programs - Applications - Material modification of operation. (a) No organization shall establish or operate a Health Maintenance Organization in this State without obtaining a certificate of authority under this Act. No person other than an organization may lawfully establish or operate a Health Maintenance Organization in this State. This Act shall not apply to the establishment and operation of a Health Maintenance Organization exclusively providing or arranging for health care services to employees of a corporate affiliate of such Health Maintenance Organization. This exclusion shall be available only to those Health Maintenance Organizations which require employee contributions which equal less than 50% of the total cost of the health care plan, with the remainder of the cost being paid by the corporate affiliate which is the employer of the participants in the plan. This Act shall not apply to the establishment and operation of a Health Maintenance Organization exclusively providing or arranging health care services under contract with the State to persons committed to the custody of the Illinois Department of Corrections. This Act does not apply to the establishment and operation of managed care community networks that are certified as risk-bearing entities under Section 5-11 of the Illinois Public Aid Code and that contract with the Department of Healthcare and Family Services (formerly Illinois Department of Public Aid) pursuant to that Section. (b) Any organization may apply to the Director for and obtain a certificate of authority to establish and operate a Health Maintenance Organization in compliance with this Act. A foreign corporation may qualify under this Act, subject to its registration to do business in this State as a foreign corporation. (c) Each application for a certificate of authority shall be filed in triplicate and verified by an officer or authorized representative of the applicant, shall be in a form prescribed by the Director, and shall set forth, without limiting what may be required by the Director, the following: (1) A copy of the organizational document; (2) A copy of the bylaws, rules and regulations, or similar document regulating the conduct of the internal affairs of the applicant, which shall include a mechanism to afford the enrollees an opportunity to participate in an advisory capacity in matters of policy and operations; (3) 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; including, but not limited to, all members of the board of directors, executive committee, the principal officers, and any person or entity owning or having the right to acquire 10% or more of the voting securities or subordinated debt of the applicant; (4) A statement generally describing the applicant, geographic area to be served, its facilities, personnel and the health care services to be offered; (5) A copy of the form of any contract made or to be made between the applicant and any providers regarding the provision of health care services to enrollees; (6) A copy of the form of any contract made or to be made between the applicant and any person listed in paragraph (3) of this subsection; (7) A copy of the form of any contract made or to be made between the applicant and any person, corporation, partnership or other entity for the performance on the applicant's behalf of any functions including, but not limited to, marketing, administration, enrollment, investment management and subcontracting for the provision of health services to enrollees; (8) A copy of the form of any group contract which is to be issued to employers, unions, trustees, or other organizations and a copy of any form of evidence of coverage to be issued to any enrollee or subscriber and any advertising material; (9) Descriptions of the applicant's procedures for resolving enrollee grievances which must include procedures providing for enrollees participation in the resolution of grievances; (10) A copy of the applicant's most recent financial statements audited by an independent certified public accountant. If the financial affairs of the applicant's parent company are audited by an independent certified public accountant but those of the applicant are not, then a copy of the most recent audited financial statement of the applicant's parent, attached to which shall be consolidating financial statements of the parent including separate unaudited financial statements of the applicant, unless the Director determines that additional or more recent financial information is required for the proper administration of this Act; (11) A copy of the applicant's financial plan, including a three-year projection of anticipated operating results, a statement of the sources of working capital, and any other sources of funding and provisions for contingencies; (12) A description of rate methodology; (13) A description of the proposed method of marketing; (14) A copy of every filing made with the Illinois Secretary of State which relates to the applicant's registered agent or registered office; (15) A description of the complaint procedures to be established and maintained as required under Section 4-6 of this Act; (16) A description, in accordance with regulations promulgated by the Illinois Department of Public Health, of the quality assessment and utilization review procedures to be utilized by the applicant; (17) The fee for filing an application for issuance of a certificate of authority provided in Section 408 of the Illinois Insurance Code, as now or hereafter amended; and (18) Such other information as the Director may reasonably require to make the determinations required by this Act. similar document regulating the conduct of the internal affairs of the applicant, which shall include a mechanism to afford the enrollees an opportunity to participate in an advisory capacity in matters of policy and operations; positions of the persons who are to be responsible for the conduct of the affairs of the applicant; including, but not limited to, all members of the board of directors, executive committee, the principal officers, and any person or entity owning or having the right to acquire 10% or more of the voting securities or subordinated debt of the applicant; geographic area to be served, its facilities, personnel and the health care services to be offered; made between the applicant and any providers regarding the provision of health care services to enrollees; made between the applicant and any person listed in paragraph (3) of this subsection; made between the applicant and any person, corporation, partnership or other entity for the performance on the applicant's behalf of any functions including, but not limited to, marketing, administration, enrollment, investment management and subcontracting for the provision of health services to enrollees; to be issued to employers, unions, trustees, or other organizations and a copy of any form of evidence of coverage to be issued to any enrollee or subscriber and any advertising material; resolving enrollee grievances which must include procedures providing for enrollees participation in the resolution of grievances; statements audited by an independent certified public accountant. If the financial affairs of the applicant's parent company are audited by an independent certified public accountant but those of the applicant are not, then a copy of the most recent audited financial statement of the applicant's parent, attached to which shall be consolidating financial statements of the parent including separate unaudited financial statements of the applicant, unless the Director determines that additional or more recent financial information is required for the proper administration of this Act; including a three-year projection of anticipated operating results, a statement of the sources of working capital, and any other sources of funding and provisions for contingencies; marketing; Secretary of State which relates to the applicant's registered agent or registered office; established and maintained as required under Section 4-6 of this Act; promulgated by the Illinois Department of Public Health, of the quality assessment and utilization review procedures to be utilized by the applicant; of a certificate of authority provided in Section 408 of the Illinois Insurance Code, as now or hereafter amended; and reasonably require to make the determinations required by this Act.
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