APPLICATION for: Accountable Care Organization Errors and Omissions and Directors and Officers Liability Insurance Claims Made Basis. Underwritten by Underwriters at Lloyd s, London Notice: This is an Application for claims-made and reported coverage, meaning coverage applies only to claims first made against an Insured during the Policy Period and reported in accordance with the terms of the Policy. Further, the Policy for which you are applying provides that the Limit of Liability available to pay damages or settlements shall be reduced and may be exhausted by amounts incurred as defense costs. The signing and submission of this Application does not guarantee coverage. General Instructions for completing this Application: 1. The Application must be signed by an executive officer of the Named Insured. 2. This Application and all exhibits shall be used for purposes of this coverage only. 3. The terms as used herein shall have the meanings as defined in the Policy. Required Attachments: 1. Business Plan Attached? Yes No N/A 2. Financial Projections minimum of three years Attached? Yes No N/A 3. Governing Body information including name and position Attached? Yes No N/A 4. Year-to-date Profit/Loss and Balance Sheet Attached? Yes No N/A 5. Prior year audit or internal Profit/Loss and Balance Sheet Attached? Yes No N/A SECTION I. GENERAL INFORMATION 1. Legal name of proposed Accountable Care Organization (ACO)/Named Insured ( Applicant ): DBA (if applicable): Physical Address: Website: (Number) (Street) (City) (State) (Zip Code) Date of ACO Formation Date of Incorporation: 2. Primary Contact for Insurance: Name/Title: Email: 3. Structure: Corporation LLC Partnership Publicly Traded Gov t Entity/Sub-division Other: 4. Tax Status: For Profit Not for Profit Other: 5. Does the Applicant contemplate transacting any mergers or acquisitions in the next 12 months? Yes No 6. Within the last or next 18 months, does/has the Applicant anticipate(d) any: a) private debt equity offering of securities? Yes No b) public offering of securities? (If Yes then terms cannot be offered) Yes No SECTION Il. GOVERNANCE AND LEADERSHIP 1. Does the Applicant have an identifiable governing body with authority to execute the functions of the ACO? Yes No 2. Does the Applicant s governing body have a conflict of interest policy that applies to members of the governing body? Yes No A1855ACO-0313 1 of 7
3. Is the Applicant s clinical management and oversight managed by a senior level Board Certified medical doctor who is a physician and one of the ACO providers? Yes No 4. Please provide details on plans to add any providers/suppliers during the coming 12 months. Check here if not applicable: N/A SECTION III. ACO INFORMATION PARTICPANTS, PROVIDERS AND SUPPLIERS 1. Types of organizations that participate in the Accountable Care Organization: (Check all that apply) Hospital / HC System Participant Provider N/A Medical Group Practice Arrangement Participant Provider N/A RE: Medical Group specialty: Private Payer Participant Provider N/A RE: Please specify by name: PPO Participant Provider N/A MCO Participant Provider N/A MSO Participant Provider N/A IPA Participant Provider N/A PHO Participant Provider N/A Third Party Administrator Participant Provider N/A Skilled Nursing Facility Participant Provider N/A Long Term Care Facility Participant Provider N/A Critical Access Hospital (CAH) Participant Provider N/A Federally Qualified Health Center (FQHC) Participant Provider N/A Rural Health Clinic (RHC) Participant Provider N/A Other: (please provide additional details on a separate page if needed) Employed/Owned Contracted 2. Number of Providers: Last 12 Months Next 12 Months Last 12 Months Next 12 Months a) Physicians (not including Psychiatrists) b) Hospitals c) Payers 3. Is Applicant listed in Section I., question #1 a legal entity separate from any of the ACO providers/suppliers? Yes No 4. Is there a contract between the Applicant and each of the ACO providers/suppliers? Yes No 5. Please provide details on the financial risk sharing arrangement: a) Does the Applicant assume capitated or other financial premium risk on behalf of itself or any of its or any of its contracted providers/suppliers? Yes No b) Has a plan for distribution of shared savings provided to all ACO providers/suppliers? Yes No NA c) Does the Applicant participate in any shared risk program with a repayment mechanism? Yes No d) If there is no current capitation or other financial risk sharing plan, are there plans to implement one in the coming 12 months? Yes No A1855ACO-0313 2 of 7
