HMO Requirements

A Health Maintenance Organization (HMO) 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 supporting documentation must also be submitted to the Alabama Department of Public Health's Managed Care Compliance (MCC) office at the address below.

Organizing your supporting documentation in accordance with the attached checklist will help expedite the health application review process.

For those HMOs who are approved to operate in Alabama and are seeking to expand into additional counties, submitting your supporting documentation in accordance with the attached checklist will help expedite the health expansion application review.

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.

• HMO Law
• HMO Rules

Physical Address:

Managed Care Compliance
Alabama Department of Public Health
The RSA Tower, Suite 700
201 Monroe Street
Montgomery, Alabama 36104

Mailing Address:

Managed Care Compliance
Alabama Department of Public Health
P.O. Box 303017
Montgomery, Alabama 36130-3017