reglab/statecodes huggingface dataset:
2023 Indiana Code › Title 27. Insurance › Article 11. Fraternal Benefit Societies › Chapter 9. Miscellaneous Provisions › 27-11-9-4. Construction of Article

Sec. 4. (a) Nothing contained in this article shall be so construed as to affect or apply to:
(1) grand or subordinate lodges of societies, orders, or associations doing business in Indiana that provide benefits exclusively through local or subordinate lodges;
(2) orders, societies, or associations that admit to membership only persons engaged in one (1) or more crafts or hazardous occupations, in the same or similar lines of business, insuring only their own members and their families, and the ladies' societies or ladies' auxiliaries to these orders, societies, or associations;
(3) domestic societies that limit their membership to employees of a particular city or town, designated firm, business house, or corporation that provide for a death benefit of not more than four hundred dollars ($400) or disability benefits of not more than three hundred fifty dollars ($350) to any person in any one (1) year, or both; or
(4) domestic societies or associations of a purely religious, charitable, or benevolent description that provide for a death benefit of not more than four hundred dollars ($400) or for disability benefits of not more than three hundred fifty dollars ($350) to any one (1) person in any one (1) year, or both.
(b) Any society or association described in subsection (a)(3) or (a)(4) that provides for death or disability benefits for which benefit certificates are issued, and any society or association included in subsection (a)(4) that has more than one thousand (1,000) members, shall not be exempted from this article but shall comply with all requirements of this article.
(c) A society that under this section is exempt from the requirements of this article, except any society described in subsection (a)(2), shall not give or allow or promise to give or allow to any person any compensation for procuring new members.
(d) Every society that provides for benefits in case of death or disability resulting solely from accident and that does not obligate itself to pay natural death or sick benefits shall have all of the privileges and be subject to all the applicable provisions and rules of this article, except that the provisions relating to medical examination, valuations of benefit certificates, and incontestability shall not apply to the society.
(e) The commissioner may require from any society or association, by examination or otherwise, such information as will enable the commissioner to determine whether the society or association is exempt from this article.
(f) Societies exempted under this section shall also be exempt from all other provisions of this title.
As added by P.L.262-1985, SEC.1.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 1. Definitions › 27-13-1-3. Repealed

As added by P.L.26-1994, SEC.25. Amended by P.L.132-2001, SEC.15; P.L.178-2003, SEC.84. Repealed by P.L.97-2004, SEC.133.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 1. Definitions › 27-13-1-4. "Basic Health Care Services"

Sec. 4. (a) "Basic health care services" means the following medically necessary services:
(1) Preventive care.
(2) Inpatient and outpatient hospital and physician care.
(3) Diagnostic laboratory care.
(4) Diagnostic and therapeutic radiological services.
(5) Emergency care.
(b) The term does not include the following:
(1) Mental health services.
(2) Services for alcohol and drug abuse.
(3) Dental services.
(4) Vision services.
(5) Long term rehabilitation treatment.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 1. Definitions › 27-13-1-5. "Capitated Basis"

Sec. 5. "Capitated basis" means fixed per member per month payment or percentage of premium payment under which the provider assumes the full risk for the cost of contracted services without regard to type, value, or frequency of services provided. For purposes of this definition, capitated basis includes the cost associated with operating staff model facilities.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 1. Definitions › 27-13-1-6. "Carrier"

Sec. 6. "Carrier" refers to any of the following:
(1) A health maintenance organization.
(2) An insurer licensed in Indiana to write Class 1(B) or Class 2(A) lines of insurance.
(3) Any other entity responsible for the payment of benefits or provision of services under a group contract.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 1. Definitions › 27-13-1-8. "Copayment"

Sec. 8. "Copayment" means an amount, or a percentage of the charge, that an enrollee must pay to receive a specific service that is not fully prepaid.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 1. Definitions › 27-13-1-10. "Covered by a Health Maintenance Organization"

Sec. 10. "Covered by a health maintenance organization" means that a person is contractually entitled, either directly or indirectly, to health care services from 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 1. Definitions › 27-13-1-10.5. "Credentialing"

Sec. 10.5. "Credentialing" means a process through which a health maintenance organization makes a determination:
(1) based on criteria established by the health maintenance organization; and
(2) concerning whether a provider may serve as a participating provider.
As added by P.L.26-2005, SEC.3.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 1. Definitions › 27-13-1-11. "Deductible"