SECTION IV. INSURANCE REQUESTED FOR ACO PROVIDERS/SUPPLIERS AND SUBSIDIARIES OF THE APPLICANT 1. If coverage is requested for any entities, subsidiaries, and/or joint ventures other than the Applicant listed in Section I., question #1, please list such entities below. Please note that coverage for these entities is not automatic. Name & Address Relationship to Applicant Description of Operations Tax Status Percent Owned Please provide details on a separate page if needed. SECTION V. LICENSING & ACCREDITATION 1. Does the Applicant maintain all required licenses by any federal, state and / or local government? Yes No 2. Is the Applicant approved by CMS for participation in the Medicare Shared Savings Program? Yes No For questions 3 through 5, if the answer is Yes, please provide details on a separate page. 3. Has the Applicant or any of the ACO Participants ever had Medicare participation status revoked or restricted in any manner? Yes No 4. Has the Centers for Medicare and Medicaid Services, Department of Health and Human Services, or other federal, state or local agency ever sanctioned the Applicant or any of the ACO Participants? Yes No 5. Have any of the Applicant s or any of the ACO Participants licenses, certifications or accreditations ever been investigated, denied, suspended or revoked, subject to any contingencies or recommendations? Yes No 6. Is the Applicant accredited or certified by any organization such as the National Committee for Quality Assurance (NCQA), URAC or any state or federal agency? (Please list) Yes No SECTION VI. ANTITRUST INQUIRIES 1. Within the last 5 years, has the Applicant obtained advice from antitrust legal counsel, including advice related to ACO formation, mergers, acquisitions or network development? Yes No 2. Has the Applicant received a legal opinion that it falls within the antitrust ACO safety zone? Yes No For questions 3 through 7, if the answer is Yes, please provide details on a separate page. 3. Do the Applicant s ACO participants/providers constitute greater than 30% of the market for such providers in a given area? Yes No 4. Has the ACO Applicant submitted to a voluntary antitrust review by the Federal Trade Commission and/or the U.S. Department of Justice? Yes No 5. Does the Applicant have exclusive contracts with any hospital or ambulatory surgery centers? Yes No 6. Does the Applicant have exclusive contracts with any other healthcare providers (besides hospitals or ASCs)? Yes No 7. Does the Applicant use anti-steering, anti-tiering, guaranteed inclusion or similar clauses to discourage payers from directing or incentivizing patients to choose providers? Yes No A1855ACO-0313 3 of 7
SECTION VII. COMPLIANCE 1. Does the Applicant have a written compliance plan in place, including HIPAA? Yes No 2. Is there a Board policy on HIPAA compliance? Yes No 3. Is there a designated compliance officer with experience in HIPAA compliance? Yes No 4. Is there a HIPAA compliance training program? Yes No 5. Does the Applicant give patients and other persons protected under HIPAA notification of their privacy rights? Yes No 6. How does the Applicant ensure that all ACO participants/suppliers and business associates are HIPAA compliant? 7. Is the ACO 100% Electronic Health Recordkeeping (EHR)? Yes No 8. Are the participating providers merging their Medicare number into the Applicants ACO TIN number or is the ACO acquiring its own Medicare number? If the answer is Yes, please provide details on a separate page. Yes No SECTION VIII. CREDENTIALING 1. Does the Applicant perform credentialing of health care providers which it: a) Employs? Yes No NA b) Contracts with or on behalf of? Yes No NA 2. How does the Applicant ensure that the credentials of all ACO participants and providers meet NCQA Standards? 3. a) Is the Applicant delegated to perform credentialing activities on behalf of any payer? Yes No b) Has any payer ever revoked previously delegated activities? Yes No If answer is Yes, please provide details of circumstances and corrected plan of action on a separate page. 4. Does the Applicant sub-delegate credentialing to any third party? Yes No If Yes, please describe oversight process to audit the third party on a separate page. 5. Are insufficient patient encounters, excessive utilization or any other economic factors grounds to disqualify or remove a a provider from the ACO? Yes No a) Have any providers been terminated from the ACO in the past 12 months? Yes No If answer is Yes, please indicate how many were terminated and for what reasons on a separate page. b) Were the terminated providers notified of their due process rights, as applicable? Yes No 6. Has the Applicant denied any provider ACO membership status in the last 12 months? Yes No If Yes, please indicate how many providers were denied and for what reasons on a separate page. 7. How does the Applicant handle complaints against providers? SECTION IX. UTILIZATION AND CASE MANAGEMENT 1. Has the Applicant developed a Case Management system that addresses the continuum of care provided by all ACO participants? Yes No 2. Has the Applicant s Case Management electronic information system been completed? Yes No A1855ACO-0313 4 of 7
