"Application for Health Maintenance Organization License in Louisiana" - Louisiana

Application for Health Maintenance Organization License in Louisiana is a legal document that was released by the Louisiana Department of Insurance - a government authority operating within Louisiana.

Form Details:

  • Released on September 1, 2019;
  • The latest edition currently provided by the Louisiana Department of Insurance;
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  • Fill out the form in our online filing application.

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L
D
I
OUISIANA
EPARTMENT OF
NSURANCE
JAMES J. DONELON
COMMISSIONER
INSTRUCTIONS FOR
APPLICATION FOR
HEALTH MAINTENANCE ORGANIZATION LICENSE
IN LOUISIANA
GENERAL INSTRUCTIONS
This packet is designed to assist the individual preparing this application in complying with the statutory and
administrative requirements and to facilitate review of the application by the LDI. Therefore, it is extremely
important that all applicants comply fully with the instructions and requirements set forth in this packet.
All communication should be directed to:
Louisiana Department of Insurance
Company Licensing
P.O. Box 94214
Baton Rouge, LA 70804-9214
OR
1702 N. 3
rd
St.
Baton Rouge, LA 70802
Phone: (225) 219-0563
Fax: (225) 219-9322
E-Mail Address:
companyapps@ldi.la.gov
While our Department will be happy to assist you and answer any questions you may have, we ask that you
thoroughly review all instructions and forms before contacting us.
1) The Louisiana Department of Insurance (LDI) accepts electronic submission of the application via
email. An application submitted in this manner must be submitted to
companyapps@ldi.la.gov
to assure receipt and prompt processing by the LDI. After submission of the application
electronically, the payment of the fees must be submitted hard copy to the address above. All
payments must be made payable to the Louisiana Department of Insurance.
2) If the application is submitted hard copy, all submittals in association with this application must
reach the LDI via the United States Postal Service or a carrier with interstate business. Hand
delivery is not acceptable and any information arriving in this manner will be returned
without review. In addition, all correspondence must be sent to the attention of Company
Licensing to assure prompt receipt and handling.
3) Submit only a fully completed application. Submittal of a partially completed application will cause
processing delays and may result in disapproval.
4) Do not alter the forms contained in this packet. If you feel the requirements do not apply to your
company, notify us. We will supply the proper form, if appropriate, and/or answer any
questions you have about the forms.
5) All original items submitted become the property of the LDI and will not be returned.
APPLICATION FOR A HEALTH MAINTENANCE ORGANIZATION
Page 1 of 17
Rev 10-2021
L
D
I
OUISIANA
EPARTMENT OF
NSURANCE
JAMES J. DONELON
COMMISSIONER
INSTRUCTIONS FOR
APPLICATION FOR
HEALTH MAINTENANCE ORGANIZATION LICENSE
IN LOUISIANA
GENERAL INSTRUCTIONS
This packet is designed to assist the individual preparing this application in complying with the statutory and
administrative requirements and to facilitate review of the application by the LDI. Therefore, it is extremely
important that all applicants comply fully with the instructions and requirements set forth in this packet.
All communication should be directed to:
Louisiana Department of Insurance
Company Licensing
P.O. Box 94214
Baton Rouge, LA 70804-9214
OR
1702 N. 3
rd
St.
Baton Rouge, LA 70802
Phone: (225) 219-0563
Fax: (225) 219-9322
E-Mail Address:
companyapps@ldi.la.gov
While our Department will be happy to assist you and answer any questions you may have, we ask that you
thoroughly review all instructions and forms before contacting us.
1) The Louisiana Department of Insurance (LDI) accepts electronic submission of the application via
email. An application submitted in this manner must be submitted to
companyapps@ldi.la.gov
to assure receipt and prompt processing by the LDI. After submission of the application
electronically, the payment of the fees must be submitted hard copy to the address above. All
payments must be made payable to the Louisiana Department of Insurance.
2) If the application is submitted hard copy, all submittals in association with this application must
reach the LDI via the United States Postal Service or a carrier with interstate business. Hand
delivery is not acceptable and any information arriving in this manner will be returned
without review. In addition, all correspondence must be sent to the attention of Company
Licensing to assure prompt receipt and handling.
3) Submit only a fully completed application. Submittal of a partially completed application will cause
processing delays and may result in disapproval.
4) Do not alter the forms contained in this packet. If you feel the requirements do not apply to your
company, notify us. We will supply the proper form, if appropriate, and/or answer any
questions you have about the forms.
