reglab/statecodes huggingface dataset:
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 5. Accident and Sickness Insurance─policy Provisions › 27-8-5-16.5. Conditions for Issuance of Certificate to Resident of Indiana Under Group Policy Delivered or Issued in Another State

Sec. 16.5. (a) As used in this section, "delivery state" means any state other than Indiana in which a policy is delivered or issued for delivery.
(b) Except as provided in subsection (c), (d), or (e), a certificate may not be issued to a resident of Indiana pursuant to a group policy that is delivered or issued for delivery in a state other than Indiana.
(c) A certificate may be issued to a resident of Indiana pursuant to a group policy not described in subsection (d) that is delivered or issued for delivery in a state other than Indiana if:
(1) the delivery state has a law substantially similar to section 16 of this chapter;
(2) the delivery state has approved the group policy; and
(3) the policy or the certificate contains provisions that are:
(A) substantially similar to the provisions required by:
(i) section 19 of this chapter;
(ii) section 21 of this chapter; and
(iii) IC 27-8-5.6; and
(B) consistent with the requirements set forth in:
(i) section 24 of this chapter;
(ii) IC 27-8-6;
(iii) IC 27-8-14;
(iv) IC 27-8-23;
(v) 760 IAC 1-38.1; and
(vi) 760 IAC 1-39.
(d) A certificate may be issued to a resident of Indiana under an association group policy, a discretionary group policy, or a trust group policy that is delivered or issued for delivery in a state other than Indiana if:
(1) the delivery state has a law substantially similar to section 16 of this chapter;
(2) the delivery state has approved the group policy; and
(3) the policy or the certificate contains provisions that are:
(A) substantially similar to the provisions required by:
(i) section 19 of this chapter or, if the policy or certificate is described in section 2.5(b)(2) of this chapter, section 2.5 of this chapter;
(ii) section 19.3 of this chapter if the policy or certificate contains a waiver of coverage;
(iii) section 21 of this chapter; and
(iv) IC 27-8-5.6; and
(B) consistent with the requirements set forth in:
(i) section 15.6 of this chapter;
(ii) section 24 of this chapter;
(iii) section 26 of this chapter;
(iv) IC 27-8-6;
(v) IC 27-8-14;
(vi) IC 27-8-14.1;
(vii) IC 27-8-14.5;
(viii) IC 27-8-14.7;
(ix) IC 27-8-14.8;
(x) IC 27-8-20;
(xi) IC 27-8-23;
(xii) IC 27-8-24.3;
(xiii) IC 27-8-26;
(xiv) IC 27-8-28;
(xv) IC 27-8-29;
(xvi) 760 IAC 1-38.1; and
(xvii) 760 IAC 1-39.
(e) A certificate may be issued to a resident of Indiana pursuant to a group policy that is delivered or issued for delivery in a state other than Indiana if the commissioner determines that the policy pursuant to which the certificate is issued meets the requirements set forth in section 17(a) of this chapter.
(f) This section does not affect any other provision of Indiana law governing the terms or benefits of coverage provided to a resident of Indiana under any certificate or policy of insurance.
As added by P.L.185-1996, SEC.12. Amended by P.L.96-2002, SEC.1; P.L.211-2003, SEC.3; P.L.127-2006, SEC.2; P.L.11-2011, SEC.30.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 5. Accident and Sickness Insurance─policy Provisions › 27-8-5-17. Exceptions; Discretionary Groups; Group Accident and Sickness Insurance

Sec. 17. (a) A group accident and sickness insurance policy shall not be delivered or issued for delivery in Indiana to a group that is not described in section 16(1)(A), 16(2)(A), 16(3)(A), 16(4)(A), 16(5)(A), 16(6)(A), 16(7), or 16(8) of this chapter unless:
(1) the group applies to the commissioner for approval as a discretionary group;
(2) the commissioner reviews the group according to the same standards as a group described in section 16 of this chapter; and
(3) the commissioner finds that:
(A) the issuance of the policy is not contrary to the best interest of the public;
(B) the issuance of the policy would result in economies of acquisition or administration; and
(C) the benefits of the policy are reasonable in relation to the premiums charged.
(b) Except as otherwise provided in this chapter, an insurer may exclude or limit the coverage under a policy described in subsection (a) on any person as to whom evidence of individual insurability is not satisfactory to the insurer.
As added by P.L.257-1985, SEC.3. Amended by P.L.268-1987, SEC.2; P.L.125-1992, SEC.2; P.L.185-1996, SEC.13; P.L.218-2007, SEC.47; P.L.11-2011, SEC.31.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 5. Accident and Sickness Insurance─policy Provisions › 27-8-5-18. Extension to Family Members or Dependents; Premiums; Exclusions; Group Accident and Sickness Insurance