Sec. 11. "Deductible" means the amount that an enrollee is responsible to pay out-of-pocket before the health maintenance organization begins to pay the costs associated with the health care services.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 1. Definitions › 27-13-1-11.7. "Emergency"

Sec. 11.7. "Emergency" means a medical condition that arises suddenly and unexpectedly and manifests itself by acute symptoms of such severity, including severe pain, that the absence of immediate medical attention could reasonably be expected by a prudent lay person who possesses an average knowledge of health and medicine to:
(1) place an individual's health in serious jeopardy;
(2) result in serious impairment to the individual's bodily functions; or
(3) result in serious dysfunction of a bodily organ or part of the individual.
As added by P.L.69-1998, SEC.2.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 1. Definitions › 27-13-1-12. "Enrollee"

Sec. 12. "Enrollee" means a subscriber or a subscriber's dependent who is covered by a health maintenance organization.
As added by P.L.26-1994, SEC.25. Amended by P.L.191-1997, SEC.1.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 1. Definitions › 27-13-1-13.5. "Experimental Treatment"

Sec. 13.5. "Experimental treatment" means medical technology or a new application of existing medical technology, including medical procedures, drugs, and devices for treating a medical condition, illness, or diagnosis that:
(1) is not generally accepted by informed health care professionals in the United States as effective; or
(2) has not been proven by scientific testing or evidence to be effective;
in treating the medical condition, illness, or diagnosis for which its use is proposed.
As added by P.L.69-1998, SEC.3.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 1. Definitions › 27-13-1-14. "Extension of Benefits"

Sec. 14. "Extension of benefits" means the continuation of coverage under a particular benefit provided under a contract following the termination of an enrollee with a total disability on the date of termination.
As added by P.L.26-1994, SEC.25. Amended by P.L.99-2007, SEC.194.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 1. Definitions › 27-13-1-15. "Grievance"

Sec. 15. "Grievance" means a written complaint submitted in accordance with the formal grievance procedure of a health maintenance organization by or on behalf of:
(1) the enrollee or subscriber regarding any aspect of the health maintenance organization relative to the enrollee or subscriber; or
(2) an individual who would be an enrollee or a subscriber under an individual contract or a group contract regarding the health maintenance organization's decision to rescind the individual contract or group contract.
As added by P.L.26-1994, SEC.25. Amended by P.L.160-2011, SEC.26.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 1. Definitions › 27-13-1-16. "Group Contract"

Sec. 16. "Group contract" means a contract for health care services which by the contract's terms limits eligibility to members of a specified group. A group contract may include coverage for dependents.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 1. Definitions › 27-13-1-18. "Health Care Services"

Sec. 18. (a) "Health care services" means:
(1) any services provided by individuals licensed under IC 25-5.1, IC 25-10, IC 25-13, IC 25-14, IC 25-22.5, IC 25-23, IC 25-24, IC 25-26, IC 25-27, IC 25-29, IC 25-33, or IC 25-35.6;
(2) services provided as a result of hospitalization;
(3) services incidental to the furnishing of services described in subdivision (1) or (2); or
(4) any other services or goods furnished for the purpose of preventing, alleviating, curing, or healing human illness, physical disability, or injury.
(b) The term does not include any service provided by, from, or through a licensed health care facility in connection with any life care, founder's fee, or other type of prepaid fee contract for residency and health care in a retirement home, community, or facility for elderly persons.
As added by P.L.26-1994, SEC.25. Amended by P.L.133-2011, SEC.2.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 1. Definitions › 27-13-1-19. "Health Maintenance Organization"

Sec. 19. "Health maintenance organization" means a person that undertakes to provide or arrange for the delivery of health care services to enrollees on a prepaid basis, except for enrollee responsibility for copayments or deductibles.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 1. Definitions › 27-13-1-20. "In-Plan Covered Services"

Sec. 20. "In-plan covered services" means the following:
(1) Covered health care services that are obtained from a provider who:
(A) is employed by;
(B) is under contract with;
(C) provides health care services to an enrollee referred by; or
(D) is otherwise affiliated with;
the health maintenance organization.
(2) Emergency services.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 1. Definitions › 27-13-1-21. "Individual Contract"

Sec. 21. (a) "Individual contract" means a contract for health care services that:
(1) is issued to; and
(2) covers;
an individual.
(b) An individual contract may include coverage for a dependent of the subscriber.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 1. Definitions › 27-13-1-21.3. "Insurance Producer"