5) All original items submitted become the property of the LDI and will not be returned.
APPLICATION FOR A HEALTH MAINTENANCE ORGANIZATION
Page 1 of 17
Rev 10-2021
6) All certified documents required in the application must be dated within six (6) months of submittal
of the application. If an application is submitted hard copy rather than electronically, all
certifications must be original.
7) All entries in the application forms must be typed or printed. Illegible entries or responses will be
considered incomplete and may result in the disapproval of the application.
8) When designating a contact person for the application process, please remember that our staff will
communicate only with this individual. The application process is considered confidential and
will not be discussed with any person other than the named contact person. The applicant
must notify the LDI in writing of any change in contact person.
9) The applicant must notify the LDI of any changes in the company or the information submitted in
association with this application which occur while the application is under review. This
includes changes in officers and directors; changes in address or domicile; and changes to the
financial statements submitted in support of this application. Failure to notify the LDI of such
changes may result in disapproval of the application.
INFORMATION REGARDING INCORPORATION
Louisiana law requires that a health maintenance organization must be a Louisiana domiciled corporation
and must be incorporated pursuant to and the Articles of Incorporation must be compliant with the
provisions of La. R.S. 22:243.
Once the Articles of Incorporation are properly prepared, the document must be submitted to the LDI for
approval along with a fee in the amount of $25.00. The LDI encourages review and discussion of the
proposed Articles of Incorporation prior to the official and final submission for approval. The documents
submitted to the LDI for final approval may be executed or unexecuted.
If the LDI finds the Articles of Incorporation are compliant with the applicable laws, the document will be
approved for recordation and returned to the submitter for recordation with the Louisiana Secretary of
State.
Once the Articles of Incorporation are properly recorded with the Louisiana Secretary of State, the company
exists as a corporation and may open bank accounts and otherwise carry on business as a corporation but
may not transact business as a health maintenance organization until such time as it is granted a Certificate
of Authority by the LDI.
SPECIAL INSTRUCTIONS REGARDING THIRD PARTY VERIFICATION REPORTS
In association with this application, the LDI requires that all applicants make arrangements for third party
verification reports for all persons for whom biographical affidavits are required. This must include all officers,
all directors, all individuals who own ten percent or more of the applicant and all other persons responsible for
the conduct of affairs of the applicant.
The reports must be prepared by one of the firms approved by the National Association of Insurance
Commissioners. A list of those approved firms is available at
http://naic.org/documents/industry_ucaa_third_party.pdf. The applicant should advise the firm that the
reports are being prepared for the LDI and make the necessary arrangements for payment.
APPLICATION FOR A HEALTH MAINTENANCE ORGANIZATION
Page 2 of 17
Rev 10-2021
SPECIAL INSTRUCTIONS REGARDING FINGERPRINTING
In association with this application, all officers, directors, trustees and all individuals who control, directly or
indirectly ten percent or more of the applicant, are required to be fingerprinted and the results transmitted to
the LDI.
For residents of Louisiana, fingerprinting services are provided by the license testing vendor PSI. No
appointment is necessary and a list of testing locations and hours of operation is available on PSI’s website
(PSIexams.com). Fingerprinting fees are paid at the site at the time of submission.
For any individual who is not a resident of Louisiana, the following steps are required:
1. Duplicate fingerprint cards for each individual must be submitted. You may submit requests for
blank fingerprint cards to companyapps@ldi.la.gov. Please include the number of cards required
and the address to which the cards should be mailed.
2.
Applicable fingerprint fees
made payable to the Louisiana State Police.
3. A completed Authorization to Disclose Criminal History Records Information for each applicant.
This form is available on the LDI
website.
4. A completed Rap Sheet Disclosure Form for each applicant.
This form is available on the LDI
website.
All of these documents should be sent to:
Louisiana State Police
Bureau of Criminal Identification and Information
P.O. Box 66614 (Mail Slip A-6)
Baton Rouge, LA 70896
Generally the Department will receive fingerprint results within three to four days from submission of the
fingerprints. If the Louisiana State Police or Federal Bureau of Investigation are unable to run the reports
due to unreadable or unclear fingerprint submissions, it may take up to sixty (60) days for a check to be
completed using alternate means.
Any individual that is currently serving as an officer or director of another domestic regulated entity or has
previously submitted fingerprints in association with a resident producer or adjuster license application may
request a waiver of the fingerprinting requirements. Requests for such a waiver should be sent to
companyapps@ldi.la.gov. The request must provide a full explanation of the application to be filed, the
names of all individuals for whom the waiver is requested and clearly explain the grounds for the request.
