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STATE OF SOUTH CAROLINA
DEPARTMENT OF CONSUMER AFFAIRS
DISCOUNT MEDICAL PLAN ORGANIZATIONS
S.C. Code Ann. 37-17-10 et seq.
HYPERLINK "http://www.scconsumer.gov" www.scconsumer.gov
(803) 734-4200
INITIAL APPLICATION
FOR
DISCOUNT MEDICAL PLAN ORGANIZATION
REGISTRATION
(Complete all parts of this Application)
Please submit an original and one (1) copy of the Application in ring binders.
All information should be reduced to 8 x 11 size and arranged in the order set forth in the Application form .
N a m e o f D M P O : F O R M T E X T
R e g i s t r a t i o n C e r t i f i c a t e s f o r D i s c o u n t M e d i c a l P l a n O r g a n i z a t i o n s ( D M P O s ) i n S o u t h C a r o l i n a a r e i s s u e d a n n u a l l y . T h e r e g i s t r a t i o n p e r i o d r u n s f r o m F e b r u a r y 1 u n t i l J a n u a r y 3 1 o f t h e f o l l o w i n g y e a r , a n d t h e a n n u a l renewal period begins January 1 and ends on January 31 each year. A discount medical plan organization that files its renewal on a timely basis may continue operating unless the registration is denied or revoked by the department.
The annual application fee must accompany each application and is NOT refundable. The fee for a DMPO with 0-50 representatives is Five Hundred Dollars ($500.00). The fee for a DMPO with 51-100 representatives is Seven Hundred Fifty Dollars ($750.00). The fee for a DMPO with over 100 representatives is One Thousand Dollars ($1000.00). Applications will not be processed without the required applications fees.
An incomplete application will only be held, pending completion, for 90 days following first receipt. If the application has not been completed within 90 days of the Departments receipt of the first application, it will be rejected. The applicant, if it chooses, may submit a new application and fee. The Department will give notice to the applicant as to why the application is incomplete and request additional information. The applicant must submit the information (to complete the application) within 90 days of the Departments first receipt. If the applicant fails to submit the information requested within the allotted time, the application is deemed incomplete and will be rejected. The applicant, if it so chooses, may withdraw the application, within the initial 90 days, if the application is incomplete and it is unable to provide the requested information. The withdrawn application would not be labeled as rejected or denied. Once the withdrawn application is completed, the applicant may resubmit the application and applicable fees as a new application.
Please make all checks payable to the South Carolina Department of Consumer Affairs.
Pursuant to the provisions of South Carolina Code 37-17-10 et. seq. (2006) as amended, the undersigned hereby makes the following statements for the purpose of REGISTERING to conduct business as a DISCOUNT MEDICAL PLAN O r g a n i z a t i o n ( D M P O ) i n t h e S t a t e o f S o u t h C a r o l i n a :
N a m e o f D M P O : F O R M T E X T D a t e o f O r g a n i z a t i o n : F O R M T E X T F e d e r a l I D # : F O R M T E X T B u s i n e s s A d d r e s s : F O R M T E X T C i t y : F O R M T E X T S t a t e : F O R M T E X T Z i p : F O R M T E X T T e l e p h o n e : F O R M T E X T F a x : F O R M T E X T W e b s i t e : F O R M T E X T
N a m e o f P r i m a r y C o n t a c t P e r s o n : F O R M T E X T B u s i n e s s A d d r e s s : F O R M T E X T C i t y : F O R M T E X T S t a t e : F O R M T E X T Z i p : F O R M T E X T T e l e p h o n e N o . : F O R M T E X T F a x N o . : F O R M T E X T E - M a i l A d d r e s s : F O R M T E X T
N a m e o f S e c o n d a r y C o n t a c t P e r s o n : F O R M T E X T B u s i n e s s A d d r e s s : F O R M T E X T C i t y : F O R M T E X T S t a t e : F O R M T E X T Z i p : F O R M T E X T T e l e p h o n e N o . : F O R M T E X T F a x N o . : F O R M T E X T E - M a i l A d d r e s s : F O R M T E X T
P l e a s e p r o v i d e t h i r t y ( 3 0 ) d a y s a d v a n c e w r i t t e n n o t i c e o f a n y c h a n g e i n a n y o f t h e a b o v e i n f o r m a t i o n to the Department.
