An application for a certificate of authority to
operate a health maintenance organization must set forth or be
accompanied by the following:
(1)A copy of the organizational documents of the applicant, such
as the articles of incorporation, partnership agreement, trust
agreement, articles of organization, or any other applicable
documents, and all amendments to those documents.
(2)A copy of the bylaws, rules and regulations, or similar
document regulating the conduct of the internal affairs of the
applicant.
(3)A list, on a form acceptable to the commissioner, of the
names, addresses, official positions, and biographical information
of the persons who are to be responsible for the conduct of the
affairs and daily operations of the applicant, including the
following:
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An application for a certificate of authority to
operate a health maintenance organization must set forth or be
accompanied by the following:
(1) A copy of the organizational documents of the applicant, such
as the articles of incorporation, partnership agreement, trust
agreement, articles of organization, or any other applicable
documents, and all amendments to those documents.
(2) A copy of the bylaws, rules and regulations, or similar
document regulating the conduct of the internal affairs of the
applicant.
(3) A list, on a form acceptable to the commissioner, of the
names, addresses, official positions, and biographical information
of the persons who are to be responsible for the conduct of the
affairs and daily operations of the applicant, including the
following:
(A) All members of the board of directors, board of trustees,
executive committee, or other governing board or committee of
the applicant.
(B) The principal officers, if the applicant is a corporation.
(C) The partners or members, if the applicant is a partnership
or an association.
(D) The manager or, if there is no manager, all members of a
limited liability company.
(4) A copy of any contract form that has been made or is to be
made between any class of providers and the health maintenance
organization.
(5) A copy of any contract that has been made or is to be made
between:
(A) third party administrators, agents, or persons identified
under subdivision (3); and
(B) the health maintenance organization.
(6) A copy of the form of evidence of coverage that is to be issued
by the health maintenance organization to an enrollee.
(7) A copy of the form of a group contract, if any, that is to be
issued by the health maintenance organization to an employer, a
union, a trustee, or another entity.
(8) Financial statements showing the assets, liabilities, and
sources of financial support of the applicant, including:
(A) a copy of the most recent certified financial statement of the
applicant; and
(B) an unaudited current financial statement.
(9) A financial feasibility plan that includes the following:
(A) Detailed enrollment projections.
(B) The methodology for determining premium rates to be
charged during the first twelve (12) months of operations,
certified by an actuary or other qualified person acceptable to
the commissioner.
(C) A projection of:
(i) balance sheets;
(ii) cash flow statements showing any capital expenditures,
purchase and sale of investments, and deposits with the state;
and
(iii) income and expense statements;
anticipated from the start of operations until the organization
has had net income for at least one (1) year.
(D) A statement of the sources of working capital as well as any
other sources of funding.
(10) If the applicant is not domiciled in Indiana, an executed
power of attorney appointing the commissioner, the
commissioner's successors in office, and authorized deputies of
the commissioner as the true and lawful attorney of the applicant
in and for Indiana upon whom all lawful process in any legal
action or proceeding against the health maintenance organization
on a cause of action arising in Indiana may be served.
(11) A statement or map reasonably indicating, on a
county-by-county basis, the service area to be served by the health
maintenance organization.
(12) A description of the internal procedures to be used by the
health maintenance organization for the investigation and
resolution of the complaints and grievances of enrollees.
(13) A description of the proposed quality management program
of the applicant, including the following:
(A) The formal organizational structure.
(B) Methods for developing criteria.
(C) Procedures for comprehensive evaluation of the quality of
care rendered to enrollees.
(D) Processes to initiate corrective action and reevaluation
when deficiencies in provider performance or organizational
performance are identified.
(14) A description of the procedures to be implemented to meet
the requirements set forth in IC 27-13-12 through IC 27-13-15.
(15) A list of the names, addresses, and license numbers of any
providers with whom the health maintenance organization has
agreements.
(16) Any other information required by the commissioner to make
the determination required under IC 27-13-3.