Sec. 18. (a) Except for a policy that conforms to the description in section 16(2) of this chapter, a group accident and sickness insurance policy may be extended to insure the employees or members, or any class or classes of employees or members, with respect to their family members or dependents, subject to subsections (b) and (c).
(b) The premium for the insurance must be paid from funds contributed by the employer, union, association, or other person to whom the policy has been issued or from funds contributed by the covered persons, or from both sources of funds. Except as provided in subsection (c), a policy on which no part of the premium for the coverage of family members or dependents is to be derived from funds contributed by the covered persons must insure all eligible employees or members, or any class or classes of eligible employees or members, with respect to their spouses and dependent children.
(c) Except as provided in section 24 of this chapter, an insurer may exclude or limit the coverage on any family member or dependent as to whom evidence of individual insurability is not satisfactory to the insurer.
As added by P.L.257-1985, SEC.4. Amended by P.L.125-1992, SEC.3.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 5. Accident and Sickness Insurance─policy Provisions › 27-8-5-20. Notice of Right to Return Policy

Sec. 20. (a) All individual accident and health insurance policies, other than those issued pursuant to direct response solicitation, must have a notice prominently printed on the first page of the policy stating in substance that the policyholder has the right to return the policy:
(1) except as provided in subdivision (2), within ten (10) days of its delivery; or
(2) if the policy is a travel accident insurance policy, until the earlier of:
(A) thirty (30) days after the policy is delivered; or
(B) the date of departure;
and to have the premium refunded if, after examination of the policy, the insured person is not satisfied for any reason.
(b) All accident and health insurance policies issued pursuant to a direct response solicitation must have a notice prominently printed on the first page stating in substance that the policyholder has the right to return the policy:
(1) except as provided in subdivision (2), within thirty (30) days of its delivery; or
(2) if the policy is a travel accident insurance policy, until the earlier of:
(A) thirty (30) days after the policy is delivered; or
(B) the date of departure;
and to have the premium refunded if, after examination of the policy, the insured person is not satisfied for any reason.
(c) Notwithstanding subsection (b), a short term health insurance policy that is written for a period of less than sixty-one (61) days and issued under a direct response solicitation must have a notice prominently printed on the first page stating in substance that the policyholder has the right to return the policy within ten (10) days after the policy's delivery and to have the premium refunded if, after examination of the policy, the insured person is not satisfied for any reason.
As added by P.L.267-1987, SEC.5. Amended by P.L.1-1991, SEC.167; P.L.173-2007, SEC.26.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 5. Accident and Sickness Insurance─policy Provisions › 27-8-5-21. Adopted Children

Sec. 21. (a) Any individual or group policy or plan of health and accident insurance regulated under this chapter or any health maintenance organization or limited service health maintenance organization regulated under IC 27-13 that provides coverage under a policy issued for delivery in Indiana must cover newly adopted children of the insured or enrollee. The coverage for newly adopted children will be the same as for other dependents. No policy or plan provision concerning preexisting condition limitations, insurability, eligibility, or health underwriting approval may be applied to newly adopted children when they are enrolled in accordance with this section.
(b) The coverage required by this section:
(1) is effective upon the earlier of:
(A) the date of placement for the purpose of adoption; or
(B) the date of the entry of an order granting the adoptive parent custody of the child for purposes of adoption;
(2) continues unless the placement is disrupted prior to legal adoption and the child is removed from placement; and
(3) continues unless required action as described in subsection (c) is not taken.
(c) If the payment of a specific premium or subscription fee is required to provide coverage for an adopted child, the policy or contract may require that notification of the adoption of the child as described in subsection (b) and the payment of the required premium or fees must be furnished to the insurer or nonprofit service or indemnity corporation within thirty-one (31) days after the adoption of the child in order to have the coverage continue beyond the thirty-one (31) day period.
As added by P.L.251-1989, SEC.1. Amended by P.L.98-1990, SEC.2; P.L.26-1994, SEC.11; P.L.116-1994, SEC.59; P.L.2-1995, SEC.106.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 5. Accident and Sickness Insurance─policy Provisions › 27-8-5-22. Refund of Unused Premiums

