reglab/statecodes huggingface dataset:
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 8. Annual Report › 27-13-8-3. Annual Statement Blank; Quarterly Reports

Sec. 3. (a) This section applies to a domestic health maintenance organization that is authorized to transact business in Indiana.
(b) On or before March 1 of each year, a health maintenance organization shall file with the NAIC and with the department a copy of the health maintenance organization's Annual Statement Blank and additional filings prescribed by the commissioner for the preceding year. A health maintenance organization shall also file quarterly statements with the NAIC and with the department, on or before May 15, August 15, and November 15 of each year, in a form prescribed by the commissioner. The information filed with the NAIC under this subsection:
(1) must be:
(A) in the same format; and
(B) of the same scope;
as is required by the commissioner under section 1 of this chapter;
(2) to the extent required by the NAIC, must include the signed jurat page and the actuarial certification; and
(3) must be filed electronically in accordance with NAIC electronic filing specifications.
The commissioner may, for good cause shown, grant an exemption from the requirement of this section to domestic health maintenance organizations that operate only in Indiana. If a health maintenance organization files any amendment or addendum to the health maintenance organization's Annual Statement Blank or quarterly statement with the commissioner, the health maintenance organization shall also file a copy of the amendment or addendum with the NAIC. Annual Statement Blanks and quarterly financial statements are considered filed with the NAIC when delivered to the address designated by the NAIC for the filings, regardless of whether the filing is accompanied by any applicable fee.
(c) The commissioner may, for good cause shown, grant a health maintenance organization an extension of time for the filing required by subsection (b).
(d) In the absence of actual malice:
(1) members of the NAIC;
(2) duly authorized committees, subcommittees, and task forces of members of the NAIC;
(3) delegates of members of the NAIC;
(4) employees of the NAIC; and
(5) other persons responsible for collecting, reviewing, analyzing, and disseminating information developed from the filing of Annual Statement Blanks under this section;
shall be considered to be acting as agents of the commissioner under the authority of this section and are not subject to civil liability for libel, slander, or any other cause of action by virtue of the collection, review, analysis, or dissemination of the data and information collected from the filings required by this section.
(e) The commissioner may suspend, revoke, or refuse to renew the certificate of authority of a health maintenance organization that fails to file the health maintenance organization's Annual Statement Blank or quarterly statements with the NAIC or with the department within the time allowed by subsection (b) or (c).
As added by P.L.203-2001, SEC.22. Amended by P.L.124-2018, SEC.93.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 8. Annual Report › 27-13-8-4. Civil Penalties

Sec. 4. (a) The commissioner may impose a civil penalty of five hundred dollars ($500), after notice and hearing under IC 4-21.5-3, on a health maintenance organization that fails to file an annual statement under this chapter.
(b) A domestic health maintenance organization that fails to file an audited annual financial statement under section 2(a)(1) of this chapter before June 1 of each year without obtaining an extension is subject to a civil penalty of fifty dollars ($50) per day until the report is received by the commissioner.
As added by P.L.203-2001, SEC.23.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 9. Information to Enrollees or Subscribers › 27-13-9-1. List of Providers

Sec. 1. (a) Upon:
(1) the enrollment; and
(2) each reenrollment;
of a subscriber, a health maintenance organization must provide to the subscriber in electronic or paper form a list of providers who provide health care services through the health maintenance organization. The health maintenance organization must also provide the list of providers in electronic or paper form to a potential enrollee upon request.
(b) A health maintenance organization shall:
(1) inform a subscriber or potential enrollee that the subscriber or potential enrollee may request a list described in subsection (a) in paper form; and
(2) provide the list in paper form upon the request of the subscriber or potential enrollee.
As added by P.L.26-1994, SEC.25. Amended by P.L.69-1998, SEC.7; P.L.125-2005, SEC.7.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 9. Information to Enrollees or Subscribers › 27-13-9-2. Notice of Change in Operation of Health Maintenance Organization

Sec. 2. Not more than thirty (30) days after any material change in the operation of a health maintenance organization that will directly affect the subscribers or enrollees of the organization, the health maintenance organization shall provide notice of the change to the subscribers or enrollees affected by the change.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 9. Information to Enrollees or Subscribers › 27-13-9-3. Termination of Provider

