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Governor Eric J. Holcomb
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Health Maintenance Organization

NAIC Electronic Application System to submit a Uniform Certificate of Authority Expansion Application.

NAIC OPTins for remittance of filing fees upon receipt of invoice from IDOI.

UCAA Requirements

  1. Foreign Corporations:
    1. Certificate of Authority, from the Secretary of State, to transact business in Indiana as a foreign corporation. ( IC 27-13-2-3 )
    2. Certificate of Deposit from state of domicile showing deposit for benefit of all policyholders. ( IC 27-13-13-6(2) )
  2. An application fee in the amount of $350 with the check payable the Indiana Department of Insurance.
  3. A Deposit in the amount of $500,000 held jointly with the applicant and Commissioner for the benefit of Indiana enrollees.  (I.C. 27-13-13-1)
  4. 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 )
  5. Minimum net worth of $1.5 million. ( IC 27-13-12-2 )
  6. A financial feasibility plan in accordance with IC 27-13-2-5(9).
  7. Statements of:
    1. Geographic area to be served, by county ( IC 27-13-2-5(11) )
    2. The company's compliance with Point of Service Products ( IC 27-13-13-8 )
  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) )
  9. 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) )
    1. Master group contract.
    2. Employee subscription certificate (benefit schedule).
    3. Enrollment application.
    4. Conversion contract.
    5. Conversion benefit schedule.
    6. Individual agreement.
    7. Individual schedule of benefits.
    8. Individual application.
    9. Medicare subscriber agreement.
    10. Medicare schedule of benefits.
    11. All applicable marketing materials.
  10. Schedule of rates including: ( IC 27-13-2-5(9)(B) )
    1. Proposed group rates and actuarial justification.
    2. Proposed conversion rates and actuarial justification.
    3. Proposed individual rates and actuarial justification.
  11. 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).
  12. 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 )
  13. Complaint Summary & Questionnaire for the past 2 years on applicant and applicant's parent.
  14. 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 )
  15. A description of the proposed quality management program of the applicant that includes the criteria per ( IC 27-13-6-1 ).
  16. A description of the procedures to be implemented to meet the requirements set forth in IC 27-13-12 through IC 27-13-19.
  17. A list of the names, addresses and license numbers of providers with whom the HMO has agreements. ( IC 27-13-2-5(15) )
  18. Indiana Biographical Affidavit