Sec. 21.3. "Insurance producer" means a person who is a licensed insurance producer under IC 27-1-15.6 and who:
(1) solicits, negotiates, effects, procures, delivers, renews, or continues a policy or contract for membership in a health maintenance organization or a prepaid limited health service organization;
(2) takes or transmits a membership fee or premium for the policy or contract other than for the insurance producer; or
(3) causes the insurance producer to be held out to the public, through advertising or otherwise, as a producer for a health maintenance organization or a prepaid limited health service organization.
As added by P.L.97-2004, SEC.102.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 1. Definitions › 27-13-1-21.5. "Managed Hospital Payment Basis"

Sec. 21.5. "Managed hospital payment basis" means agreements in which the financial risk is primarily related to the degree of utilization rather than to cost of services.
As added by P.L.255-1995, SEC.13.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 1. Definitions › 27-13-1-22. "Net Worth"

Sec. 22. (a) "Net worth" means the excess of total admitted assets over total liabilities.
(b) For the purposes of subsection (a), "liabilities" does not include fully subordinated debt.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 1. Definitions › 27-13-1-23. "Out-of-Plan Covered Services"

Sec. 23. (a) "Out-of-plan covered services" means nonemergency, self-referred covered health care services that:
(1) are obtained from a provider who is:
(A) not otherwise employed by;
(B) not under contract with; and
(C) not otherwise affiliated with;
the health maintenance organization; or
(2) are obtained from a participating provider without a referral.
(b) The term does not include uncovered services.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 1. Definitions › 27-13-1-24. "Participating Provider"

Sec. 24. "Participating provider" means a provider who, under an express or implied contract with:
(1) the health maintenance organization; or
(2) a contractor of the health maintenance organization or any subcontractor of a contractor of the health maintenance organization;
has agreed to provide health care services to enrollees with an expectation of directly or indirectly receiving payment, other than copayment or deductible, from the health maintenance organization.
As added by P.L.26-1994, SEC.25. Amended by P.L.195-1996, SEC.1.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 1. Definitions › 27-13-1-25. "Person"

Sec. 25. "Person" includes the following:
(1) An individual.
(2) A partnership.
(3) An association.
(4) A trust.
(5) A limited liability company.
(6) A corporation.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 1. Definitions › 27-13-1-26. "Point-of-Service Product"

Sec. 26. "Point-of-service product" means a product that covers both:
(1) in-plan covered services; and
(2) out-of-plan covered services.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 1. Definitions › 27-13-1-27. "Limited Service Health Maintenance Organization"

Sec. 27. "Limited service health maintenance organization" has the meaning set forth in IC 27-13-34-4.
As added by P.L.26-1994, SEC.25. Amended by P.L.2-1998, SEC.70.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 1. Definitions › 27-13-1-27.5. "Primary Care Provider"

Sec. 27.5. "Primary care provider" means a provider under contract with a health maintenance organization who is designated by the health maintenance organization to coordinate, supervise, or provide ongoing care to an enrollee.
As added by P.L.69-1998, SEC.4.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 1. Definitions › 27-13-1-28. "Provider"

Sec. 28. (a) "Provider" means a physician, a hospital, or any other person licensed or authorized to furnish health care services.
(b) The term includes an entity that:
(1) is owned in whole or in part by one (1) or more physicians, hospitals, or other persons licensed or authorized to furnish health care services; and
(2) was established for purposes of furnishing health care services through:
(A) contracts; or
(B) employment agreements;
with one (1) or more physicians, hospitals, or other persons licensed or authorized to furnish health care services.
As added by P.L.26-1994, SEC.25. Amended by P.L.195-1996, SEC.2.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 1. Definitions › 27-13-1-32. "Subscriber"

Sec. 32. "Subscriber" means:
(1) an individual whose employment status or other status, except family dependency, is the basis for eligibility for enrollment in the health maintenance organization; or
(2) in the case of an individual contract, the person in whose name the contract is issued.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 1. Definitions › 27-13-1-33. "Subscriber Premiums"

Sec. 33. "Subscriber premiums" means money or any other thing of value paid or given in consideration to a health maintenance organization, agent, or solicitor on account of or in connection with a contract under which a health maintenance organization provides or arranges for the delivery of health care benefits to enrollees.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 1. Definitions › 27-13-1-34. "Telehealth Services"

Sec. 34. "Telehealth services" means health care services delivered by use of technology allowed under IC 25-1-9.5-6, including the following:
(1) Medical exams and consultations.
(2) Behavioral health, including substance abuse evaluations and treatment.
As added by P.L.185-2015, SEC.26. Amended by P.L.85-2021, SEC.31.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 2. Establishment of Health Maintenance Organizations › 27-13-2-1. Persons Applying for Certificate of Authority

