"Medical Discount Plant (Mdp) License Renewal Form" - Connecticut

Medical Discount Plant (Mdp) License Renewal Form is a legal document that was released by the Connecticut Insurance Department - a government authority operating within Connecticut.

Form Details:

  • Released on July 1, 2015;
  • The latest edition currently provided by the Connecticut Insurance Department;
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Download "Medical Discount Plant (Mdp) License Renewal Form" - Connecticut

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Medical Discount Plant (MDP)
License Renewal
Instructions and Application
Effective January 1, 2006, Public Act 05-237, as modified by Public Act No. 08-181, codified
as Connecticut General Statutes §38a-479rr, requires all Medical Discount Plans (“MDP”)
offering services in the State of Connecticut to be licensed. The State of Connecticut
Insurance Department (“Department”) is charged with licensing MDPs. If you have any
questions about your responsibility to be licensed, please refer to C. G. S. §38a-479rr.
Instructions:
To assure that a MDP license be renewed prior to continuing services in Connecticut, the
Department suggests that applications be submitted at least two months in advance. If
your Plan meets the guidelines for licensure, an invoice for the license fee of $625 will be
forwarded to you. This invoice must be paid prior to the license effective date.
The application must be filled out, completed and signed by an officer or authorized
representative of the MDP entity certifying that all information provided is true and
accurate.
Submit your application and attachments via electronic to:
Peter.Nakano@ct.gov
DO NOT SUBMIT THE LICENSE FEE WITH THIS APPLICATION.
You will be billed.
Revised 7/1/2015
MDP License Renewal
Page 1 of 15
Medical Discount Plant (MDP)
License Renewal
Instructions and Application
Effective January 1, 2006, Public Act 05-237, as modified by Public Act No. 08-181, codified
as Connecticut General Statutes §38a-479rr, requires all Medical Discount Plans (“MDP”)
offering services in the State of Connecticut to be licensed. The State of Connecticut
Insurance Department (“Department”) is charged with licensing MDPs. If you have any
questions about your responsibility to be licensed, please refer to C. G. S. §38a-479rr.
Instructions:
To assure that a MDP license be renewed prior to continuing services in Connecticut, the
Department suggests that applications be submitted at least two months in advance. If
your Plan meets the guidelines for licensure, an invoice for the license fee of $625 will be
forwarded to you. This invoice must be paid prior to the license effective date.
The application must be filled out, completed and signed by an officer or authorized
representative of the MDP entity certifying that all information provided is true and
accurate.
Submit your application and attachments via electronic to:
Peter.Nakano@ct.gov
DO NOT SUBMIT THE LICENSE FEE WITH THIS APPLICATION.
You will be billed.
Revised 7/1/2015
MDP License Renewal
Page 1 of 15
Medical Discount Plan (MDP)
License Renewal
FOR CALENDAR YEAR _________
Name of MDP: _____________________________________________________________________
E-mail address: _____________________________________________________________________
List all names (including trade-names, brand-names or dba’s) used to market the MDP card:
__________________________________________________________________________________
__________________________________________________________________________________
MDP CT License Number: ____________________________________________________________
MDP Tax Identification Number (TIN/FEIN): _____________________________________________
MDP Business Address: ______________________________________________________________
______________________________________________________________
______________________________________________________________
MDP Mailing Address (if different): ____________________________________________________
______________________________________________________________
______________________________________________________________
MDP Phone Number: ________________________________________________________________
Has any suspension, sanction or disciplinary action been taken against the MDP in Connecticut or any
other state over the past ten years? If so, please provide us with a complete list on an annual basis,
even if the disciplinary action was previously disclosed.
No
Yes
If answered yes, explain: ____________________________________________
________________________________________________________________
________________________________________________________________
NOTE: Failure to disclose actions accurately and truthfully will be cause for denial of your
application.
Has any suspension, sanction or disciplinary action been taken against the controlling company or
organization in Connecticut or any other state over the past ten years? If so, please provide us with a
complete list on an annual basis, even if the disciplinary action was previously disclosed.
No
Yes
If answered yes, explain: ____________________________________________
________________________________________________________________
________________________________________________________________
NOTE: Failure to disclose actions accurately and truthfully will be cause for denial of your
application.
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MDP License Renewal
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How many total enrollees are served by the MDP: Nationwide: _______________________
Connecticut: _______________________
List all Provider Networks with whom MDP has contracts or agreements to provide discounted health
care services to Connecticut enrollees:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Indicate types of discount services that the MDP provides to Connecticut enrollees:
Physician Medical services
Hospital services
Laboratory services
Radiology services
Prescription Drugs
