20-115

20-115. Department jurisdiction over certain
health care providers; exception; examination; disclosure

A. Any person or other entity, including a provider sponsored organization that
operates under the Medicare-plus-choice program established under the balanced budget act
of 1997 (42 United States Code sections 1395w-21 through 1395w-28 and title XVIII, part C
of the social security act, sections 1851 through 1859), that provides coverage in this
state for medical, surgical, chiropractic, naturopathic medicine, occupational therapy,
physical therapy, speech pathology, audiology, professional mental health, dental,
hospital or optometric expenses, whether the coverage is by direct payment, reimbursement
or otherwise, is presumed to be subject to the jurisdiction of the department unless the
person or other entity shows that while providing coverage it is subject to the
jurisdiction of another agency of this state, any political subdivision of this or any
other state or the federal government.

B. A person or entity that provides coverage for services identified in subsection
A may show that it is subject to the jurisdiction of another agency of this state, any
political subdivision of this or any other state or the federal government by providing
to the director the appropriate certificate, license or other document that is issued by
the other governmental agency and that permits or qualifies it to provide those services.

C. Any person or entity that provides coverage in this state for services described
in subsection A and is unable to show it is subject to the jurisdiction of another agency
of this state, any political subdivision of this or any other state or the federal
government:

1. Shall submit to an examination by the director to determine the organization and
solvency of the person or the entity and to determine whether or not the person or entity
is in compliance with the applicable provisions of this title.

2. Is subject to all appropriate provisions of this title regarding the conduct of
its business.

D. Any production agency or administrator which advertises, sells, transacts or
administers coverage in this state for services described in subsection A which is
provided by any person or entity described in subsection C, if that coverage is not fully
insured or otherwise fully covered by an admitted life or disability insurer, nonprofit
hospital service plan or nonprofit health care plan, shall advise any purchaser,
prospective purchaser or covered person of the lack of insurance or other coverage.

E. Any administrator which advertises or administers coverage in this state for
services described in subsection A which is provided by any person or entity described in
subsection C shall advise any production agency of the elements of the coverage including
the amount of stop-loss insurance in effect.

F. This section does not apply to or prohibit a self-insured program operated by a
single employer for the benefit of its employees or the employees of a wholly-owned
subsidiary.