Sec. 3. (a) A health maintenance organization shall notify an enrollee in writing of the termination of:
(1) the provider who currently provides primary health care services to that enrollee;
(2) any other participating provider seen by the enrollee during the previous year; and
(3) a hospital.
(b) After the termination of the provider who provided primary health care services to an enrollee, the health maintenance organization shall assist the enrollee in transferring to another participating primary care provider.
(c) If a health maintenance organization notifies an enrollee of the termination of a hospital, the notice must include the names of all participating providers employed by the hospital.
As added by P.L.26-1994, SEC.25. Amended by P.L.133-1999, SEC.3; P.L.196-2001, SEC.2.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 9. Information to Enrollees or Subscribers › 27-13-9-4. Information on Services and Filing Grievances; Telephone Number

Sec. 4. A health maintenance organization shall provide to each enrollee and subscriber:
(1) information on:
(A) how services can be obtained;
(B) where additional information on access to services can be obtained;
(C) how to file a grievance under IC 27-13-10 and IC 27-13-10.1;
(D) the health maintenance organization's:
(i) structure;
(ii) health care benefits and exclusions; and
(iii) criteria for denying coverage; and
(E) costs for which the enrollee or subscriber is responsible; and
(2) a toll free telephone number through which the enrollee can contact the health maintenance organization at no cost to the enrollee to obtain information and to file grievances.
The information under this section must be provided to a potential enrollee of the health maintenance organization upon request.
As added by P.L.26-1994, SEC.25. Amended by P.L.191-1997, SEC.3; P.L.69-1998, SEC.8; P.L.133-1999, SEC.4.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 9. Information to Enrollees or Subscribers › 27-13-9-5. Prescription Drug Information Card

Sec. 5. (a) This section applies to a health maintenance organization that provides coverage for prescription drugs or devices and issues a card or other technology for claims processing.
(b) The card or other technology issued by a health maintenance organization must contain uniform prescription drug information that complies with the requirements established under subsection (c).
(c) Prescription drug information cards or other technology must meet either of the following criteria:
(1) Be in a format and contain information fields approved by the National Council for Prescription Drug Programs (NCPDP) as contained in the National Council for Prescription Drug Programs Pharmacy ID Card Implementation Guide in effect on the October 1 most immediately preceding the issuance of the card.
(2) Contain the following information:
(A) The health benefit plan's name.
(B) The enrollee's name, group number, and identification number.
(C) A telephone number to inquire about pharmacy related issues.
(D) The issuer's international identification number or ANSI BIN number, labeled as RxBIN.
(E) The processor control number, labeled as RxPCN.
(F) The insured's pharmacy benefits group number if different than medical group number, labeled as RxGRP.
Only those fields listed in clauses (A) through (F) that are required for proper adjudication of the claim must appear on the card. If the card is used to adjudicate non-pharmacy claims, then the designation "Rx" listed in clauses (D) through (F) is not required to be used by the issuer.
(d) A health maintenance organization may not be required to issue a prescription drug information card or other technology to a person more than one (1) time during a twelve (12) month period.
(e) The prescription drug information cards or other technology issued under this section may be used for health care service coverage other than the coverage to which this chapter applies.
As added by P.L.230-2001, SEC.3. Amended by P.L.1-2002, SEC.123.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 9. Information to Enrollees or Subscribers › 27-13-9-6. "Health Plan Information Card"; Indication of Benefits and Health Care Services

Sec. 6. (a) As used in this section, "health plan information card" means a card that:
(1) a health maintenance organization; or
(2) a third party administrator of a self-insured plan;
provides to an individual so that the individual may present the card to establish the eligibility of the individual or the individual's dependents to receive benefits or health care services.
(b) A health plan information card must indicate that the benefits and health care services are provided by:
(1) a health maintenance organization; or
(2) a third party administrator.
(c) Subsection (b) applies only to a health plan information card issued:
(1) initially to an individual as a new enrollee; or
(2) to an individual at the time of the individual’s renewal of enrollment;
in a health maintenance organization after June 30, 2020.
(d) The department of insurance shall adopt rules under IC 4-22-2 to ensure compliance with this section.
As added by P.L.111-2020, SEC.14.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 9. Information to Enrollees or Subscribers › 27-13-9-7. Electronic Data Base Requirements; Rulemaking Authority

Sec. 7. (a) The electronic data base by which a health maintenance organization or by which a third party administrator of benefits and health care services offered under a health maintenance organization contract allows an enrollee or a provider to verify an enrollee's coverage or benefits under a health maintenance organization contract must include the following information for each enrollee:
(1) Whether benefits and health care services under the health maintenance organization contract are provided by:
(A) the health maintenance organization; or
(B) a third party administrator.
(2) Whether the health maintenance organization contract is a self-funded or fully-funded plan.
(b) The department shall adopt rules under IC 4-22-2 to ensure compliance with this section.
As added by P.L.111-2020, SEC.15.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 10. Grievance Procedures › 27-13-10-1. Establishment of Procedures