Sec. 1. Notwithstanding any other law, any person may apply to the commissioner for a certificate of authority to establish and operate a health maintenance organization under this article.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 2. Establishment of Health Maintenance Organizations › 27-13-2-2. Certificate of Authority Required

Sec. 2. (a) A person may not establish or operate a health maintenance organization without obtaining a certificate of authority under this article.
(b) If a participating provider contracts with another provider under a contract that complies with IC 27-13-15 to provide health services on a prepaid basis to enrollees of a health maintenance organization that holds a certificate of authority, neither provider, with respect to the contract is:
(1) considered to be engaged in the business of insurance; or
(2) required to obtain a certificate of authority under this article.
As added by P.L.26-1994, SEC.25. Amended by P.L.195-1996, SEC.3.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 2. Establishment of Health Maintenance Organizations › 27-13-2-3. Foreign Entities Obtaining Certificate of Authority

Sec. 3. (a) A foreign corporation, other than a foreign corporation defined under IC 27-1-2-3, may obtain a certificate of authority if the foreign corporation:
(1) is authorized to do business in Indiana under IC 23-0.5-5; and
(2) complies with this article.
(b) A foreign corporation (as defined in IC 27-1-2-3) may obtain a certificate of authority if the foreign corporation complies with this article.
(c) A foreign or alien health maintenance organization granted a certificate of authority under this section has the same but no greater rights and privileges than a domestic health maintenance organization.
As added by P.L.26-1994, SEC.25. Amended by P.L.203-2001, SEC.15; P.L.118-2017, SEC.121.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 2. Establishment of Health Maintenance Organizations › 27-13-2-4. Certificate of Authority Application; Verification; Form

Sec. 4. An application for a certificate of authority to operate a health maintenance organization must be:
(1) verified by an officer or authorized representative of the applicant; and
(2) submitted on a form prescribed by the commissioner.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 2. Establishment of Health Maintenance Organizations › 27-13-2-6. Certificate of Authority Application; Modifications or Amendments

Sec. 6. (a) An applicant shall submit to the commissioner any modifications or amendments to the items of information required in an application under section 5 of this chapter.
(b) The commissioner may adopt rules under this section that provide that any modifications or amendments to the items of information in the application required of a health maintenance organization:
(1) must be submitted to the commissioner before the modification or amendment takes effect:
(A) for the approval of the commissioner; or
(B) for the information of the commissioner only; or
(2) must be indicated by the health maintenance organization to the commissioner at the time of the next succeeding site visit or examination of the organization by the department of insurance.
(c) A health maintenance organization shall file any assumed corporate name with the department at least thirty (30) days before assuming the name.
As added by P.L.26-1994, SEC.25. Amended by P.L.203-2001, SEC.16.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 2. Establishment of Health Maintenance Organizations › 27-13-2-7. Certificate of Authority Application; Approval of Modifications or Amendments

Sec. 7. Any modification or amendment requiring the approval of the commissioner under rules adopted under section 6 of this chapter is considered approved unless the commissioner disapproves the modification or amendment not more than thirty (30) days after the modification or amendment is submitted. However, the commissioner may postpone the action, if necessary for proper consideration, and if the commissioner gives written notice of the postponement to the applicant before the expiration of the thirty (30) day period.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 2. Establishment of Health Maintenance Organizations › 27-13-2-8. Waiver of Rights Under Bankruptcy Laws

Sec. 8. The commissioner may not issue a certificate of authority to operate a health maintenance organization unless the applicant has submitted to the commissioner a written waiver of the health maintenance organization's rights under the federal bankruptcy laws.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 2. Establishment of Health Maintenance Organizations › 27-13-2-9. Prohibited Names

Sec. 9. (a) A health maintenance organization established under this article may not:
(1) use as a part of its corporate name the words "United States", "Federal", "government", "official", or any word that would imply that the company is an administrative agency of the state of Indiana or of the United States, or that it is subject to supervision of any department other than the department of insurance; or
(2) take or assume a corporate name the same as, or confusingly similar to, an existing name of any other insurance company or other entity licensed or regulated under IC 27, unless at the same time:
(A) the other company changes its corporate name or withdraws from transacting business in Indiana; and
(B) the written consent of the other company, signed and verified under oath by its secretary, is filed with the department.
(b) This section does not affect the right of any health maintenance organization that:
(1) exists under the laws of Indiana as of July 1, 2001;
(2) exists under the laws of Indiana as of July 1, 2001, and thereafter reorganizes or reincorporates under this article; or
(3) is authorized to transact business in Indiana as of July 1, 2001;
to continue the use of its corporate name.
As added by P.L.203-2001, SEC.17.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 2. Establishment of Health Maintenance Organizations › 27-13-2-10. Application of Other Laws to Domestic Health Maintenance Organizations

