Health Maintenance Organization
The following state specific items must be submitted along with the Uniform Certificate of Authority Application (UCAA) in order to obtain a Certificate of Authority.
All applications must be three-hole punched and placed into a binder with each section tabbed according to the UCAA Admission Checklist.
- A Fidelity bond ($250,000 minimum), covering all of the officers and employees of the plan. Must be approved by Board of Directors. ( IC 27-13-5-2 )
- Minimum net worth of $1.5 million. ( IC 27-13-12-2 )
- A financial feasibility plan in accordance with IC 27-13-2-5(9).
- Statements of:
- Geographic area to be served, by county ( IC 27-13-2-5(11) )
- The company's compliance with Point of Service Products ( IC 27-13-13-8 )
- A copy of any contract that has been made or is to be made between the HMO and a Third Party Administrator, agent(s) or person(s) identified as members of the governing body and officers responsible for the conduct of the affairs of the applicant. ( IC 27-13-2-5(5) )
- Evidence of coverage to enrollees with proper identifiable form numbers, to include the following items applicable to the proposed plan: ( IC 27-13-2-5(6)(7) )
- Master group contract.
- Employee subscription certificate (benefit schedule).
- Enrollment application.
- Conversion contract.
- Conversion benefit schedule.
- Individual agreement.
- Individual schedule of benefits.
- Individual application.
- Medicare subscriber agreement.
- Medicare schedule of benefits.
- All applicable marketing materials.
- Schedule of rates including: ( IC 27-13-2-5(9)(B) )
- Proposed group rates and actuarial justification.
- Proposed conversion rates and actuarial justification.
- Proposed individual rates and actuarial justification.
- Provider contracts ( IC 27-13-2-5(4) ) containing appropriate hold harmless language ( IC 27-13-15-1 ) and evidence of intended providers ( IC 27-13-2-5(4) ) (i.e. letters of intent).
- A statement that waives the corporation's rights under federal bankruptcy laws signed by an officer or other person with the authority to bind the corporation. ( IC 27-13-2-8 )
- Complaint Summary & Questionnaire for the past 2 years on applicant and applicant's parent.
- A description of the internal procedures to be used by the HMO for the investigation and resolution of the complaints and grievances of enrollees. ( IC 27-13-2-5(12) & IC 27-13-10-1 )
- A description of the proposed quality management program of the applicant that includes the criteria per ( IC 27-13-6-1 ).
- A description of the procedures to be implemented to meet the requirements set forth in IC 27-13-12 through IC 27-13-19.
- A list of the names, addresses and license numbers of providers with whom the HMO has agreements. ( IC 27-13-2-5(15) )
- Indiana Biographical Affidavit
- The IDOI utilizes the Uniform Certificate of Authority Primary Application.
Once the Department completes its review, we will prepare a certificate of authority and send it to the contact person listed on the application.
Once Company has received a Certificate of Authority a NAIC Company Code may be obtained from the:
National Association of Insurance Commissioners (NAIC)
120 West 12th Street, Suite 1100
Kansas City, MO 64105
The information requested in the preceding should be delivered to the following:
Indiana Department of Insurance
311 West Washington Street, Suite 300
Indianapolis, Indiana 46204-2787