Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 40 - Health Maintenance Organizations › Rule 191-40.11 - Application for Certificate of Authority

Current through Register Vol. 47, No. 3, July 24, 2024
The application for certificate of authority shall be in the
				  following form:
HEALTH MAINTENANCE ORGANIZATION APPLICATION FOR CERTIFICATE
				  OF AUTHORITY
______________________________________
(Name of Health Maintenance Organization)
Organized
				  as___________________________________________________________________________
				  under the laws of the state of_______________________________, hereby makes
				  application to the commissioner of insurance for a certificate of authority to
				  establish and operate a health maintenance organization in compliance with Iowa
				  Code chapter 514B.
Attached hereto and hereby made a part of this application
				  are exhibits bearing numbers corresponding to the following:
1. A copy of the basic organizational
				document, of the applicant such as the articles of incorporation, articles of
				association, partnership agreement, trust agreement, or other applicable
				documents, and all of its amendments.
2. A copy of the bylaws, rules or similar
				document, regulating the conduct of the internal affairs of the
				applicant.
3. A list of the names,
				addresses, and official positions of the persons who are to be responsible for
				the conduct of the affairs of the applicant, including all members of the board
				of directors, board of trustees, executive committee, or other governing board
				or committee, the principal officers if a corporation and the partners or
				members if a partnership or association.
3.1 A list of the names and addresses of each owner of 5
				  percent or more of the health maintenance organization.
4. A copy of any contract made or to be made
				between any providers and the applicant.
4.1 A copy of any contract made or to be made between the
				  applicant and any person listed in item (3).
4.2 A copy of any contract made or to be made between the
				  applicant and any person for management services.
5. A statement generally describing the
				health maintenance organization including, but not limited to, a description of
				its facilities and personnel.
6. A
				copy of the form of evidence of coverage.
7. A copy of the form of the group contract,
				if any, which is to be issued to employers, unions, trustees or other
				organizations.
8. Financial
				statements showing the applicant's assets, liabilities, and sources of
				financial support. If the applicant's financial affairs are audited by an
				independent certified public accountant, a copy of the applicant's most recent
				regular certified financial statement is attached.
8.1 A copy of any contract made or to be made between the
				  applicant and its reinsurer
8.2A copy of any contract made or to be made between the
				  applicant and any person for cash or asset management services.
9. A description of the proposed
				method of marketing the plan, a financial plan which includes a three-year
				projection of operating results anticipated, and a statement as to the sources
				of funding.
10. A power of attorney
				executed by the applicant, if not domiciled in this state, appointing the
				commissioner, his successors in office and deputies as the true and lawful
				attorney of the applicant for this state upon whom all lawful process in any
				legal action or proceeding against the health maintenance organization on a
				cause of action arising in this state may be served.
11. A statement reasonably describing the
				geographic area to be served and assessing in detail the economic feasibility
				of the HMO's projected operation.
12. A description of the complaint procedures
				to be utilized as required under Iowa Code section
				514B14..
13. A description of the procedures and
				programs to be implemented to meet the requirements for quality of health care
				as determined by the commissioner of insurance in consideration, when deemed
				appropriate, with the director of public health, under Iowa Code section
				514B4..
14. A description of the mechanism by which
				enrollees shall be allowed to participate in matters of policy and operation as
				required by Iowa Code section
				514B7..
14.1 A copy of the notice to be given to enrollees of the
				  procedure for nomination and election of members of the governing body.
15. A schedule of the liability
				and workmen's compensation insurance to be maintained in force by the health
				maintenance organization.
15.1 Copies of the forms of policies or contracts to be
				  offered to terminated enrollees as provided in 40.10(2).
VERIFICATION
The undersigned deposes and says that deponent has duly
				  executed the attached application dated
_____________________, 20________, for and on behalf
				  of___________________________________;
(Name of Applicant)
that deponent is
				  the______________________________________________________of such
				  company,
(Title of Officer)
and that deponent is authorized to execute and file such
				  instrument. Deponent further says that deponent is familiar with such
				  instrument and the contents thereof, and that the facts therein set forth are
				  true to the best of deponent's knowledge, information and belief.
(Signature)________________________________________________________________________
(Type or print name
				  beneath)_________________________________________________________
Subscribed and sworn to before me
				  by_______________________________________________on
				  this______________________day of__________________________,
				  20___________.
__________________________
(Notary Public)