Sec. 10. (a) A domestic health maintenance organization that is admitted to transact business in Indiana shall do the following:
(1) If the health maintenance organization is a domestic health maintenance organization admitted to transact business in Indiana after June 30, 2011, comply with IC 27-1-6-21.
(2) If the health maintenance organization changes the physical location of its home office, provide written notice to the department and all subscribers at least thirty (30) days before the location is changed, including the address and telephone number of the new location.
(b) A domestic health maintenance organization operating under this article is subject to IC 27-1-7-11.
As added by P.L.11-2011, SEC.37.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 3. Issuance of Certificates of Authority › 27-13-3-1. Satisfaction of Requirements

Sec. 1. After receiving a completed application, the commissioner shall issue a certificate of authority to operate a health maintenance organization to the applicant if:
(1) the application fee is received by the commissioner; and
(2) the commissioner is satisfied that the following requirements are met:
(A) The persons responsible for the conduct of the affairs of the applicant are competent, trustworthy, and have good reputations.
(B) The health maintenance organization will effectively provide or arrange for the provision of the health care services covered in the health maintenance organization's individual and group contracts on a prepaid basis, through insurance or other means, except to the extent of reasonable requirements for copayments and deductibles.
(C) The health maintenance organization complies with IC 27-13-12 through IC 27-13-19.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 3. Issuance of Certificates of Authority › 27-13-3-1.5. Approval of Certificate of Authority

Sec. 1.5. (a) Except as provided in subsection (b), a completed application for a certificate of authority is considered approved one hundred twenty (120) days after the completed application is submitted to the commissioner.
(b) If the commissioner issues an order under IC 27-13-24-3(b) within one hundred twenty (120) days after a completed application is submitted under subsection (a), the review and processing of the application are subject to IC 27-13-24-3 and IC 27-13-24-4.
As added by P.L.195-1996, SEC.4.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 3. Issuance of Certificates of Authority › 27-13-3-2. Denial of Application

Sec. 2. An application for a certificate of authority may be denied only after the commissioner complies with the requirements set forth in IC 27-13-24.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 4. Powers of Health Maintenance Organizations › 27-13-4-1. General Powers

Sec. 1. (a) Subject to section 3 of this chapter, the powers of a health maintenance organization include the following:
(1) The purchase, lease, construction, renovation, operation, or maintenance of:
(A) hospitals and medical facilities;
(B) equipment for hospitals and medical facilities; and
(C) other property reasonably required for the principal office of the health maintenance organization or for purposes necessary in the transaction of the business of the organization.
(2) Engaging in transactions between affiliated entities, including loans and the transfer of responsibility under any or all contracts:
(A) between affiliates; or
(B) between the health maintenance organization and the parent organization of the health maintenance organization.
(3) The furnishing of health care services through:
(A) providers;
(B) provider associations; and
(C) agents for providers;
who are under contract with or are employed by the health maintenance organization. The contracts with providers, provider associations, or agents of providers may include fee for service, cost plus, capitation, or other payment or risk-sharing arrangements.
(4) Contracting with any person for the performance on behalf of the health maintenance organization of certain functions, including:
(A) marketing;
(B) enrollment; and
(C) administration.
(5) Contracting with:
(A) an insurance company licensed in Indiana;
(B) an authorized reinsurer; or
(C) a hospital authorized to conduct business in Indiana;
for the provision of insurance, indemnity, or reimbursement against the cost of health care services provided by the health maintenance organization.
(6) The offering of point-of-service products.
(7) The joint marketing of products with:
(A) an insurance company that is licensed in Indiana; or
(B) a hospital that is authorized to conduct business in Indiana;
if the company that is offering each product is clearly identified.
(8) Administration of the provision of health care services at the expense of a self-funded plan.
(b) A health maintenance organization may offer any of the following:
(1) Plans that include only basic health care services.
(2) Plans that include basic health care services and other health care services.
(3) Plans that include health care services other than basic health care services so long as at least one (1) of the plans offered by the health maintenance organization includes basic health care services.
(c) Notwithstanding subsection (a)(5), a health maintenance organization may not take credit for reinsurance unless the risk is ceded to a reinsurer qualified under IC 27-6-10.1.
As added by P.L.26-1994, SEC.25. Amended by P.L.2-1995, SEC.111; P.L.203-2001, SEC.18; P.L.130-2020, SEC.15.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 4. Powers of Health Maintenance Organizations › 27-13-4-3. Filing Notice With Commissioner Before Exercising Power; Disapproval of Exercise of Power; Exemptions From Filing Requirement