Sec. 1. A health maintenance organization or limited service health maintenance organization shall establish and maintain a grievance procedure for the resolution of grievances initiated by enrollees and subscribers of the organization. The grievance procedure of a health maintenance organization or limited service health maintenance organization must be approved by the commissioner.
As added by P.L.26-1994, SEC.25. Amended by P.L.191-1997, SEC.4.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 10. Grievance Procedures › 27-13-10-3. Records of Grievances

Sec. 3. A health maintenance organization or limited service health maintenance organization shall maintain records regarding all grievances of enrollees that the organization has received since the examination by the commissioner of the grievance procedure of the organization that immediately preceded the receipt of the grievances.
As added by P.L.26-1994, SEC.25. Amended by P.L.191-1997, SEC.5.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 10. Grievance Procedures › 27-13-10-4. Notice of Grievance Related Information

Sec. 4. (a) A health maintenance organization shall provide, at the request of the enrollee, subscriber, or legal representative of the enrollee or subscriber, and upon contract issuance, at each contract renewal, and with any notice of denial of a claim, timely, adequate, and appropriate notice to each enrollee, subscriber, or legal representative, of:
(1) the grievance procedure under this chapter and IC 27-13-10.1;
(2) information on how to file:
(A) a grievance under this chapter; and
(B) a request for an external grievance review under IC 27-13-10.1; and
(3) the address for the Internet web site established by the department under IC 27-1-3-33.
(b) A health maintenance organization shall prominently display on all notices to enrollees and subscribers the telephone number and address at which a grievance may be filed.
(c) A written description of the enrollee's or subscriber's right to file a grievance must be posted by the provider in a conspicuous public location in each facility that offers services on behalf of a health maintenance organization.
As added by P.L.191-1997, SEC.6. Amended by P.L.133-1999, SEC.5; P.L.18-2016, SEC.5.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 10. Grievance Procedures › 27-13-10-5. Filing; Oral or Written Grievance; Telephone Number; Date

Sec. 5. (a) An enrollee or a subscriber may file a grievance orally or in writing.
(b) A health maintenance organization shall make available to enrollees and subscribers a toll free telephone number through which grievances may be filed. The toll free number must:
(1) be staffed by a qualified representative of the health maintenance organization;
(2) be available for at least forty (40) normal business hours per week; and
(3) accept grievances in the languages of the major population groups served.
(c) A grievance is considered to be filed on the first date it is received, either by telephone or in writing.
As added by P.L.191-1997, SEC.7.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 10. Grievance Procedures › 27-13-10-6. Filing; Procedures; Representative

Sec. 6. (a) A health maintenance organization shall establish procedures to assist enrollees and subscribers in filing grievances.
(b) An enrollee or subscriber may designate a representative to file a grievance for the enrollee or subscriber and to represent the enrollee or subscriber in a grievance under this chapter.
As added by P.L.191-1997, SEC.8.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 10. Grievance Procedures › 27-13-10-7. Resolution of Grievances

Sec. 7. (a) A health maintenance organization shall establish written policies and procedures for the timely resolution of grievances filed under this chapter. The policies and procedures must include the following:
(1) An acknowledgment of the grievance, orally or in writing, to the enrollee or subscriber within three (3) business days.
(2) Documentation of the substance of the grievance and any actions taken.
(3) An investigation of the substance of the grievance, including any aspects involving clinical care.
(4) Notification to the enrollee or subscriber of the disposition of the grievance and the right to appeal.
(5) Standards for timeliness in responding to complaints and providing notice to enrollees and subscribers of the disposition of the complaint and the right to appeal that accommodate the clinical urgency of the situation.
(b) The health maintenance organization shall appoint at least one (1) individual to resolve the complaint.
(c) A grievance must be resolved as expeditiously as possible, but not more than twenty (20) business days after the grievance is filed. If a health maintenance organization is unable to make a decision regarding the grievance within the twenty (20) day period due to circumstances beyond the health maintenance organization's control, the health maintenance organization shall:
(1) notify the enrollee or subscriber in writing of the reason for the delay before the twentieth business day; and
(2) issue a written decision regarding the complaint within an additional ten (10) business days.
(d) A health maintenance organization shall notify the enrollee or subscriber in writing of the resolution of the grievance within five (5) business days after completing the investigation. The grievance resolution notice must contain the following:
(1) The decision reached by the health maintenance organization.
(2) The reasons, policies, and procedures that are the basis of the decision.
(3) Notice of the enrollee's or subscriber's right to appeal the decision.
(4) The department, address, and telephone number through which an enrollee may contact a qualified representative to obtain more information about the decision or the right to appeal.
As added by P.L.191-1997, SEC.9.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 10. Grievance Procedures › 27-13-10-11. Action Against Provider Representing Enrollee or Subscriber

