HMO Certification

HMO certification is the process of applying for a certificate of authority to operate a health maintenance organization (HMO). The application process and applicable rules vary between states, but have several common features.

Organization Documents

A business or group planning to offer HMO services must clearly identify the individuals involved in the HMO's management, identify the areas in which the HMO intends to operate, bylaws and financial statements.

Conflicts of Interest

Businesses are required to identify any potential conflicts of interest that may impact their management of the HMO. For example, New York requires a listing of all health-related operations controlled by the holding company applying for HMO certification for the preceding 10 years.

Recertification and Incentives

HMO certifications must be regularly renewed to ensure compliance with applicable state laws. Some states, such as Wisconsin, have programs to streamline the recertification process to lower management costs and accreditation programs.

References

• Texas Department of State: Texas Administrative Code Title 28 Part 1 Chapter 11
• ForwardHealth Portal:
• Center for Health Transformation: Wisconsin Medicaid HMO Accreditation Incentive