Section 031-191-6 - Application Submission Requirements In addition to the requirements of 24-A M.R.S.§4203(3), an application for an HMO certificate of authority shall include the information and documents set forth in this section.All data submitted by an applicant to the Commissioner of the Department of Health and Human Services must also be submitted to the Superintendent.
[Drafting Note:Any request for confidential handling of specific portions of the application is subject to the confidentiality protocol established by the Superintendent.]
A.Certification The certification required by 24-A M.R.S. §4203(3) must include a statement that the applicant is aware of the requirements of Title 24-A Chapter 56 and this rule and agrees to conform to those requirements and any other prospectively applicable enacted or adopted requirements of which it has notice or should have cause to notice.
B.HMOs Affiliated With Insurers An insurer operating in this State under a current Certificate of Authority may directly or through a subsidiary or affiliate corporation or other business entity, organize and operate an HMO in this State.If such joint affiliation is effected and the HMO is controlled by, under common control with, or exerts control over such affiliate, these corporations and the HMO, if a distinct entity, shall be subject to the law applicable to insurance holding companies, including 24-A M.R.S. §222and Bureau of Insurance Rule Chapter 180.
C.Power of Attorneyand Agent for Service of Process A power of attorney must be filed by all foreign applicants to the extent required by 24-A M.R.S. §4203(3)(J).In addition, all foreign and domestic health maintenance organizations are subject to and must comply with the requirements of 24-A M.R.S.§421.At the time of application for a certificate of authority, the applicant shall appoint an agent for service of process and file the appointment with the Superintendent.
D.Organizational Structure and Operations Applications must include:
1) An organizational chart for the HMO setting out the position classifications of personnel responsible for various phases of health care delivery and administrative responsibility.2) Biographical sketches and independent third party reviews using the National Association of Insurance Commissioners (NAIC) form current at the time of application of the applicant's directors and officers, or, if the applicant is an association or a society, its partners or members.3) Disclosure by all principal officers and directors of the HMO, in statements attested under oath, of any real or potential conflict of interest, including pertinent employment contracts, deferred compensation contracts or other pecuniary interests.Such disclosure shall extend to any provider under contract with the HMO to provide health care services who also has managerial or directorship responsibilities with the HMO that permit the provider to influence the HMO's decision-making. 4) A description of any physical treatment centers such as clinics or satellite medical facilities owned or leased by the HMO.E.Financial Information1) The financial feasibility plan required by 24-A M.R.S. §4203(3)(I) shall include: a) Projected financial statements for a three year period, including at a minimum, a balance sheet and income statement.b) A description of the anticipated working funds available for day-to-day operational expenses of the HMO.c) Detailed enrollment projections including marketing pro forma operating result projections for the coming three-year period.d) The proposed methodology for determining liabilities consistent with the requirements of 24-A M.R.S. §4204(5).e) The proposed investment strategy consistent with the requirements of 24-A M.R.S. §4204(3-A).2) Financial statements filed shall conform with NAIC adopted standards current at the time of application.3) The applicant shall provide its NAIC group code. If the applicant is not affiliated with an NAIC-designated insurance group, the applicant shall provide financial information satisfactory to the Superintendent relating to its parent company or other controlling person and its affiliates.F.Quality Assurance Plan Applications must include a written quality assurance plan which meets the requirements of 24-A M.R.S. §§4203(3)(M) and 4204(2-A)(B).
G.Marketing Materials(Repealed)H.Point of Service Plans Applicants seeking to offer a point-of-service plan to enrollees shall file all information necessary to demonstrate the plan's consistency with the requirements of 24-A M.R.S. §4207-A.
I.Complaint System Applicants must file a description of their complaint system which demonstrates consistency with the requirements of 24-A M.R.S. §4211 and the Health Plan Improvement Act, Chapter 56-A.
J.(Omitted intentionally)K.Contracts1) Copies of the following contracts must be filed with the application: a) Any contracts with insurers, non-profit hospital or medical service corporations, the United States Government or any other organization forproviding health care services or insuring or providing for the cost of such services.b) Any fidelity bonds, arrangements or agreements entered into for self-insurance to respond to claims for:ii) employers liability; and iii) workers' compensation. c) All property insurance policies covering owned medical facilities.2) The provider contract filing requirement of 24-A M.R.S. §4203(D) may be satisfied by filing template contracts and applicable subcontracts, along with all proposed material deviations from those templates. 02-031 C.M.R. ch. 191, § 6