Sec. 11. A health maintenance organization may not take action against a provider solely on the basis that the provider represents an enrollee or subscriber in a grievance filed under this chapter.
As added by P.L.191-1997, SEC.11.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 10. Grievance Procedures › 27-13-10-12. Approval of Grievance and Appeals Procedures

Sec. 12. (a) Notwithstanding IC 27-13, the department shall approve the grievance and appeals procedures of a health maintenance organization if:
(1) the health maintenance organization certifies in writing to the department of the health maintenance organization's compliance with grievance and appeals procedures established by the federal Centers for Medicare and Medicaid Services of the United States Department of Health and Human Services; and
(2) the department certifies that the grievance and appeals procedures established by the federal Centers for Medicare and Medicaid Services of the United States Department of Health and Human Services are substantially similar to the grievance and appeals process in IC 27-13.
(b) Subsection (a) does not:
(1) limit the authority of the department;
(2) limit the responsibility of a health maintenance organization;
(3) release a health maintenance organization from the prohibitions established under section 11 of this chapter; or
(4) require a health maintenance organization to use a grievance and appeals procedure established by the federal Centers for Medicare and Medicaid Services of the United States Department of Health and Human Services.
As added by P.L.191-1997, SEC.12. Amended by P.L.66-2002, SEC.17.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 10.1. External Review of Grievances › 27-13-10.1-0.1. Application of Chapter

Sec. 0.1. The addition of this chapter by P.L.133-1999 applies to grievances filed under IC 27-13-10-5 after January 1, 2000.
As added by P.L.220-2011, SEC.459.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 10.1. External Review of Grievances › 27-13-10.1-1. External Grievance Procedure Established

Sec. 1. A health maintenance organization shall establish and maintain an external grievance procedure for the resolution of grievances regarding the following:
(1) The following determinations made by the health maintenance organization or an agent of the health maintenance organization regarding a service proposed by the treating physician:
(A) An adverse utilization review determination (as defined in IC 27-8-17-8).
(B) An adverse determination of medical necessity.
(C) A determination that a proposed service is experimental or investigational.
(2) The health maintenance organization's decision to rescind an individual contract or a group contract.
As added by P.L.133-1999, SEC.7. Amended by P.L.160-2011, SEC.28.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 10.1. External Review of Grievances › 27-13-10.1-2. Requirements of Procedure

Sec. 2. (a) An external grievance procedure established under section 1 of this chapter must:
(1) allow an enrollee or the enrollee's representative to file a written request with the health maintenance organization for an appeal of the health maintenance organization's grievance resolution under IC 27-13-10-8 not later than one hundred twenty (120) days after the enrollee is notified of the resolution under IC 27-13-10-8; and
(2) provide for:
(A) an expedited appeal for a grievance related to an illness, a disease, a condition, an injury, or a disability that would seriously jeopardize the enrollee's:
(i) life or health; or
(ii) ability to reach and maintain maximum function; or
(B) a standard appeal for a grievance not described in clause (A).
An enrollee may file not more than one (1) appeal of a health maintenance organization's grievance resolution under this chapter.
(b) Subject to the requirements of subsection (d), when a request is filed under subsection (a), the health maintenance organization shall:
(1) select a different independent review organization for each appeal filed under this chapter from the list of independent review organizations that are certified by the department under section 8 of this chapter; and
(2) rotate the choice of an independent review organization among all certified independent review organizations before repeating a selection.
(c) The independent review organizations shall assign a medical review professional who is board certified in the applicable specialty for resolution of an appeal.
(d) The independent review organization and the medical review professional conducting the external review under this chapter may not have a material professional, familial, financial, or other affiliation with any of the following:
(1) The health maintenance organization.
(2) Any officer, director, or management employee of the health maintenance organization.
(3) The physician or the physician's medical group that is proposing the service.
(4) The facility at which the service would be provided.
(5) The development or manufacture of the principal drug, device, procedure, or other therapy that is proposed by the treating physician.
However, the medical review professional may have an affiliation under which the medical review professional provides health care services to enrollees of the health maintenance organization and may have an affiliation that is limited to staff privileges at the health facility if the affiliation is disclosed to the enrollee and the health maintenance organization before commencing the review and neither the enrollee nor the health maintenance organization objects.
(e) The enrollee shall not pay any of the costs associated with the services of an independent review organization under this chapter. All costs must be paid by the health maintenance organization.
As added by P.L.133-1999, SEC.7. Amended by P.L.160-2011, SEC.29; P.L.81-2012, SEC.41.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 10.1. External Review of Grievances › 27-13-10.1-3. Cooperation With Review Organization; Requirements of Enrollee

