Limited Service Health Maintenance Organization
The following state specific items must be submitted along with the Uniform Certificate of Authority Primary 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.
- Certificate of Authority, from Secretary of State, to transact business in Indiana.
- A Deposit in the amount of $50,000 held jointly with the applicant and Commissioner for the benefit of Indiana enrollees. ( I.C. 27-13-34-17)
- Fidelity bond - $50,000 minimum, covering all of the officers and employees of the plan. Must be approved by Board of Directors. ( IC 27-13-34-18 )
- Minimum net worth equal to the greater of $50,000 or 2.5% of annual gross subscription income. ( IC 27-13-34-16 )
- A financial plan in accordance with IC 27-13-34-8(10).
- Statements of:
- Geographic area to be served, by county.
- The company's compliance with Point of Service Products. ( IC 27-13-34-10(6) )
- Acknowledgment that all lawful process in any legal action or proceeding against the applicant on a cause of action arising in Indiana is valid if served in accordance with the Indiana Rules of Trial Procedure. ( IC 27-13-34 )
- Copies of the form(s) of any contract(s) made or to be made between the applicant and any person(s) identified as members of the governing body and officers responsible for the conduct of the affairs of the applicant. ( IC 27-13-34-8(7) )
- Evidence of coverage to enrollees with proper identifiable form numbers, to include the following items applicable to the proposed plan: ( IC 27-13-34-8(8) )
- Master group contract.
- Employee subscription certificate (benefit schedule).
- Enrollment application.
- Conversion contract.
- Conversion benefit schedule.
- Individual agreement.
- Individual schedule of benefits.
- Individual application.
- All applicable marketing materials.
- Provider contracts containing appropriate hold harmless language ( IC 27-13-34-12(4) ) and evidence of intended providers (i.e. letters of intent). ( IC 27-13-34-8(5) )
- 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 27-13-34-8(17) )
- Complaint Summary & Questionnaire for past 2 years on applicant and applicant's parent. ( IC 27-13-34-8(18) )
- A description of the complaint procedures to be established and maintained under IC 27-13-10 & IC 27-13-34-12(1).
- A description of the quality assessment and utilization review procedures to be used by the applicant. ( IC 27-13-34-8(14) )
- 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