3. Is there a process in place to measure patient satisfaction and clinical outcomes for all ACO participants and providers? Yes No 4. Does the ACO use HEDIS, the Physician Quality Reporting System, or the Consumer Assessment of Healthcare Providers and Systems (CAHPS)? Yes No 5. a) Is the Applicant delegated to perform utilization management activities on behalf of any health plan? Yes No b) Has any health plan ever revoked previously delegated activities? Yes No If answer is Yes, please provide details on a separate page. 6. Does the Applicant utilize guidelines such as Milliman and Robertson, InterQual and/or URAC for its utilization decisions? Yes No 7. Does the Applicant follow a written prescribed process for appeals to the Payer(s)? Yes No 8. Does the Applicant sub-delegate utilization management to any third party? Yes No If Yes, please identify such third parties and describe oversight process to audit the third party on a separate page. 9. In any of the Applicant s contracts, does the Applicant have the responsibility to make the final determination as to whether or not a procedure is covered? Yes No 10. What are the credentials of the personnel who draft and/or issue denial(s) of benefits? SECTION X. CLAIMS ADJUDICATION 1. a) Is the Applicant delegated to perform claims adjudication activities on behalf of any payer? Yes No b) Has any payer ever revoked previously delegated activities? Yes No If the answer is Yes, please provide details on a separate page. 2. If Applicant is delegated to perform claims adjudication activities, what activities is the Applicant delegated to perform: Review of claims Yes No Processing of reimbursement Yes No Issuance of denial of claims Yes No Claims appeals Yes No Final determination of benefits Yes No 3. Does the Applicant have an information system(s) to manage the claims processing? Yes No SECTION XI. MARKETING/SALES 1. Is any sales or promotional material bearing the name or identity of the Applicant distributed to Enrollees/Beneficiaries? Yes No 2. Does such material always refer to contracted providers as Independent Contractors? Yes No 3. Are any warranties or representations as to quality of health care made in any sales or promotional materials? Yes No 4. Does the Applicant have such material reviewed by legal counsel prior to publication? Yes No SECTION XII. PRIOR ACTIVITIES INFORMATION 1. Within the last five years, has any person or entity proposed for this insurance been the subject of, received, or been involved in any litigation, administrative proceedings, demand letter, or formal or informal governmental investigation or inquiry? Yes No If Yes, please complete the Supplemental Claim/Wrongful Act Incident form for each matter. 2. Is the Applicant or any person or entity proposed for this insurance aware of any actual or alleged wrongful act, error, omission, fact, incident or any circumstance which might reasonably result in a claim? Yes No If Yes, please provide details on a separate page. A1855ACO-0313 5 of 7
SECTION XIII. LIMITS REQUESTED AND OTHER INSURANCE Limits of Liability (in Millions) Requested $1.0 $1.0/3.0 $2.0 $5.0 Retention ACO Errors & Omissions Yes No $ ACO Directors & Officers Yes No $ 1. a) Please provide details of insurance/reinsurance currently in force (If None, so state): Type of Coverage Medical Malpractice* (Required) Managed Care E&O Insurance Carrier(s) Policy Period Limits Deductible Premium D&O EPLI General Liability* (Required) Privacy and Network Security Government Billing E&O Stop Loss * Signed Warranty Statement and/or evidence of Medical Malpractice Insurance and General Liability Insurance will be required for Policy Issuance b) Has any Insurance carrier canceled or non-renewed any of the above or indicated an intent not to offer renewal terms? Yes No If Yes, please provide details on a separate page. 2. Do all entities involved with the ACO carry General Liability (GL) insurance? Yes No If No, then coverage cannot be bound until confirmation is provided. 