1351
. Each application for licensure as a health care service plan
or specialized health care service plan under this chapter shall be
verified by an authorized representative of the applicant, and shall
be in a form prescribed by the department. This application shall be
accompanied by the fee prescribed by subdivision (a) of Section 1356
and shall set forth or be accompanied by each and all of the
following:
(a) The basic organizational documents of the applicant; such as,
the articles of incorporation, articles of association, partnership
agreement, trust agreement, or other applicable documents and all
amendments thereto.
(b) A copy of the bylaws, rules and regulations, or similar
documents regulating the conduct of the internal affairs of the
applicant.
(c) A list of the names, addresses, and official positions of the
persons who are to be responsible for the conduct of the affairs of
the applicant, which shall include among others, all members of the
board of directors, board of trustees, executive committee, or other
governing board or committee, the principal officers, each
shareholder with over 5-percent interest in the case of a
corporation, and all partners or members in the case of a partnership
or association, and each person who has loaned funds to the
applicant for the operation of its business.
(d) A copy of any contract made, or to be made, between the
applicant and any provider of health care services, or persons listed
in subdivision (c), or any other person or organization agreeing to
perform an administrative function or service for the plan. The
director by rule may identify contracts excluded from this
requirement and make provision for the submission of form contracts.
The payment rendered or to be rendered to such provider of health
care services shall be deemed confidential information that shall not
be divulged by the director, except that such payment may be
disclosed and become a public record in any legislative,
administrative, or judicial proceeding or inquiry. The plan shall
also submit the name and address of each physician employed by or
contracting with the plan, together with his or her license number.
(e) A statement describing the plan, its method of providing for
health care services and its physical facilities. If applicable, this
statement shall include the health care delivery capabilities of the
plan including the number of full-time and part-time primary
physicians, the number of full-time and part-time and specialties of
all nonprimary physicians; the numbers and types of licensed or
state-certified health care support staff, the number of hospital
beds contracted for, and the arrangements and the methods by which
health care services will be provided. For purposes of this
subdivision, primary physicians include general and family
practitioners, internists, pediatricians, obstetricians, and
gynecologists.
(f) A copy of the forms of evidence of coverage and of the
disclosure forms or material which are to be issued to subscribers or
enrollees of the plan.
(g) A copy of the form of the individual contract which is to be
issued to individual subscribers and the form of group contract which
is to be issued to any employers, unions, trustees, or other
organizations.
(h) Financial statements accompanied by a report, certificate, or
opinion of an independent certified public accountant. However,
financial statements from public entities or political subdivisions
of the state need not include a report, certificate, or opinion by an
independent certified public accountant if the financial statement
complies with such requirements as may be established by regulation
of the director.
(i) A description of the proposed method of marketing the plan and
a copy of any contract made with any person to solicit on behalf of
the plan or a copy of the form of agreement used and a list of the
contracting parties.
(j) A power of attorney duly executed by any applicant, not
domiciled in this state, appointing the director the true and lawful
attorney in fact of such applicant in this state for the purposes of
service of all lawful process in any legal action or proceeding
against the plan on a cause of action arising in this state.
(k) A statement describing the service area or areas to be served,
including the service location for each provider rendering
professional services on behalf of the plan and the location of any
other plan facilities where required by the director.
(l) A description of enrollee-subscriber grievance procedures to
be utilized as required by this chapter, and a copy of the form
specified by subdivision (c) of Section 1368.
(m) A description of the procedures and programs for internal
review of the quality of health care pursuant to the requirements set
forth in this chapter.
(n) A description of the mechanism by which enrollees and
subscribers will be afforded an opportunity to express their views on
matters relating to the policy and operation of the plan.
(o) Evidence of adequate insurance coverage or self-insurance to
respond to claims for damages arising out of the furnishing of health
care services.
(p) Evidence of adequate insurance coverage or self-insurance to
protect against losses of facilities where required by the director.
(q) If required by the director by rule pursuant to Section 1376,
a fidelity bond or a surety bond in the amount prescribed.
(r) Evidence of adequate workmen's compensation insurance coverage
to protect against claims arising out of work-related injuries that
might be brought by the employees and staff of a plan against the
plan.
(s) All relevant information known to the applicant concerning
whether the plan, its management company, or any other affiliate of
the plan, or any controlling person, officer, director, or other
person occupying a principal management or supervisory position in
the plan, management company, or other affiliate, has any of the
following:
(1) Any history of noncompliance with applicable state or federal
laws, regulations, or requirements related to providing, or arranging
to provide for, health care services or benefits in this state or
any other state.
(2) Any history of noncompliance with applicable state or federal
laws, regulations, or requirements related to providing, or arranging
to provide for, health care services or benefits authorized for
reimbursement under the federal Medicare or Medicaid Program.
(3) Any history of noncompliance with applicable state or federal
laws, regulations, or requirements related to providing, or arranging
for the provision of, health care services as a licensed health
professional or an individual or entity contracting with a health
care service plan or insurer in this state or any other state.
(t) Such other information as the director may reasonably require.