Sec. 3. (a) A domestic health maintenance organization must file notice with the commissioner, with supporting information that the commissioner deems adequate, before exercising any power granted in:
(1) section 1(a)(1); or
(2) section 1(a)(4);
of this chapter if the proposed transaction is equal to or greater than ten percent (10%) of the health maintenance organization's admitted assets.
(b) A domestic health maintenance organization must file notice with the commissioner, with the supporting information that the commissioner deems adequate, before exercising any power granted in section 1(a)(2), if the proposed transaction is equal to or greater than three percent (3%) of the health maintenance organization's admitted assets.
(c) The commissioner may disapprove an exercise of power referred to in a notice received under subsection (a) or (b) only if, in the opinion of the commissioner, the exercise of the power would:
(1) substantially and adversely affect the financial soundness of the health maintenance organization; and
(2) endanger the ability of the health maintenance organization to meet its obligations.
(d) If the commissioner does not disapprove an exercise of power referred to in a notice received under subsection (a) or (b) within thirty (30) days after the notice is filed with the commissioner, the exercise of power is considered approved.
(e) The commissioner may adopt rules under IC 4-22-2 exempting from the filing requirement of this section certain activities that have a minimal effect on:
(1) the financial soundness of the health maintenance organization; and
(2) the ability of the health maintenance organization to meet its obligations.
As added by P.L.26-1994, SEC.25. Amended by P.L.203-2001, SEC.19.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 5. Fiduciary Responsibilities › 27-13-5-1. Persons Having Fiduciary Responsibilities

Sec. 1. Any:
(1) director;
(2) officer;
(3) employee; or
(4) partner;
of a health maintenance organization who receives, collects, disburses, or invests funds in connection with the activities of the organization has a fiduciary responsibility to the organization for the funds.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 5. Fiduciary Responsibilities › 27-13-5-2. Fidelity Bond or Fidelity Insurance

Sec. 2. A health maintenance organization shall maintain in force a fidelity bond or fidelity insurance on the directors, officers, employees, and partners referred to in section 1 of this chapter:
(1) in an amount:
(A) not less than two hundred and fifty thousand dollars ($250,000) for each health maintenance organization; or
(B) not more than five million dollars ($5,000,000) in the aggregate on behalf of all health maintenance organizations owned by a common parent organization; or
(2) in an amount prescribed by the commissioner.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 6. Quality Management Programs › 27-13-6-1. Procedures; Establishment

Sec. 1. (a) A health maintenance organization shall establish procedures based on professionally recognized standards to assess and monitor the health care services provided to enrollees of the organization.
(b) The procedures established under this section must include mechanisms to implement corrective action when necessary and to assess the availability, accessibility, and continuity of care.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 6. Quality Management Programs › 27-13-6-2. Internal Quality Management Program Required

Sec. 2. A health maintenance organization shall have an ongoing internal quality management program to monitor and evaluate the health care services it provides, including:
(1) primary and specialist physician services; and
(2) ancillary and preventive health care services;
across all institutional and noninstitutional settings.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 6. Quality Management Programs › 27-13-6-3. Quality Management Program Requirements

Sec. 3. The quality management program required by section 2 of this chapter must include at least the following:
(1) A written statement of the scope and purpose of the health maintenance organization's quality management program, including a written statement of goals and objectives that emphasizes improved health status in evaluating the quality of care rendered to enrollees.
(2) The organizational structure responsible for quality management activities.
(3) Any contractual arrangements, when appropriate, for delegation of quality management activities.
(4) Confidentiality of policies and procedures.
(5) A system of ongoing evaluation activities.
(6) A system of focused evaluation activities.
(7) A system for credentialing providers and performing peer review activities.
(8) Duties and responsibilities of the designated physician responsible for the quality management activities.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 6. Quality Management Programs › 27-13-6-4. Written Statement of Quality Management Activities

