17:48H-12 Form, contents of application.

12. Application for a license to operate an organized delivery system shall be made to the Commissioner of Banking and Insurance on a form prescribed by the commissioner, shall be certified by an officer or authorized representative of the applicant, and shall include the following:

a. A copy of the applicant's basic organizational documents. For purposes of this subsection, "basic organizational documents" means the articles of incorporation, articles of association, partnership agreement, management agreement, trust agreement, or other applicable documents as appropriate to the applicant's form of business entity and all amendments to those documents;

b. A copy of the executed bylaws, rules, and regulations, or similar documents, regulating the conduct of the applicant's internal affairs;

c. A list, in a form approved by the Commissioner of Banking and Insurance, 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, the members of the board of directors, executive committee or other governing board or committee, the principal officers, and any person or entity owning or having the right to acquire 10% or more of the voting securities of the applicant; in the case of a partnership or association, the names of the partners or members; each person who has loaned funds to the applicant for the operation of its business; and a statement of any criminal convictions or civil, enforcement or regulatory action, including actions relating to professional licenses, taken against any person who is a member of the board, the executive committee or other governing board or committee, or the principal officers, or the persons who are responsible for the conduct of the affairs of the applicant; d. A statement generally describing the applicant, its facilities, personnel, and the health care services to be offered by the organized delivery system;

e. A copy of the standard form of any provider agreement made or to be made between the applicant and any providers relative to the provision of health care services;

f. A copy of the form of any contract made or to be made between the applicant and any carrier for the provision of or arrangement to provide health care services, which contract shall contain provisions establishing the respective duties of the carrier and the applicant with respect to compliance with P.L.1997, c.192 (C.26:2S-1 et seq.);

g. 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 company, audited by an independent certified public accountant, shall be submitted. A consolidated financial statement of the applicant and its parent company shall satisfy this requirement unless the Commissioner of Banking and Insurance determines that additional or more recent financial information is required for the proper administration of this act;

h. 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;

i. With respect to each contract made or to be made between the applicant and any other person who will provide comprehensive or limited health care services:

(1) A list of the persons who are to provide the health care services, and the geographical area in which they are located and in which the services are to be performed;

(2) A list of any affiliate of the applicant which provides services to the applicant in this State and a description of any material transaction between the affiliate and the applicant;

(3) A description of the health care services or benefits to be offered or proposed to be offered;

(4) A description of the means which will be utilized to assure the availability and accessibility of the health care services to enrollees or contract holders;

(5) A plan, in the event of the insolvency of the organized delivery system, for continuation of the health care services to be provided for under the contract; and

(6) A description of the means by which the organized delivery system shall be compensated for each contract entered into with a carrier;

j. A power of attorney, duly executed by the applicant, if not domiciled in this State, appointing the Commissioner of Banking and Insurance and the commissioner's successors in office as the true and lawful attorney of the applicant in and for this State upon whom all lawful process in any legal action or proceeding against the organized delivery system in a cause of action arising in this State may be served;

k. A list of all administrative, civil, or criminal actions and proceedings to which the applicant, or any of its affiliates, or persons who are responsible for the conduct of the affairs of the applicant or affiliate, have been subject and the resolution of those actions and proceedings. If a license, certificate or other authority to operate has been refused, suspended, or revoked by any jurisdiction, the applicant shall provide a copy of any orders, proceedings and determinations relating thereto; and

l. Other information as may be required by the Commissioner of Banking and Insurance.

L.1999, c.409, s.12; amended 2012, c.17, s.48.