Organizational Structure
FORMCHECKBOX Corporation FORMCHECKBOX Limited Liability Company FORMCHECKBOX General Partnership FORMCHECKBOX Limited Partnership FORMCHECKBOX Sole Proprietorship FORMCHECKBOX Other (specify) FORMTEXT
1 . A t t a c h a s t a t e m e n t g e n e r a l l y d e s c r i b i n g t h e a p p l i c a n t a n d i t s p e r s o n n e l .
2 . I f a p p l i c a n t i s a c o r p o r a t i o n , p r o v i d e a c o p y o f c o m p a n y s f i l e d A r t i c l e s o f I n c o r p o r a t i o n , i n c l u d i n g a l l a m e n d m e n t s . I f o t h e r t h a n c o r p o r a t i o n , p r o v i d e o t h e r a p p r o priate documents to show when and by whom the business was organized. The required filings must be recently certified by the official public records custodian in the applicants state of domicile. The certification letter must be an original.
3. Provide a copy of the applicants By-Laws, Constitution, and/or Rules and Regulations. The By-Laws must be sealed, signed and recently dated by the Secretary of the company.
4. Provide an original copy of a letter of good standing from the applicants state of domicile.
5. Provide an organizational chart of the applicant.
6. Provide an original copy of the Certificate of Authorization issued by the South Carolina Secretary of State demonstrating the applicants authority to conduct business in South Carolina and that all state taxes and fees have been paid. If the applicant is not already appropriately registered to do business in South Carolina, the necessary forms and other information can be found on the South Carolina Secretary of States Web site at HYPERLINK "http://www.scsos.com" www.scsos.com. Any business entity that fails to maintain its qualification with the South Carolina Secretary of State forfeits its right to do business in this state and must immediately surrender any registration certificates issued by this Department.
7. Provide the contact information requested below for the applicants current agent for service of process as registered with the South Carolina Secretary of States office.
Name of Current South Carolina Agent for Ser v i c e
o f P r o c e s s : F O R M T E X T B u s i n e s s A d d r e s s : F O R M T E X T C i t y : F O R M T E X T S t a t e : F O R M T E X T Z i p : F O R M T E X T T e l e p h o n e N o . : F O R M T E X T F a x N o . : F O R M T E X T E - M a i l A d d r e s s : F O R M T E X T
8 . A t t a c h a p h o t o c o p y o f y o u r l i c e n s e , r e g i s t r a t i o n c e r t i f i c a t e , o r c e r t i f i c a t i o n l e t t e r f o r e a c h s t a t e i n w h i c h t h e A p p l i c a n t i s c u r r e n t l y a u t h o r i z e d t o p r o v i d e D M P O s e r v i c e s , o r a n y s u b s e t , s u c h a s p r e s c r i p t i o n d r u g d i s c o u n t c a r d s . C e r t i f i c a t i o n s should be attached in alphabetical order by state.
MANAGEMENT
In the spaces provided below, provide the requested information for the individuals who are responsible for conducting the applicant DMPOs 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 percent or more of the voting securities of the applicant. Fill out each section completely. All persons who qualify as a member of applicants management must be listed below.
EACH PROPOSED MEMBER OF MANAGEMENT must submit a MANAGEMENT BIOGRAPHICAL AFFIDAVIT (Form DMPO-03).
Corporations: If the applicant is owned by another corporate entity, list any officers of the parent firm and the ultimate owners (natural persons) in the tables below that qualify management, and attach an organizational chart.
Management Based on Ownership:
List the names of all persons or entities who directly or indirectly own, control, hold with the power to vote, or hold proxies representing ten percent (10%) or more of the voting securities of the Applicant. If necessary, attach additional sheet(s) providing the same information requested below.
