§ 3804. Certificate of authority — Conditions for issuance; disapproval; expiration; renewal.
588 words·~3 min read·
/de/title-18/chapter-38-dental-plan-organization-act/3804·A research copy — for the controlling text, always check the official state or federal source. Not legal advice.
(a)The Commissioner shall issue a certificate of authority if the Commissioner is satisfied that the following conditions are met:
(1)The persons responsible for conducting the affairs of the dental plan organization are competent and trustworthy and are professionally capable of providing, arranging for or administering the services offered by the plan;
(2)The dental plan organization constitutes an appropriate mechanism to achieve an effective dental plan, as determined by the Commissioner;
(3)The dental plan organization has demonstrated the potential to provide dental services in a manner that will assure both availability and accessibility of adequate personnel and facilities;
(4)The dental plan organization has arrangements for an ongoing quality of dental care assurance programs;
(5)The dental plan organization has a procedure to establish and maintain uniform systems of cost accounting and reports and audits that meet the requirements of the Commissioner;
(6)The dental plan organization is financially responsible and may reasonably be expected to meet its obligations to enrollees. In making this determination the Commissioner shall consider:
a. The financial soundness of the dental plan’s arrangements for services and the schedule of charges used;
b. Any arrangement with an insurer or medical or dental service corporation for a continuation of coverage in the event of discontinuance of the plan on an indemnity basis through a group vehicle to the end of the period for which premiums were paid to the discontinued dental plan organization; and
c. The sufficiency of an agreement with dentists for the provision of dental services;
(7)A general surplus is maintained as required in § 3805 of this title;
(8)A contingent surplus is accumulated and maintained as required in § 3805 of this title;
(9)The condition or methods of operation of the dental plan organization are not such as would render its operation hazardous to its enrollees or the public;
(10)a. Each employer or other organization which employs or has 15 or more employees or members during the full preceding calendar year and which contributes to a dental plan organization contract which restricts the covered persons in selecting the providers of dental services to a single provider or limited number of providers shall also offer its employees and their eligible dependents and members and members’ eligible dependents at the time a dental benefits plan is offered or renewed the option of selecting alternative coverage which permits covered persons to obtain dental services from any licensed dentist.
b. An employer or other organization shall be required to pay for or contribute towards the provision of alternative coverage an amount equal to the premium or cost which it pays or contributes to the dental plan organization contract which limits the number of providers of dental services.
c. By February 12, 1988, the Commissioner shall promulgate rules and regulations necessary to effectuate the purpose of this paragraph, including procedures for notice to covered persons, employers and other organizations of the provisions of this paragraph;
(11)The dental plan organization has demonstrated the potential to provide dental services and adequate reimbursement for such services for children with a severe disability.
(b)When the Commissioner disapproves an application for a certificate of authority he or she shall notify the dental plan organization in writing of the reasons for the disapproval.
(c)A certificate of authority shall expire 1 year following the date of issuance or previous renewal. If the dental plan organization remains in compliance with this chapter and has paid a renewal fee of $100 its certificate shall be renewed.