Indiana § 27-13-2-5 - Certificate of authority application; requirements

§ 27-13-2-5. Certificate of authority application; requirements

Sec. 5. 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.

As added by P.L.26-1994, SEC.25. Amended by P.L.208-2018, SEC.27.