Full Name
And AddressDate of Birth
(mm-dd-yyyy)% OwnershipSSN #/FEIN * FORMTEXT F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T
* C o m p l i a n c e N o t e : T h e F a m i l y I n d e p e n d e n c e A c t o f 1 9 9 5 r e q u i r e s t h e S o u t h C a r o l i n a D e p a r t m e n t o f S o c i a l S e r v i c e s C h i l d E n f o r c e m e nt Division (Division) to operate a license revocation program for the purpose of enforcing and establishing child support. In accordance with this Act, South Carolina law ( 20-7-944) requires that all licensing entities submit to the Division licensee data for all new and renewal licenses issued. Therefore, identifying information (i.e., name, social security number and date of birth, etc.) for all members of management licensed with this application will be forwarded to the Division upon the issuance of each license. Personal information will not be used for any other purpose and is not subject to disclosure under the South Carolina Freedom of Information Act. South Carolina Code 30-4-10 et seq.
Management Based on Position:
List the names and titles/positions of all officers, directors and any person who has direct or indirect control of the organization, including but not limited to contracted management company personnel. If necessary, attach additional sheet(s) providing the same information re q u e s t e d b e l o w .
F u l l N a m e
A n d A d d r e s s T i t l e / P o s i t i o n D a t e o f B i r t h
( m m - d d - y y y y ) S S N # F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T A p p l i c a n t B u s i n e s s H i s t o r y
I f a n y q u e s t i o n i s a n s w e r e d Y e s , a t t a c h s e p a r a t e p a g e ( s ) d e t a i l i n g t h e c i r c u m s t a n c e s ( i n c l u d i n g any applicable details such as state, license number, dates, etc.)
1. Have any of the Applicants proposed management ever been convicted or found guilty of any misdemeanors or felonies (with the exception of minor traffic violations) in any jurisdiction or territory in the United States?
FORMCHECKBOX Yes FORMCHECKBOX No
2. Has either the Applicant or any of its proposed management ever been refused a license, registration, or certification as a discount medical plan, or renewal thereof, in any jurisdiction or territory in the United States?
FORMCHECKBOX Yes FORMCHECKBOX No
3. Has either the Applicant or any of its proposed management ever had a license revoked, suspended, or otherwise acted against (including probation, fine, or reprimand) in a disciplinary action in any jurisdiction or territory in the United States?
FORMCHECKBOX Yes FORMCHECKBOX No
4. Has either the Applicant or any of its proposed management ever been involved in or owned an interest in an organization that has been adjudicated bankrupt, filed proceedings under the Bankruptcy Act, or has otherwise closed due to insolvency?
FORMCHECKBOX Yes FORMCHECKBOX No
5. Are any of the licenses, registrations, or certifications of the Applicant or any of its management currently under investigation or currently pending disciplinary action in any jurisdiction or territory in the United States?
FORMCHECKBOX Yes FORMCHECKBOX No
6. Has the Applicant or any of its proposed management ever failed to satisfy any tax liabilities?
FORMCHECKBOX Yes FORMCHECKBOX No
7. Has the Applicant or any of its proposed management ever had a lien or levy placed against it/them?
FORMCHECKBOX Yes FORMCHECKBOX No
8. Has the Applicant or any of its proposed management ever been the subject of an indictment or a cease and desist order in any jurisdiction or territory in the United States?
FORMCHECKBOX Yes FORMCHECKBOX No
9. Has the Applicant or any of its proposed management ever been the subject of a governmental investigation?
FORMCHECKBOX Yes FORMCHECKBOX No
10. Is there any litigation or legal proceeding currently pending or threatened against the Applicant or any of its proposed management in any jurisdiction or territory in the United States?
FORMCHECKBOX Yes FORMCHECKBOX No
South Carolina Operations
Provide a list of all offices, including branch offices, located in South Carolina:
FORMCHECKBOX C h e c k i f t h e A p p l i c a n t h a s n o S o u t h C a r o l i n a o f f i c e s .
