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

Medical Discount Plan (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 August 25, 2016;
  • The latest edition currently provided by the Connecticut Insurance Department;
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Medical Discount Plan (MDP)
License Application
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 issued prior to offering services in Connecticut, the
Department suggests that applications be submitted at least two months in advance. If
your Plan meets the requirements 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 8/25/2016
MDP License Application
Page 1 of 17
Medical Discount Plan (MDP)
License Application
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 issued prior to offering services in Connecticut, the
Department suggests that applications be submitted at least two months in advance. If
your Plan meets the requirements 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 8/25/2016
MDP License Application
Page 1 of 17
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 Tax Identification Number (TIN/FEIN): _____________________________________________
MDP Business Address: ______________________________________________________________
______________________________________________________________
______________________________________________________________
MDP Mailing Address (if different): ____________________________________________________
______________________________________________________________
______________________________________________________________
MDP Phone Number: ________________________________________________________________
Contact Information (used by the Department for all future correspondence):
Name: ____________________________________ Title: ___________________________________
Mailing Address: ____________________________________________________________________
____________________________________________________________________
Phone Number: _____________________________ FAX Number: ____________________________
Name and description of controlling company or organization: ________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Controlling company’s or organization’s contact name: ______________________________________
__________________________________________________________________________________
Business Address: _____________________________________________________________
_____________________________________________________________
Mailing Address (if different): ___________________________________________________
______________________________________________________________
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MDP License Application
Page 2 of 17
Name of related or predecessor controlling company or organization: __________________________
__________________________________________________________________________________
Address: _____________________________________________________________________
_____________________________________________________________________
Explain current relationship with related or predecessor controlling company: ____________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
List all states where you hold or have applied for a Medical Discount Plan license or authorization.
Please provide the license or certificate 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.
Revised 8/25/2016
MDP License Application
Page 3 of 17
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: __________________________________________
__________________________________________
Revised 8/25/2016
MDP License Application
Page 4 of 17
PLEASE SUBMIT THE FOLLOWING AS ATTACHMENTS:
1. A copy of the applicant’s articles of incorporation, or articles of organization, including
all statements.
2. A copy of the applicant’s bylaws.
3. 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.
4. A list of the names, addresses, official positions of the individuals who are responsible
for conducting the applicant MDP’s affairs, including, but not limited to, all members of
the board of directors, board of trustees, executive committee, or other governing
committee, the officers, contracted management company personnel, and any person or
entity owning or having the right to acquire ten per cent or more of the voting securities
of the applicant. This list shall fully disclose the extent and nature of any contracts or
arrangements between the applicant and any individual who is responsible for
conducting the applicant’s affairs, including any possible conflicts of interest.
5. Biographical affidavits on the form provided for each person listed above.
6. A statement generally describing the applicant, its personnel and the health care services
offered at a discount.
7. 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).
8. 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. (Note special rules apply for marketers authorized by the MDP to
brand under a different name).
9. 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.
10. A description of the proposed methods of marketing by the MDP and its
brokers/subcontractors.
11. A detailed description of the subscriber complaint procedures to be established and
maintained.
Revised 8/25/2016
MDP License Application
Page 5 of 17