Sec. 3. (a) An enrollee who files an appeal under this chapter shall:
(1) not be subject to retaliation for exercising the enrollee's right to an appeal under this chapter;
(2) be permitted to utilize the assistance of other individuals, including physicians, attorneys, friends, and family members throughout the review process;
(3) be permitted to submit additional information relating to the proposed service throughout the review process; and
(4) cooperate with the independent review organization by:
(A) providing any requested medical information; or
(B) authorizing the release of necessary medical information.
(b) A health maintenance organization shall cooperate with an independent review organization selected under section 2 of this chapter by promptly providing any information requested by the independent review organization.
As added by P.L.133-1999, SEC.7.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 10.1. External Review of Grievances › 27-13-10.1-4. Requirements of Independent Review Organization

Sec. 4. (a) An independent review organization shall:
(1) for an expedited appeal filed under section 2(a)(2)(A) of this chapter, within seventy-two (72) hours after the appeal is filed; or
(2) for a standard appeal filed under section 2(a)(2)(B) of this chapter, within fifteen (15) business days after the appeal is filed;
make a determination to uphold or reverse the health maintenance organization's grievance resolution under IC 27-13-10-8 based on information gathered from the enrollee or the enrollee's designee, the health maintenance organization, and the treating physician, and any additional information that the independent review organization considers necessary and appropriate.
(b) When making the determination under this section, the independent review organization shall apply:
(1) standards of decision making that are based on objective clinical evidence; and
(2) the terms of the enrollee's benefit contract.
(c) The independent review organization shall notify the health maintenance organization and the enrollee of the determination made under this section:
(1) for an expedited appeal filed under section 2(a)(2)(A) of this chapter, within seventy-two (72) hours after the appeal is filed; or
(2) for a standard appeal filed under section 2(a)(2)(B) of this chapter, within seventy-two (72) hours after making the determination.
As added by P.L.133-1999, SEC.7. Amended by P.L.72-2016, SEC.26.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 10.1. External Review of Grievances › 27-13-10.1-4.5. Information From Independent Review Organization

Sec. 4.5. Upon the request of an enrollee who is notified under section 4(c) of this chapter that the independent review organization has made a determination, the independent review organization shall provide to the enrollee all information reasonably necessary to enable the enrollee to understand the:
(1) effect of the determination on the enrollee; and
(2) manner in which the health maintenance organization may be expected to respond to the determination.
As added by P.L.173-2007, SEC.43.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 10.1. External Review of Grievances › 27-13-10.1-6. Reconsideration of Resolution

Sec. 6. (a) If at any time during an external review performed under this chapter, the enrollee submits information to the health maintenance organization that is relevant to the health maintenance organization's resolution under IC 27-13-10-8 and was not considered by the health maintenance organization under IC 27-13-10:
(1) the health maintenance organization shall reconsider the health maintenance organization's resolution under IC 27-13-10-8; and
(2) the independent review organization shall cease the external review process until the reconsideration under subsection (b) is completed.
(b) A health maintenance organization to which information is submitted under subsection (a) shall reconsider the resolution under IC 27-13-10-8 based on the information and notify the enrollee of the health maintenance organization's decision:
(1) within seventy-two (72) hours after the information is submitted for a reconsideration related to an illness, a disease, a condition, an injury, or a disability that would seriously jeopardize the enrollee's:
(A) life or health; or
(B) ability to reach and maintain maximum function; or
(2) within fifteen (15) days after the information is submitted for a reconsideration not described in subdivision (1).
(c) If the decision reached under subsection (b) is adverse to the enrollee, the enrollee may request that the independent review organization resume the external review under this chapter.
As added by P.L.133-1999, SEC.7.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 10.1. External Review of Grievances › 27-13-10.1-7. Terms of Coverage Unchanged

