HMO Certificate Of Authority Application Guidelines Illinois Department of Financial and Professional Regulation Division of Insurance

Applicable Illinois Laws and Regulations

215 ILCS 125/1-1 et seq. (HMO Act)
50 Ill. Adm. Code 851-854
50 Ill. Adm. Code 904
50 Ill. Adm. Code 916
50 Ill. Adm. Code 925
50 Ill. Adm. Code 5420
50 Ill. Adm. Code 5421
77 Ill. Adm. Code 240

Copies of Illinois Law and Regulations may be obtained from:

State of Illinois
Secretary of State
Index Department
Springfield, Illinois 62756
(217) 782-6537

Organization must submit a non-refundable filing fee with application. The filing fee is two thousand ($2,000) dollars for a domestic organization and five thousand ($5,000) dollars for a foreign organization.

One (1) original and two (2) copies of all documents must be submitted. These should be sent to:

Etta Mae Credi
Corporate Regulatory Division
Illinois Division of Insurance
320 West Washington, 4th Floor
Springfield, Illinois 62767-001

Supporting documents for application must be tabbed and indexed. These documents must NOT be permanently bound. The documents must be in the same order as outlined in these guidelines and in an easily read format.

Questions should be addressed to:
Etta Mae Credi
Corporate Regulatory Division
Illinois Division of Insurance
320 West Washington, 4th Floor
Springfield, Illinois 62767-001

William Bell
Division of Health Care Facilities and Programs
Illinois Department of Public Health
525 West Jefferson
Springfield, Illinois 62761
(217) 782-0345

The following instructions and/or documents are in addition to the material set forth in Section 2-1(c) of the HMO Act and must be a part of the filed application.

Subsection 1

Organization Documents - A certified copy of the organization's Articles of Incorporation filed with the Secretary of State. If the organization is a foreign corporation, include a certified copy of the Articles of Incorporation from the state of domicile and evidence of registration with the Illinois Secretary of State.

Subsection 2

Bylaws - The fiscal year must be synonymous with the calendar year.

Subsection 3

Name, Address and Positions - Biographical Affidavit (PDF Format).

Conflict of Interest Statement (HTML Format) - Original signature (Part 5421.90).

Include a draft of the Holding Company Registration Statement or the most recent Holding Company Statement filed in your home state (Section 5-3 and Part 852).

Subsection 4

Service Area - List only the counties in which you are initially going to do business. Include a legible map of area by zip code to be served by HMO showing location of its office and ambulatory health care facilities.

Corporate Plan of Operation (HTML Format).

Subsection 5

Provider Contracts - Section 2-8 and Part 5421.50.

Subsection 6

Contracts with Related Parties

Subsection 7

Administrative and Miscellaneous Contracts

Subsection 8

Group Contracts and Evidences of Coverage
Group Health Maintenance Organization Evidence Of Coverage Checklist (HTML Format)

To facilitate flexibility in contract filing, group contracts and evidences of coverage may be filed on an insert page basis - each page being identified by a unique form number located in the lower left-hand corner (not to exceed 15 characters). These insert pages may then be replaced as required by other approved pages. If the contract is not numbered in such a fashion and a modification is required, then the entire contract must be refiled for approval. When forms are to be approved in this manner, the general transmittal sheet must list each page as a policy form (50 Ill. Adm. Code 916).

Subsection 9

Grievance Procedures
Group Health Maintenance Organization Evidence Of Coverage Checklist (HTML Format)
Individual Health Maintenance Organization Evidence Of Coverage Checklist (HTML Format)

Subsection 10

Audited Financial Information

Subsection 11

Statutory deposit (Section 2-6).

Financial Information - The organization must have minimum $2,000,000 net worth before application will be reviewed.

A. FOR NEW CORPORATION

1. A copy of an executed escrow agreement with an Illinois Bank or other Financial Institution, restricting access to funds on deposit until a Certificate of Authority is issued by the Division of Insurance, certification is denied, or the application is withdrawn.
2. A dated balance sheet reflecting a net worth for the organization of not less than $2,000,000 will be submitted upon notice from the Department that review of this application is near completion.
3. Provide debt agreements which meet the requirements of Section 2-9 and 50 Ill. Adm. 5421.70 if part or all of the initial capital will be provided through subordinated debt.

B. FOREIGN CORPORATION CURRENTLY OPERATING AS AN HMO

1. Copies of annual financial statements filed in the organization's state of domicile (or state where certified the longest) for the past three years.
2. Quarterly statements for any quarters that have elapsed since the last annual statement's reporting date. THE CORPORATION MUST HAVE A MINIMUM NET WORTH OF $2,000,000 AS OF THE MOST RECENT REPORTING DATE.
3. A statement from the agency charged with regulation of the organization to the effect that it is currently in compliance with applicable laws and regulations which the agency is charged to enforce.
4. A statement from the organization stating they are aware of the investment limitations and admitted assets sections of the Illinois HMO Act and will be in compliance with these sections when computing the financial statements.

Subsection 12

Rate Methodology

Subsection 13

Marketing
Group Health Maintenance Organization Evidence Of Coverage Checklist (HTML Format)
Individual Health Maintenance Organization Evidence Of Coverage Checklist (HTML Format)

Subsection 14

Registered Agent

Subsection 15

Complaint Procedures
Group Health Maintenance Organization Evidence Of Coverage Checklist (HTML Format)
Individual Health Maintenance Organization Evidence Of Coverage Checklist (HTML Format)

Subsection 16

Quality Assessment and Utilization and Review

Filing Fee - The filing fee must be included with the filing of the application and supporting documents. This fee is non-refundable.

Subsection 17

Supply the Federal Employers Identification Number (FEIN) assigned to the organization.

Attached Documents

• Application for Certificate of Authority (PDF Format)
• Biographical Affidavit (PDF Format)
• Conflict of Interest Statement (HTML Format)
• Corporate Plan of Operation in Illinois (HTML Format)
• Group Health Maintenance Organization Evidence Of Coverage Checklist (HTML Format)
• Individual Health Maintenance Organization Evidence Of Coverage Checklist (HTML Format)

(Rev. 1/05)

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