Dental Services
Other – List types of services
________________________________________________________________________
________________________________________________________________________
Does membership with the MDP’s discount card include any insurance coverages?
No
Yes
If Yes, what are the insurance benefits? And what is the name/s of the insurer/s.
________________________________________________________________________
________________________________________________________________________
Does the MDP and/or its marketing force maintain a Connecticut producer license?
No
Yes If Yes, list CT license numbers: __________________________________________
__________________________________________
PLEASE SUBMIT THE FOLLOWING AS ATTACHMENTS:
1. Certificates from the Secretary of State affirming that the MDP and its controlling
company or organization (if applicable) is in good standing in the state. In addition, for
out of state MDPs, controlling companies or organizations, a certificate that such MDP,
controlling company or organization is in good standing in its state of organization.
2. A statement generally describing the applicant, its personnel and the health care services
offered at a discount.
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MDP License Renewal
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3. A copy of the form of all contracts made or to be made between the applicant and any
providers or provider networks regarding the provision of discount health care services
to members. Clearly identify/highlight the language as required by C.G.S. 38a-479rr (h)
and 38a-479rr (i).
4. A copy of the form of any contract made or to be made between the applicant and any
person for the performance on the applicant’s behalf of any function, including, but not
limited to, marketing, administration, enrollment, and subcontracting for the provision of
health care services to members. This should include internal marketing staff as well as
external marketers.
5. A copy of the applicant’s most recent financial statements audited by an independent
certified public accountant, or, in the case of an applicant that is a subsidiary of a person
or parent corporation that prepares audited financial statements reflecting the
consolidated operations of the person or parent corporation, a copy of the person’s or
parent corporation’s most recent financial statements audited by an independent certified
public accountant , provided the person or parent company also issues a written
guarantee that the minimum capital requirements of the applicant required will be met.
6. A description of the proposed methods of marketing by the MDP and its
brokers/subcontractors.
7. Copies of all marketing materials that will be used in Connecticut and a description of
the media (TV, internet, mass mailing etc.) used for each of the materials submitted.
8. Provide a list of the names, addresses and telephone numbers of the marketers the
applicant has authorized to market a medical discount plan in Connecticut under a name
that is different from the name of the applicant in electronic format. Any change,
addition or subtraction, made to the list of unauthorized marketers shall be electronically
filed with this Department. If a change is to add a marketer to the medical discount plan
organization’s list of authorized marketers, the change shall be electronically filed by the
medical discount plan organization prior to the marketer doing business in the State of
Connecticut.
9. Please be advised that no marketer shall market, advertise or sell to a resident of this
state a medical discount plan under a name that is different than the medical discount
plan organization’s name unless: (1) The medical discount plan organization has
obtained a license from the Department (2) the marketer is listed on such medical
discount plan organization’s list of authorized marketers (3) the name, address and
telephone number of the medical discount plan organization appears on the plan
materials; (4) the marketer does not contract directly with providers or provider
networks.
10. C. G. S. §38a-479rr § (k) requires each MDP to maintain (1) a net worth of at least two
hundred fifty thousand dollars, or (2) to post a surety bond in the amount of one hundred
thousand dollars. Indicate which option the MDP will use and attach either: a Statement
of Net Worth signed by the CFO or CEO, or, a $100,000 bond.
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MDP License Renewal
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OFFICER OR AUTHORIZED REPRESENTATIVE CERTIFICATION OF ACCURACY
I, ______________________________________, ________________________________________of
(Printed Name)
(Title)
_________________________________________________________________, hereby certify that
(Medical Discount Plan)
I have reviewed the information submitted in accordance with C. G. S. §38a-479rr, and that the
information is true and accurate. I understand that at least thirty (30) days advance written notice of
any change in the medical discount organization’s name, address, principal business address or mailing
address must be provided to the Insurance Commissioner. I hereby certify that I am acting on my own
behalf, and that the foregoing statements are true and correct to the best of my knowledge and belief.
_________________________________________
______________________________
(Signature of Officer or Authorized Representative)
(Date)
State of _______________________________
County of ______________________________
The foregoing instrument was acknowledged before me this _________day of __________, 20___
By _________________________________, and:
who is personally known to me, or
who produced the following identification:
[SEAL]
____________________________
Notary Public
____________________________
Printed Notary Name
____________________________
My Commission Expires
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MDP License Renewal
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