Sec. 4. The quality management program required by section 2 of this chapter must contain a written statement describing the system of ongoing quality management activities, including the following:
(1) Problem assessment, identification, selection, and study.
(2) Corrective action, monitoring, evaluation, and reassessment.
(3) Interpretation and analysis of patterns of care rendered to individual patients by individual providers.
(4) Comparison between patterns of care, including outcomes, rendered to patients by providers and the cost to the health maintenance organization of that care.
(5) A written statement describing the system of focused quality assurance activities based on representative samples of the enrolled population that identifies method of topic selection, study, data collection, analysis, interpretation, and report format.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 6. Quality Management Programs › 27-13-6-5. Written Plans for Correcting Insufficient Service

Sec. 5. The quality management program required by section 2 of this chapter must contain written plans for taking appropriate corrective action whenever the quality management program determines that:
(1) inappropriate or substandard services have been provided; or
(2) services that should have been provided were not provided.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 6. Quality Management Programs › 27-13-6-6. Patient Record System

Sec. 6. A health maintenance organization shall ensure the use and maintenance of an adequate patient record system that will facilitate:
(1) documentation and retrieval of clinical information to enable the health maintenance organization to evaluate continuity and coordination of patient care; and
(2) the assessment of the quality of health and medical care provided to enrollees.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 6. Quality Management Programs › 27-13-6-8. Records of Proceedings; Confidentiality

Sec. 8. A health maintenance organization shall:
(1) record the proceedings of formal quality management program activities; and
(2) maintain its documentation of the quality management program in a confidential manner.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 6. Quality Management Programs › 27-13-6-9. Inspection of Records by Commissioner

Sec. 9. The commissioner may inspect the records of a health maintenance organization's quality management program. The health maintenance organization shall cooperate with the inspections by making available to the commissioner the records requested by the commissioner, while protecting the confidentiality of enrollee medical records.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 6. Quality Management Programs › 27-13-6-10. Hospital Accreditation

Sec. 10. (a) A health maintenance organization may not refuse to enter into an agreement with a hospital solely because the hospital has not obtained accreditation from an accreditation organization that:
(1) establishes standards for the organization and operation of hospitals;
(2) requires the hospital to undergo a survey process for a fee paid by the hospital; and
(3) was organized and formed in 1951.
(b) This section does not prohibit a health maintenance organization from using performance indicators or quality standards that:
(1) are developed by private organizations; and
(2) do not rely upon a survey process for a fee charged to the hospital to evaluate performance.
As added by P.L.259-1995, SEC.3.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 7. Requirements for Group Contracts, Individual Contracts, and Evidence of Coverage › 27-13-7-0.1. Application of Certain Amendments to Chapter

Sec. 0.1. The following amendments to this chapter apply as follows:
(1) The addition of sections 15.3 and 16 of this chapter by P.L.170-1999 applies to health maintenance organization contracts that are issued, delivered, or renewed after June 30, 1999.
(2) The addition of section 18 of this chapter by P.L.166-2003 applies to a health maintenance organization contract that is entered into, delivered, amended, or renewed after December 31, 2003.
(3) The amendments made to section 14 of this chapter by P.L.204-2003 apply to an individual contract or a group contract that is entered into, delivered, amended, or renewed after June 30, 2003.
(4) The amendments made to section 14.8 of this chapter by P.L.226-2003 apply to a group or an individual contract with a health maintenance organization that is entered into, delivered, amended, or renewed after June 30, 2003.
(5) The amendments made to section 14.5 of this chapter by P.L.196-2005 apply to a health maintenance organization contract that is entered into, delivered, amended, or renewed after June 30, 2005.
(6) The amendments made to section 3 of this chapter by P.L.218-2007 apply to a health maintenance organization contract that is entered into, delivered, amended, or renewed after June 30, 2007.
(7) The addition of section 19 of this chapter by P.L.109-2008 applies to an individual contract or a group contract that is entered into, delivered, amended, or renewed after June 30, 2008.
As added by P.L.220-2011, SEC.457.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 7. Requirements for Group Contracts, Individual Contracts, and Evidence of Coverage › 27-13-7-1. Persons Entitled to Copies of Contracts

Sec. 1. Any holder of a group or an individual contract with a health maintenance organization is entitled to a copy of the group or individual contract.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 7. Requirements for Group Contracts, Individual Contracts, and Evidence of Coverage › 27-13-7-2. Deceptive Contract Provisions Prohibited

