voting securities of the MCO. The director will presume possession or control exists if any person, directly or indirectly, holds the power to vote or holds proxies of any other person representing 10 percent or more of the voting securities of the MCO;
(h) Provide MCO services other than as allowed by section (4) of this rule;
(i) Enter into any contract with the MCO that limits the ability of the MCO to accept business from any other source; or
(j) Direct or interfere with the MCO’s delivery of medical and health care services.
(4) Notwithstanding section (3) of this rule, an MCO may contract with an insurer to provide certain managed care services. However, such insurer-provided services must be according to protocols and standards established by the certified MCO plan. The insurer may not provide or participate in the provision of managed care services related to dispute resolution, service utilization review, or physician peer review.
Rule 436-015-0009 — Formed, Owned, or Operated,