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Indiana Department of Insurance

IDOI > Financial Services > Foreign Admission Requirements > Limited Service Health Maintenance Organization Limited Service Health Maintenance Organization

AnThe following state specific items must be submitted along with the Uniform Certificate of Authority Expansion 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 Application Checklist.

  1. Foreign Corporations:
    1. Certificate of Authority, from the Secretary of State, to transact business in Indiana as a foreign corporation. ( I.C. 27-13-34-7 )
    2. Power of Attorney, appointing the Commissioner, Indiana Department of Insurance, ("Commissioner") as attorney for service of process. ( I.C. 27-13-34-8(19) )
    3. Power of Attorney
    4. Resolution by Board of Directors appointing Commissioner as Power of Attorney to receive process of service.
    5. Certificate of Deposit from state of domicile showing deposit for benefit of all policyholders. ( I.C. 27-13-34-17(g)(l) )
  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 $50,000 held jointly with the applicant and Commissioner for the benefit of Indiana enrollees. ( I.C. 27-13-34-17)
  4. 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 )
  5. Minimum net worth equal to the greater of $50,000 or 2.5% of annual gross subscription income. ( IC 27-13-34-16 )
  6. A financial plan in accordance with IC 27-13-34-8(10).
  7. Statements of:
    1. Geographic area to be served, by county.
    2. The company's compliance with Point of Service Products. ( IC 27-13-34-10(6) )
    3. 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 )
  8. 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) )
  9. 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) )
    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. All applicable marketing materials.
  10. 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) )
  11. 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) )
  12. Complaint Summary & Questionnaire for past 2 years on applicant and applicant's parent. ( IC 27-13-34-8(18) )
  13. A description of the complaint procedures to be established and maintained under IC 27-13-10 & IC 27-13-34-12(1).
  14. A description of the quality assessment and utilization review procedures to be used by the applicant. ( IC 27-13-34-8(14) )
  15. The IDOI utilizes the Uniform Certificate of Authority Expansion Application.