Certificate of Need and Commercial Managed Care Unit

Certificate of Need and Commercial Managed Care Unit

Certificate of Need

The CON program is a regulatory process that requires certain health care providers to obtain state approval before offering certain new or expanded services. The program currently regulates hospices, skilled nursing facilities, and intermediate care facilities for the developmentally disabled.  It does not regulate outpatient services, home health services, purchases of major medical equipment, assisted living facilities, or hospital beds and services.

Commercial Managed Care

Commercial Managed Care program staff conduct reviews of Health Maintenance Organizations (HMOs), Prepaid Health Clinics (PHCs), Exclusive Provider Organizations (EPOs), and Workers' Compensation Managed Care Arrangements (WCMCAs). The HMO and PHC reviews consist of initial and biennial renewal Health Care Provider Certificates, expansion affidavits, annual risk management and triennial accreditation organization reviews. The EPO reviews consist of initial approval of the “Plan of Operation”, expansion affidavits, semi-annual provider networks and annual grievance reporting. The WCMCA reviews consists of annual and semi-annual provider network reviews to ensure network adequacy for Worker’s Compensation product lines. The program staff also manage the Health Flex Plan Program, the Statewide Provider and Health Plan Claim Dispute Resolution Program and reviews complaints received by the Agency complaint administration unit regarding balanced billing.