Sec. 7. This chapter does not add to or otherwise change the terms of coverage included in a contract under which an enrollee receives health care benefits under IC 27-13.
As added by P.L.133-1999, SEC.7.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 10.1. External Review of Grievances › 27-13-10.1-9. Confidentiality

Sec. 9. Except as provided in section 8(g) of this chapter, documents and other information created or received by the independent review organization or the medical review professional in connection with an external review under this chapter:
(1) are not public records;
(2) may not be disclosed under IC 5-14-3; and
(3) must be treated in accordance with confidentiality requirements of state and federal law.
As added by P.L.133-1999, SEC.7.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 10.1. External Review of Grievances › 27-13-10.1-10. Immunity From Civil Liability

Sec. 10. (a) An independent review organization is immune from civil liability for actions taken in good faith in connection with an external review under this chapter.
(b) The work product or determination, or both, of an independent review organization under this chapter are admissible in a judicial or administrative proceeding. However, the work product or determination, or both, do not, without other supporting evidence, satisfy any party's burden of proof or persuasion concerning any material issue of fact or law.
As added by P.L.133-1999, SEC.7.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 10.1. External Review of Grievances › 27-13-10.1-11. Medicare Review

Sec. 11. If an enrollee has the right to an external review under Medicare (42 U.S.C. 1395 et seq.) the enrollee may not request an external review under this chapter.
As added by P.L.133-1999, SEC.7.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 11. Investments › 27-13-11-1. Permitted Investments

Sec. 1. Except for investments under IC 27-13-4-1(a)(1), the funds of a health maintenance organization or limited service health maintenance organization may be invested only as follows:
(1) The funds of a health maintenance organization or limited service health maintenance organization that is domiciled in Indiana may be invested only in the types of securities and other investments in which investment is authorized under IC 27-1-13-3.
(2) The funds of a foreign corporation (as defined in IC 27-1-2-3) that obtains a certificate of authority to operate a health maintenance organization under IC 27-13-2-3 or a limited service health maintenance organization under IC 27-13-34-9 may be invested only in the types of securities and other investments in which investment is authorized:
(A) under the law of the state in which the foreign corporation is domiciled, if that law is acceptable to the commissioner; or
(B) under IC 27-1-13-3, if the law of the state in which the foreign corporation is domiciled is silent or if the law of that state is not acceptable to the commissioner.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 12. Protection Against Insolvency; Net Worth Requirements › 27-13-12-1. "Net Worth" Defined; Computation

Sec. 1. (a) As used in this chapter, "net worth" means the excess of total assets over total liabilities, excluding liabilities that have been subordinated in a manner acceptable to the commissioner.
(b) For the purposes of computing net worth, the total assets must be reduced by the value assigned to the following intangible assets:
(1) Goodwill.
(2) Going concern value.
(3) Organizational expense.
(4) Start-up costs.
(5) Long term prepayments of deferred charges.
(6) Nonreturnable deposits.
(7) Obligations of officers, directors, owners, or affiliates, except short term obligations of affiliates for goods or services that:
(A) arise in the normal course of business;
(B) are payable on the same terms as equivalent transactions with nonaffiliates; and
(C) are not past due.
(c) For purposes of computing net worth, the health maintenance organization may include in its assets the value assigned to the following:
(1) Medical equipment that:
(A) is owned by the health maintenance organization and is not subject to any lien, claim, or encumbrance;
(B) is used in the treatment, diagnosis, or care of enrollees of the health maintenance organization;
(C) has an initial cost of at least three thousand dollars ($3,000) for each piece of equipment; and
(D) has a useful life of at least two (2) years.
(2) Data processing equipment that is:
(A) owned by the health maintenance organization and is not subject to any lien, claim, or encumbrance; and
(B) used in the operation of the health maintenance organization.
(d) The value assigned to the assets described in subsection (c) must equal the lesser of:
(1) the fair market value; or
(2) the cost of the equipment, minus its accumulated depreciation, calculated in accordance with generally accepted accounting principles.
(e) The aggregate value of the medical equipment described in subsection (c)(1) may not exceed thirty percent (30%) of the total assets permitted to be included in the computation of net worth.
As added by P.L.26-1994, SEC.25. Amended by P.L.195-1996, SEC.6.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 12. Protection Against Insolvency; Net Worth Requirements › 27-13-12-2. Initial Minimum Net Worth