INITIAL FINANCIAL EXAMINATION AND CONFIRMATION OF ASSETS
Prior to the issuance of a Certificate of Authority to a health maintenance organization, the LDI will conduct an
initial financial examination and confirmation of the assets of the applicant.
The applicant must be properly capitalized, and its funds invested in compliance with the applicable statutes
and in the name of the applicant upon submission of the application. If the funds are not properly invested and
verifiable, the application will be disapproved.
The applicant must provide written notice to all depositories authorizing the release of information to the LDI.
APPLICATION FOR A HEALTH MAINTENANCE ORGANIZATION
Page 3 of 17
Rev 10-2021
LOCATION OF BOOKS AND RECORDS
Pursuant to La. R.S. 22:251 the books and records of a Louisiana domiciled health maintenance organization
must be maintained in Louisiana unless a plan to keep them out of state has been adopted by the board of
directors of the insurer and approved by the LDI.
If the applicant intends to maintain books and records outside of Louisiana, the required plan must be
submitted as part of this application. That plan must include a detailed description of what books and records
shall be maintained outside of Louisiana and a description of how those books and records will be made
available to the LDI in compliance with La. R.S. 22:251 and all other applicable statutes.
INSTRUCTIONS FOR ATTESTATION PAGE
The Attestation Page of this application must be completed by two officers of the applicant. Each signature
must be witnessed by two individuals and notarized. The same two individuals may witness both signatures but
a signatory of the document may not also act as a witness. The Attestation Page may also be signed in codicil by
reproducing the form.
SPECIAL INSTRUCTIONS FOR MEDICARE ADVANTAGE APPLICANTS
If the applicant is filing this application for the sole purpose of writing Medicare Advantage business in
Louisiana, certain exhibits in the application are not required. See the Exhibits portion of this application
package for indications of which exhibits are not required.
APPLICATION FOR A HEALTH MAINTENANCE ORGANIZATION
Page 4 of 17
Rev 10-2021
COMMON QUESTIONS
The following are some of the most commonly asked questions regarding the application package and process.
Q: What is the time-frame for the review of an application?
A: The LDI makes every effort to review all applications as soon after submittal as possible. The review process
can be expected to take from sixty (60) to ninety (90) days from receipt of a complete application.
Please take this time frame into account when considering deadlines and operation schedules for the
applicant.
Q: Can the forms in the application packet be recreated on a word processor for completion by the applicant?
A: No. The forms in this packet are designed for ease of recognition by our staff and, in many cases, in strict
compliance with statutory wording requirements. Therefore, any changes in the format or wording of
the forms will cause delays in the review and may lead to the disapproval of the application.
Q: The Exhibits portion of the application form requires certain biographical information on owners of 10% or
more of the applicant. What if all owners are corporations? Do the officers and directors of those
corporations supply the biographical information?
A: Initially, no. However, the LDI reserves the right to request biographical information for all persons who
would exercise control over the insurer up to and including the ultimate controlling party. The LDI will
determine if additional information is required upon review of the application and notify the applicant.
Q: Can we meet with the LDI for a preliminary review of our application prior to submission?
A: Yes. Our staff will be happy to meet with representatives of the applicant to review the application before it
is actually submitted. It should be noted, however, this courtesy review is to help assure completeness
only, and the LDI will not issue a preliminary approval or disapproval of the application prior to
submission. Any application sent to this Office via U.S. Mail will be considered submitted for review
and will not be eligible for a pre-review. You may make an appointment for preliminary review by
contacting the Company Licensing Section of the LDI. Preliminary reviews will be performed only
with an appointment.
Q: What factors should go into considering who should be named as the contact person?
A: Among the things to be considered when naming the contact person for the application process are:
Knowledge - The person acting as the contact should have a thorough knowledge of the application
packet and company functions.
Accessibility - You should consider whether or not the contact person is easily reachable. A person who
is often absent from the office or who is otherwise difficult to reach is a poor choice due to the
nature of the application process.
Location - All requests for additional information include a deadline to supply this information.
Therefore, you should consider the location of the contact person and whether or not he or she
can reasonably be expected to obtain needed documents or information within a time frame
which is usually set at 30 days.
APPLICATION FOR A HEALTH MAINTENANCE ORGANIZATION
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Rev 10-2021
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