A d d r e s s C o n t a c t P e r s o n T e l e p h o n e # E - m a i l a d d r e s s F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T
D I S C O U N T M E D I C A L P L A N O P E R A T I O N S A N D M A R K E T I N G
1 . A t t a c h a l i s t a l l n a m e s ( i n c l u d i n g t r a d e n a m e s , b r a n d n a m e s , p r i v a t e l a b e l n a m e s o r d b a s ) u s e d t o m a r k e t t h e D M P O s d i s c o u n t p r o g r a m .
2 . A t t a c h a l i s t a n d f u l l y d e s c r i b e t h e h e a l t h c a r e s e r v i c e s o ffered at a discount to customers who purchase the DMPOs discount plan in South Carolina.
3. Does the DMPO include any insurance coverage with the discount program?
FORMCHECKBOX Yes FORMCHECKBOX No
4. If Yes, please attach an explanation of the insurance benefits, including the name(s) of the insurer(s). Please submit copies of all policies.
5. Attach copies of the form of any contract made or to be made between the applicant and any person for the performance on the applicants behalf of any function, including, but not limited to, marketing, administration, enrollment, and subcontracting for the provision of health care services to customers. This should include internal marketing staff as well as external marketers, including call centers.
6. Do your direct agreements with external marketing companies permit those companies to further subcontract marketing functions to other companies (sub-marketers or private label brands) with or without your approval?
FORMCHECKBOX Yes FORMCHECKBOX No
7. If yes, please attach an explanation of the DMPOs policies and procedures.
8. Provide an organizational chart showing all authorized marketer, sub-marketer, or private label companies and their relationship with the DMPO.
9. Provide copies of all training materials for marketers and representatives (internal and external).
10. Attach a statement describing the proposed methods of marketing by the DMPO and its marketers/sub-marketers/private label brands.
11. Provide copies of all marketing materials that will be used in South Carolina and a description of the media (TV, Internet, mass mailing etc.) used for each of the materials submitted. This should include the marketing materials of the DMPO and any authorized marketer or sub-marketer of your plan, including private label brands. All advertisements must contain the name and address of the company offering the service and must conform to the name on file with the Department. In addition, these materials must clearly disclose the amount of all discounts offered. It is important FOR you to verify that all marketing materials meet the requirements of S.C. Code Section 37-17-10 et. seq. before submitting THEM with your application.
12. Does the applicant require its external marketing companies, including private label brands, to get prior approval from the DMPO of their advertising materials?
FORMCHECKBOX Yes FORMCHECKBOX No
13. If yes, attach a description of this procedure.
14.South Carolina law requires the prominent display of the Internet Web site address which contains an up-to-date list of the names and addresses of providers with which a DMPO has contracted directly or through a provider network on all advertising, marketing material, brochures and discount medical plan cards. What is that Web site address? FORMTEXT
1 5 . I f t h e W e b s i t e i s p a s s w o r d p r o t e c t e d o r f o r c u s t o m e r s - o n l y , p l e a s e p r o v i d e c o d e s t o t h e D e p a r t m e n t t o e n a b l e a f u l l r e v i e w o f t h e s i t e .
1 6 . P r o v i d e c o p i e s o f a l l a p p l i c a t i o n f o r m s u s e d b y t h e D M P O a n d i t s m a r k e t e r s / s u b - m a r k e t e r s t o s i g n u p c ustomers. It is important FOR you to verify that all FORMs meet the requirements of S.C. Code Section 37-17-10 et. seq. before submitting THEM with your application.
17. Provide copies of all the discount cards issued by the DMPO and its marketers/sub-marketers, including private label brands.
18. Attach a copy of the notice, included in membership agreements and marketing materials, that each customer receives stating the terms under which the discount medical plan may be returned or cancelled.
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20. Attach copies of the form of all contracts made or to be made between the applicant and any providers or provider networks regarding the provision of medical services to South Carolina customers.