Sec. 2. Before issuing a certificate of authority to a health maintenance organization, the commissioner shall require that the health maintenance organization:
(1) have an initial net worth of at least one million five hundred thousand dollars ($1,500,000); and
(2) maintain, after issuance of the certificate, at least the minimum net worth required under section 3 of this chapter.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 12. Protection Against Insolvency; Net Worth Requirements › 27-13-12-3. Maintenance of Minimum Net Worth

Sec. 3. Except as provided in sections 4 and 5 of this chapter, a health maintenance organization shall maintain a minimum net worth equal to the greater of:
(1) one million dollars ($1,000,000);
(2) based on annual premium revenues as reported on the most recent annual financial statement filed with the commissioner, the total of two percent (2%) of annual premium revenues on the first one hundred fifty million dollars ($150,000,000) of premium and one percent (1%) of annual premium on the premium in excess of one hundred fifty million dollars ($150,000,000);
(3) an amount equal to the sum of three (3) months of uncovered health care expenditures, as reported on the most recent financial statement of the health maintenance organization filed with the commissioner under IC 27-13-8-2(a)(1); or
(4) an amount equal to the sum of:
(A) eight percent (8%) of annual health care expenditures except those paid on a capitated basis or managed hospital payment basis as reported on the most recent financial statement filed with the commissioner; and
(B) four percent (4%) of annual hospital expenditures paid on a managed hospital payment basis as reported on the most recent financial statement filed with the commissioner.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 12. Protection Against Insolvency; Net Worth Requirements › 27-13-12-4. Net Worth Schedule

Sec. 4. A health maintenance organization licensed before July 1, 1994, must maintain a net worth equal to the following:
(1) Twenty-five percent (25%) of the amount required under section 3 of this chapter by December 31, 1994.
(2) Fifty percent (50%) of the amount required under section 3 of this chapter by December 31, 1995.
(3) Seventy-five percent (75%) of the amount required under section 3 of this chapter by December 31, 1996.
(4) One hundred percent (100%) of the amount required under section 3 of this chapter by December 31, 1997.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 12. Protection Against Insolvency; Net Worth Requirements › 27-13-12-5. Consideration of Debts

Sec. 5. (a) In determining net worth under this chapter, a debt may not be considered fully subordinated unless:
(1) the subordination clause is in a form acceptable to the commissioner; and
(2) any interest obligation relating to the repayment of the subordinated debt is subordinated under a clause that is in a form acceptable to the commissioner.
(b) The interest expense relating to the repayment of any fully subordinated debt is considered a covered expense.
(c) Any debt that:
(1) is incurred through a note that meets the requirements of this chapter; and
(2) is otherwise acceptable to the commissioner;
may not be considered liability and must be recorded as equity.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 12. Protection Against Insolvency; Net Worth Requirements › 27-13-12-6. Adoption of Rules

Sec. 6. The commissioner may adopt rules to further define whether and to what extent the assets of a health maintenance organization may be considered admitted assets for purposes of complying with the requirements of this chapter.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 13. Protection Against Insolvency; Deposit Requirements › 27-13-13-1. Items Deposited; Minimum Value

Sec. 1. Except as provided in this chapter, a health maintenance organization shall deposit with the commissioner or, at the discretion of the commissioner, with any bank or bank and trust company or other trustee acceptable to the commissioner through which a custodial or controlled account is used:
(1) cash;
(2) certificates of deposit;
(3) United States government obligations acceptable to the commissioner;
(4) any other securities acceptable to the commissioner; or
(5) a combination of items described in subdivisions (1) through (4);
which at all times must have a value of at least five hundred thousand dollars ($500,000).
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 13. Protection Against Insolvency; Deposit Requirements › 27-13-13-2. Deposit Schedule

Sec. 2. A health maintenance organization that is in operation on July 1, 1994, shall make:
(1) a deposit with the commissioner equal to two hundred fifty thousand dollars ($250,000) on July 1, 1994; and
(2) an additional deposit with the commissioner equal to two hundred fifty thousand dollars ($250,000) by December 31, 1995.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 13. Protection Against Insolvency; Deposit Requirements › 27-13-13-3. Deposits Considered Admitted Asset

Sec. 3. Deposits made under this chapter shall be considered an admitted asset of the health maintenance organization in the determination of the net worth of the organization.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 13. Protection Against Insolvency; Deposit Requirements › 27-13-13-4. Income From Deposits; Replacing Deposits