3. Does the Applicant require that all medical providers and entities maintain Professional Liability (PL)/Medical Malpractice insurance? If No, then coverage cannot be bound until confirmation is provided. Yes No Minimum limits of liability required of providers and entities: $ Minimum Deductible: $ SECTION XIV. ACO DIRECTORS & OFFICERS COVERAGE 1. Is the Applicant seeking ACO Directors & Officers coverage? Yes No If Yes, please answer the following questions. 2. Do the Directors and Officers as a whole, directly or indirectly, own or control the voting rights of more than 5% of the outstanding securities of the Applicant? Yes No If Yes, please list each name and their ownership amount on a separate page. 3. Are there processes in place for the Board to review the Applicant s: a. Evidence based medicine Yes No b. Patient engagement Yes No c. Quality and cost measurements Yes No d. Coordination of care amongst the ACO providers/suppliers Yes No A1855ACO-0313 6 of 7
For questions 4 through 7, if the answer is Yes, then please provide details on a separate page. 4. Does the Applicant render any professional services for others for a fee or compensation? Yes No 5. Does the Applicant act as a general partner in any partnership? Yes No 6. Does the Applicant have any direct or indirect insurance operations? Yes No 7. Is coverage requested for Outside Service positions on any for-profit entity or public corporate boards or other joint venture? Yes No If Yes, please submit the following for the outside company: name, audited financial statement, schedule of primary D&O, and schedule of proposed Insured Persons and their capacity. 8. Prior Insurance Information a. Describe any current/previous D&O insurance maintained: Insurance Carrier(s) Policy Period Limits Deductible Premium b. Has any insurer made payments to or on behalf of the Applicant or any person or entity proposed for this insurance at any time in the last five years? Yes No c. Has the Applicant or any person or entity proposed for this insurance given written notice under the provisions of any current or prior policy providing similar insurance of any specific facts or circumstances which might give rise to a claim under such insurance? Yes No d. Has any insurer ever cancelled or non-renewed any similar D&O or Errors and Omissions insurance? Yes No 9. Prior Activities Information a. Within the last five years, has the Applicant or any person or entity proposed for this insurance been the subject of, received, or been involved in any litigation, administrative proceedings, demand letter, or formal or informal governmental investigation or inquiry? Yes No If Yes, please complete the Supplemental Claim/Wrongful Act Incident form for each matter. b. Is the Applicant or any person or entity proposed for this insurance aware of any actual or alleged wrongful act, error, omission, fact, incident or any circumstance which might reasonably result in a claim? Yes No If Yes, please provide details on a separate page. SECTION XV. SIGNATURE APPLICABLE TO ALL REQUESTED COVERAGE The undersigned declares that the statements herein are true. The signing of this Application does not bind the Underwriters to offer, nor the Applicant to accept, the insurance, but it is agreed that this Application shall be the basis of the contract should a Policy be issued. This Application will be attached to and become a part of the Policy, if issued. The Underwriters hereby are authorized to make any investigation and inquiry in connection with this Application as they may deem necessary. It is warranted that the particulars and statements contained in the Application for the proposed Policy and any materials submitted herewith (which shall be retained on files by Underwriters and which shall be deemed attached hereto, as if physically attached hereto), are the basis for the proposed Policy and are to be considered as incorporated into and constituting a part of the proposed Policy. It is agreed that in the event there is any material change in the answers to the questions contained herein prior to the effective date of the Policy, the applicant will notify Underwriters and, at the sole discretion of Underwriters, any outstanding quotations may be modified or withdrawn. Submitted by: Signed: (Agent) Must be signed by an Executive of the Named Insured Date: Name: (Month) (Day) (Year) Please Print or Type Title: Named Insured: Date: (Month) (Day) (Year) A1855ACO-0313 7 of 7