21. Attach a detailed description of the customer complaint procedures to be established and maintained by the DMPO and its marketers/sub-marketers, including private label brands.
MARKETERS
1. Provide a list of all of the Applicants authorized marketers, as defined in S.C. Code Ann. 37-17-20 (5), including any sub-marketers and private label brands. This information should be provided using either the Marketer Company List (Form DMPO-04) or in a report that you generate provided, however, that all of the information requested in the table below is included in the separate report.
2.How many representatives, as defined in S.C. Code An n . 3 7 - 1 7 - 2 0 ( 6 ) , i n c l u d i n g t h o s e e m p l o y e d b y a l l s u b - m a r k e t e r s a n d p r i v a t e l a b e l b r a n d s , a r e a u t h o r i z e d t o m a r k e t t h e A p p l i c a n t s d i s c o u n t m e d i c a l p l a n s ? F O R M T E X T
3 . P r o v i d e a l i s t o f a l l o f t h e A p p l i c a n t s a u t h o r i z e d r e p r e s e n t a t i v e s , i n c l uding all representatives of authorized marketing companies, including sub-marketers and private label brands. This information should be provided using either the Authorized Representative List (Form DMPO-05) or in a report that you generate provided, however, that all of the information requested on that form is included in the separate report.
Financial
1. Applicants must attach copies of the companys Audited Financial Statements for the most recent accounting period preceding this application. The most recent statement must be for annual period ending no earlier than 180 days before the date of this application, certified by two principal officers of the applicant (if the applicant is not a corporation, by others the administrator requires),and shall be attested to by an independent Certified Public Accountant. If the most recent audited financial statement currently available is dated more than 180 days before the date of this application, the applicant must certify to the Department that there have been no material adverse changes in the financial position of the company since the date of the last financial statements, and shall provide a copy of the next financial statement as soon as it becomes available.
If the applicant is a subsidiary of a parent entity that is publicly traded and that prepares audited financial statements reflecting the consolidated operations of the parent entity, the subsidiary may submit, in lieu of the certified financial statement of the applicant, the audited financial statement of the parent.
The financial statements must be prepared in accordance with generally accepted accounting principles and must include a statement of income and retained earnings, balance sheet, statement of changes in financial position (cash flow), and applicable footnotes. The financial statements also must reflect positive working capital and positive tangible net worth.
Information supplied regarding net worth is proprietary and confidential and is exempt from disclosure to third parties.
2. Applicants must provide a bond in the amount of $50,000 as required by S.C. Code Ann. 37-17-40(A)(3) (2006). A sample bond form is available as (Form DMPO-06).
Affidavit of Applicant
I swear or affirm and certify that I have completed and/or reviewed all information on this form and submitted with this Application, and to the best of my knowledge and belief, all information contained herein is true, correct and complete; and that there are no material omissions of fact which would have a bearing upon the South Carolina Department of Consumer Affairs decision to grant the requested registration certificate. I further certify that I understand that giving false information constitutes cause for denial or revocation of the application and subjects me to criminal prosecution for perjury. I acknowledge that I have a duty and agree to update and correct this information as it changes.
Signature FORMTEXT D a t e F O R M T E X T T y p e o r P r i n t y o u r N a m e a n d T i t l e
S W O R N T O A N D S U B S C R I B E D b e f o r e m e
t h i s _ _ _ _ _ _ _ _ d a y o f _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ , 2 0 _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ( S E A L )
N o t ary Public For __________________________________
My Commission Expires:
_____________________________The completed Application should be submitted to:
South Carolina Department of Consumer Affairs
Attn: DMPO Regulation
P.O. Box 5757
Columbia, SC 29250-5757
Do not fax this form. An original, signed and notarized form is required.
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DMPO Initial Application
SCDCA Form DMPO-01
Revised 11/07
Page PAGE 2 of NUMPAGES 10
Street Address
3600 Forest Drive
Columbia, SC 29204-4006
Mailing Address
P.O. Box 5757
Columbia, SC 29250-5757
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