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.