The application for a certificate of authority must contain
the following, in this order:
(1) a completed name application form along with any
certificate of reservation of corporate name issued by the secretary
of state;
(2) a completed certificate of authority application
form;
(3) the basic organizational documents and all amendments,
complete with the original incorporation certificate with charter
number and seal indicating certification by the secretary of state,
if applicable;
(4) the bylaws, rules, or any similar document regulating
the conduct of the internal affairs of the applicant;
(5) information about officers, directors, and staff,
including:
(A) a completed officers and directors page;
(B) NAIC UCAA biographical data forms for all persons
who are to be responsible for the day-to-day conduct of the applicant's
affairs, including all members of the board of directors, board of
trustees, executive committee or other governing body or committee,
the principal officers, and controlling shareholders of the applicant
if the applicant is a corporation, or all partners or members if the
applicant is a partnership or association; and
(C) a complete set of fingerprints for each person
to whom the fingerprint requirements of Chapter 1 of this title (relating
to General Administration) apply;
(6) organizational information, as follows:
(A) a chart or list clearly identifying the relationships
between the applicant and any affiliates, and a list of any currently
outstanding loans or contracts to provide services between the applicant
and the affiliates;
(B) a chart showing the internal organizational structure
of the applicant's management and administrative staff; and
(C) a chart showing contractual arrangements of the
HMO's delivery network;
(7) a fidelity bond or deposit for officers and employees
that must be:
(A) an original or copy of a bond complying with Insurance
Code §843.402 (concerning Officers' and Employees' Bond), which
must not contain a deductible; or
(B) a cash deposit held under Insurance Code §843.402
or as provided by Insurance Code §423.004 (concerning Statutory
Deposits with Department) in the same amount and subject to the same
conditions as the bond described in this paragraph;
(8) information relating to out-of-state licensure
and service of legal process for all applicants must be submitted
by using the attorney for service form; provided that:
(A) if the applicant is domiciled in another jurisdiction,
an agent for service of legal process must be appointed in compliance
with Insurance Code Chapter 804 (concerning Service of Process) using
Form FIN 312 (rev. 04/00), and the applicant must furnish a copy of
the certificate of authority from the domiciliary jurisdiction's licensing
authority; and
(B) the applicant must furnish a statement acknowledging
that all lawful process in any legal action or proceeding against
the HMO on a cause of action arising in this state is valid if served
as provided in Insurance Code Chapter 804;
(9) the evidence of coverage to be issued to enrollees
and any group agreement that is to be issued to employers, unions,
trustees, or other organizations as described in Chapter 11, Subchapter
F, of this title (relating to Evidence of Coverage);
(10) financial information, consisting of the following:
(A) a financial statement that includes a balance sheet
reflecting the required net worth, assets, and any liabilities;
(B) if the applicant is newly formed, a balance sheet
reflecting the HMO's proposed initial funding;
(C) projected financial statements using the NAIC UCAA
ProForma Financial Statements for Health Companies, commencing with
the proposed beginning of operations and containing at least two full
calendar year projections, and including the identity and credentials
of the person preparing the projections; and
(D) the most recent audited financial statements of
the HMO's immediate parent company, the ultimate holding company parent,
and any sponsoring organization;
(11) the schedule of charges, excluding any charges
for Medicaid products, with an actuarial certification and supporting
documentation meeting the qualifications specified in §11.702
of this title (relating to Actuarial Certification),
(12) if the applicant proposes to write Medicaid products,
an actuarial certification and supporting documentation meeting the
qualifications specified in §11.702 of this title, and noting
whether the proposed rates are the maximum rates allowed by the contracting
state agency, if rates less than the maximum rates allowed are being
proposed or if the contracting state agency rates are not available;
(13) a description and a map of the applicant's proposed
service area, with key and scale, which must identify the county or
counties, or portions of counties, to be served; provided that all
copies of the map must be in color, if the HMO submits a map on paper
and in color;
(14) the form of any contract or monitoring plan between
the applicant and:
(A) any person listed on the officers and directors
page;
(B) any physician, medical group, association of physicians,
or any other provider, and the form of any subcontract between those
entities and any physician, medical group, association of physicians,
or any other provider to provide health care services, provided that
contracts, including subcontracts between physician and provider groups
with the individual members of the groups providing health care services
to the HMO's enrollees, must include a hold-harmless provision and
comply with all other provisions of §11.901 of this title (relating
to Required and Prohibited Provisions);
(C) any affiliated exclusive agent or agency;
(D) any affiliated person who will perform marketing,
administrative, data processing services, or claims processing services;
(E) any affiliated person who will perform management
services, together with a deposit or the original or a copy of a bond
with no deductible meeting the requirements of Insurance Code §843.105
(concerning Management and Exclusive Agency Contracts);
(F) an ANHC that agrees to arrange for or provide health
care services, other than medical care or services ancillary to the
practice of medicine, or a provider HMO that agrees to arrange for
or provide health care services on a risk-sharing or capitated risk
arrangement on behalf of a primary HMO as part of the primary HMO
delivery network; together with a monitoring plan, as required by §11.1604
of this title (relating to Requirements for Certain Contracts Between
Primary HMOs and ANHCs and Between Primary HMOs and Provider HMOs);
(G) any insurer or group hospital service corporation
to offer indemnity benefits under a point-of-service contract; and
(H) any delegated entity or delegated network, as those
terms are described in Insurance Code Chapter 1272 (concerning Delegation
of Certain Functions by Health Maintenance Organization);
(15) a description of the quality improvement program
and work plan that includes a process for medical peer review required
by Insurance Code §843.082 (concerning Requirements for Approval
of Application) and §843.102 (concerning Health Maintenance Organization
Quality Assurance); provided that arrangements for sharing pertinent
medical records between physicians, providers, or both, contracting
or subcontracting under paragraph (14)(B) of this section with the
HMO and ensuring the confidentiality of the records must be explained;
(16) insurance, guarantees, and other protection against
insolvency:
(A) any affiliated reinsurance agreement and any other
affiliated agreement described in Insurance Code §843.082(4)(C),
covering excess of loss, stop-loss, catastrophes, or any combination
thereof, which must provide that the Commissioner and HMO will be
notified no less than 60 days before termination or reduction of coverage
by the insurer;
(B) any conversion policy or policies that will be
offered by an insurer to an HMO enrollee in the event of the applicant's
insolvency;
(C) any other arrangements offering protection against
insolvency, including guarantees, as specified in §11.808 of
this title (relating to Liabilities) and §11.810 of this title
(relating to Guarantee from a Sponsoring Organization);
(17) authorization for bank disclosure to the Commissioner
of the applicant's initial funding;
(18) the written description of health care plan terms
and conditions made available by:
Cont'd... |
