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Health Maintenance Organization (HMO) Requirements

A Health Maintenance Organization seeking a "Certificate of Authority" in Alabama must contact the Department of Insurance (DOI) for an application.  Send  the application along with supporting documentation to the DOI.  A copy of the same must be submitted to the Alabama Department of Public Health's Managed Care Compliance (MCC) office at the following address:

Managed Care Compliance
Alabama Department of Public Health
The RSA Tower, Suite 710
201 Monroe Street
Montgomery, Alabama 36104.

Reporting Requirements:  Send the following information quarterly and annually to the DOI and the MCC office.  The quarters are as follows: 

1.  First Quarter:  January 1 to March 31 but no later than May 15
2.  Second Quarter:  April 1 to June 30, but no later than August 15
3.  Third Quarter:  July 1 to September 30, but no later than November 15
4.  Fourth Quarter:  October 1 to December 31; submit concurrently with the annual report

Quarterly and annually where indicated submit a:

  • Copy of any quarterly financial report required by the Commissioner.
  • Summary of the total number of grievances/complaints handled, a compilation of causes underlying the grievances, and resolution of grievances/complaints.  Submit concurrently with the annual report. 
  • Statement of the number of providers leaving the health maintenance organization and the number of providers replacing them and the total number of providers.  Submit concurrently with the annual report.
  • Summary of enrollment and disenrollment rate during the quarter. Submit concurrently with the annual report.
  • Utilization statistics containing the following minimum data:
    a.  The hospitalization experience in terms of the number of days of inpatient hospitalization experienced per 1,000 enrollees on a quarterly basis, year-to-date basis, and annualized basis.
    b.  The average number of physician inpatient and outpatient visits per enrollee on a quarterly basis, year-to-date basis, and annualized basis.

Annually, and in addition to the above mentioned items, submit a:

  • Copy of the annual financial report submitted to the Commissioner.
  • Copies of the quality improvement and utilization review reports submitted to the governing body according to 420-5-6.07.
  • Copy of the compliant resolution system established according to 420-5-6.08.  See above.

See the HMO Law and Rules for additional information.


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