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Governor Eric J. Holcomb
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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.

  1. 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 )
  2. Minimum net worth of $1.5 million. ( IC 27-13-12-2 )
  3. A financial feasibility plan in accordance with IC 27-13-2-5(9).
  4. 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 )
  5. 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) )
  6. 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.
  7. 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.
  8. 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).
  9. 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 )
  10. Complaint Summary & Questionnaire for the past 2 years on applicant and applicant's parent.
  11. 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 )
  12. A description of the proposed quality management program of the applicant that includes the criteria per ( IC 27-13-6-1 ).
  13. A description of the procedures to be implemented to meet the requirements set forth in IC 27-13-12 through IC 27-13-19.
  14. A list of the names, addresses and license numbers of providers with whom the HMO has agreements. ( IC 27-13-2-5(15) )
  15. Indiana Biographical Affidavit
  16. 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
(816) 842-3600

The information requested in the preceding should be delivered to the following:
Admissions Coordinator
Indiana Department of Insurance
311 West Washington Street, Suite 300
Indianapolis, Indiana 46204-2787