Sec. 2. A contract or an evidence of coverage referred to in section 1 or section 5 of this chapter may not contain provisions or statements that are unjust, unfair, inequitable, misleading, or deceptive or that encourage misrepresentation prohibited by IC 27-1-15.6-12 or IC 27-4-1-4.
As added by P.L.26-1994, SEC.25. Amended by P.L.132-2001, SEC.16.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 7. Requirements for Group Contracts, Individual Contracts, and Evidence of Coverage › 27-13-7-3. Contract Provisions

Sec. 3. (a) A contract referred to in section 1 of this chapter must clearly state the following:
(1) The name and address of the health maintenance organization.
(2) Eligibility requirements.
(3) Benefits and services within the service area.
(4) Emergency care benefits and services.
(5) Any out-of-area benefits and services.
(6) Copayments, deductibles, and other out-of-pocket costs.
(7) Limitations and exclusions.
(8) Enrollee termination provisions.
(9) Any enrollee reinstatement provisions.
(10) Claims procedures.
(11) Enrollee grievance procedures.
(12) Continuation of coverage provisions.
(13) Conversion provisions.
(14) Extension of benefit provisions.
(15) Coordination of benefit provisions.
(16) Any subrogation provisions.
(17) A description of the service area.
(18) The entire contract provisions.
(19) The term of the coverage provided by the contract.
(20) Any right of cancellation of the group or individual contract holder.
(21) Right of renewal provisions.
(22) Provisions regarding reinstatement of a group or an individual contract holder.
(23) Grace period provisions.
(24) A provision on conformity with state law.
(25) A provision or provisions that comply with the:
(A) guaranteed renewability; and
(B) group portability;
requirements of the federal Health Insurance Portability and Accountability Act of 1996 (26 U.S.C. 9801(c)(1)).
(26) That the contract provides, upon request of the subscriber, coverage for a child of the subscriber until the date the child becomes twenty-six (26) years of age.
(b) For purposes of subsection (a), an evidence of coverage which is filed with a contract may be considered part of the contract.
As added by P.L.26-1994, SEC.25. Amended by P.L.91-1998, SEC.22; P.L.218-2007, SEC.50; P.L.160-2011, SEC.27.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 7. Requirements for Group Contracts, Individual Contracts, and Evidence of Coverage › 27-13-7-4. Compliance With Requirements; Ten Day Grace Period

Sec. 4. (a) An individual contract must comply with all provisions of section 3(a) of this chapter and provide for a period of ten (10) days during which the individual entering into the contract with the health maintenance organization may:
(1) examine the contract; and
(2) if the individual decides, return the contract to the health maintenance organization and obtain a refund of the premium paid.
(b) If:
(1) services were received during the ten (10) day period referred to in subsection (a); and
(2) the individual returns the contract to receive a refund of the premium paid;
the individual must pay for the services received during the ten (10) day period.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 7. Requirements for Group Contracts, Individual Contracts, and Evidence of Coverage › 27-13-7-5. Evidence of Coverage

Sec. 5. (a) A subscriber under a group contract must receive an evidence of coverage from:
(1) the group contract holder; or
(2) the health maintenance organization.
(b) A group contract holder or health maintenance organization may provide the evidence of coverage required under subsection (a) in electronic or paper form. The group contract holder or health maintenance organization shall provide the evidence of coverage in paper form upon the request of the subscriber.
(c) A health maintenance organization shall include in the health maintenance organization's enrollment materials information concerning the manner in which a subscriber may:
(1) obtain an evidence of coverage; and
(2) request the evidence of coverage in paper form.
As added by P.L.26-1994, SEC.25. Amended by P.L.125-2005, SEC.6.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 7. Requirements for Group Contracts, Individual Contracts, and Evidence of Coverage › 27-13-7-6. Evidence of Coverage; Prohibited Provisions

Sec. 6. The evidence of coverage required by section 5 of this chapter may not contain provisions or statements:
(1) that are unfair, unjust, inequitable, misleading, or deceptive; or
(2) that encourage misrepresentation prohibited by IC 27-1-15.6-12 or IC 27-4-1-4.
As added by P.L.26-1994, SEC.25. Amended by P.L.132-2001, SEC.17.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 7. Requirements for Group Contracts, Individual Contracts, and Evidence of Coverage › 27-13-7-7. Evidence of Coverage; Required Statement

Sec. 7. The evidence of coverage required by section 5 of this chapter must contain a clear statement of the matters set forth in section 3(a) of this chapter.
As added by P.L.26-1994, SEC.25.