Sec. 4. (a) All income from deposits made under this chapter is an asset of the organization that made the deposits.
(b) A health maintenance organization that has made a deposit under this chapter may replace the deposit or any part of the deposit with an equal amount and value of:
(1) cash;
(2) certificates of deposit;
(3) United States government obligations acceptable to the commissioner;
(4) any other securities acceptable to the commissioner; or
(5) any combination of subdivisions (1) through (4).
(c) Any obligations of the United States government must be approved by the commissioner before being deposited or substituted under this chapter.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 13. Protection Against Insolvency; Deposit Requirements › 27-13-13-5. Use of Deposit

Sec. 5. (a) A deposit made by a health maintenance organization under this chapter must be used to protect the interest of the enrollees of the health maintenance organization.
(b) The commissioner may use the deposit for administrative costs that are attributable to a receivership of the health maintenance organization.
(c) If the health maintenance organization is placed in receivership, the deposit made by the organization must be treated as an asset of the organization subject to IC 27-9.
As added by P.L.26-1994, SEC.25. Amended by P.L.208-2018, SEC.28.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 13. Protection Against Insolvency; Deposit Requirements › 27-13-13-6. Reduction or Elimination of Deposit Requirements for Foreign Corporations

Sec. 6. The commissioner may reduce or eliminate the requirement of a deposit under this chapter for a health maintenance organization that is a foreign corporation as defined in IC 27-1-2-3 if:
(1) the organization makes a deposit that meets the requirements of section 1 of this chapter with the treasurer of state, insurance commissioner, or other official body of the state or jurisdiction in which the organization is domiciled for the protection of all subscribers and enrollees of the health maintenance organization; and
(2) the organization delivers to the commissioner a certificate, duly authenticated by the appropriate state official holding the deposit, that the requirements of this section have been met.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 13. Protection Against Insolvency; Deposit Requirements › 27-13-13-7. Return of Deposit

Sec. 7. If:
(1) a health maintenance organization ceases operation for reasons other than:
(A) insolvency; or
(B) receivership;
(2) the organization is not a debtor in any pending bankruptcy proceeding;
(3) the health maintenance organization submits a request in writing to the commissioner for the return of the deposit made by the organization; and
(4) the health maintenance organization has furnished the commissioner with written proof that all claims liabilities of the health maintenance organization have been paid;
the commissioner shall return all or a part of the deposit to the health maintenance organization not more than thirty (30) days after the commissioner receives written proof from the organization under subdivision (4).
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 13. Protection Against Insolvency; Deposit Requirements › 27-13-13-8. Additional Financial Requirements

Sec. 8. (a) In addition to meeting all other financial requirements imposed by IC 27-13-12 and this chapter, a health maintenance organization that offers a point of service product shall maintain either of the following:
(1) A reinsurance agreement, which must be satisfactory to the commissioner, that cedes one hundred percent (100%) of the liability for out-of-plan services.
(2) A ratio of the revenues of the health maintenance organization from the point of service product to the net worth of the organization of not more than three (3) to one (1).
(b) The reinsurance to which subsection (a)(1) refers may be used to:
(1) directly make payments for out-of-plan services; or
(2) reinsure coverage for out-of-plan services.
(c) To achieve the ratio referred to in subsection (a)(2), a health maintenance organization may use reinsurance to cede part or all of the liability for out-of-plan services.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 14. Protection Against Insolvency; Liabilities › 27-13-14-1. Determination of Liabilities

Sec. 1. When determining its liabilities, a health maintenance organization shall include an amount estimated in the aggregate to provide:
(1) for any unearned premium;
(2) for the payment of all claims for health care expenditures, whether reported or unreported:
(A) that have been incurred;
(B) that are unpaid; and
(C) for which the organization is or may be liable; and
(3) for the expense of adjustment or settlement of claims described in subdivision (2).
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 14. Protection Against Insolvency; Liabilities › 27-13-14-2. Computation of Liabilities

Sec. 2. The liabilities of a health maintenance organization must be computed:
(1) in accordance with rules adopted by the commissioner; and
(2) upon reasonable consideration of the ascertained experience and character of the health maintenance organization.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 15. Participating Providers; Contracts and Legal Actions › 27-13-15-0.1. Application of Certain Amendments to Chapter

Sec. 0.1. The addition of section 4 of this chapter by P.L.74-2007 applies to a contract between a health maintenance organization and a participating provider that is entered into, amended, or renewed on or after April 26, 2007.
As added by P.L.220-2011, SEC.460.