Sec. 22. (a) All individual policies of accident and sickness insurance issued for delivery in Indiana after June 30, 1990, must provide for the refund of unused premiums upon the death of the insured during the contract period.
(b) The amount of premium refund shall be prorated from the date following the date of death of the insured to the end of the contract period for which the premium has been paid.
(c) The refund required by this section shall be paid as follows:
(1) If a person other than the insured paid the premium, to that person. A person entitled to a refund under this subdivision must furnish proof of payment to the insurer.
(2) If the insured paid the premium, to the surviving spouse of the insured. If there is no surviving spouse, the premium shall be paid in the same manner as distributions of the net estate of a person who dies intestate under IC 29-1-2-1(d). A parent disqualified under IC 29-1-2-1(e) from receiving an intestate share of the parent's child's estate is not entitled to a refund under this section of insurance premiums paid by the child.
(d) A person entitled to receive a refund under this section must do the following:
(1) Submit a written request for the refund.
(2) Furnish proof of the insured's death.
(e) This section does not affect the rights of a dependent under a policy covered by this section to obtain a conversion policy upon the death of the insured.
As added by P.L.151-1990, SEC.1. Amended by P.L.101-2008, SEC.4.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 5. Accident and Sickness Insurance─policy Provisions › 27-8-5-23. Statute or Rule Mandating Particular Types of Health Care Coverage; Applications to Insurer

Sec. 23. (a) This section does not apply to IC 27-8-6.
(b) A statute or rule mandating that one (1) or more particular types of health care coverage be provided does not apply to an insurer unless the statute or rule applies equally to employee welfare benefit plans described in 29 U.S.C. 1001 et seq.
As added by P.L.152-1990, SEC.1. Amended by P.L.119-1991, SEC.2.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 5. Accident and Sickness Insurance─policy Provisions › 27-8-5-24. Insured Issued New Policy Within Year After Cancellation or Nonrenewal; Mandatory Coverage

Sec. 24. If an insurer cancels or declines to renew a group accident and sickness policy for reasons other than fraud or nonpayment of a premium and issues a new policy to the policyholder within one (1) year after the effective date of cancellation of the policy, the insurer must accept for coverage under the new policy an individual who:
(1) was covered under the old policy; and
(2) has continued to meet the requirements for membership in the group that applied to the old policy.
However, the insurer may not exclude or limit the coverage to the individual or individual's dependent due to evidence of insurability.
As added by P.L.125-1992, SEC.4.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 5. Accident and Sickness Insurance─policy Provisions › 27-8-5-25. Maternity Benefits; Replacement of Discontinued Policy; Prohibition on Preexisting Condition Limitation or Exclusion of Coverage

Sec. 25. (a) As used in this section, "employer" means an employer who offers health insurance to the employer's employees.
(b) As used in this section, "insurer" means an insurer subject to IC 27.
(c) When an employer that has a group policy issued by an insurer that contains maternity benefits:
(1) discontinues the group health policy provided by the insurer; and
(2) replaces the discontinued policy with coverage through a succeeding insurer;
the succeeding insurer's policy may not contain a preexisting condition limitation for maternity or exclude coverage due to pregnancy for employees or spouses of employees who were covered under the prior policy on the date the prior plan was discontinued.
(d) Subsection (c) only applies if the employer obtains a new group insurance policy within thirty-one (31) days after the discontinuance of an insurance policy.
As added by P.L.116-1994, SEC.60.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 5. Accident and Sickness Insurance─policy Provisions › 27-8-5-26. Post-Mastectomy Coverage

Sec. 26. (a) As used in this section, "mastectomy" means the removal of all or part of the breast for reasons that are determined by a licensed physician to be medically necessary.
(b) A policy of accident and sickness insurance that provides coverage for a mastectomy may not be issued, amended, delivered, or renewed in Indiana unless the policy provides coverage as required under 29 U.S.C. 1185b, including coverage for:
(1) prosthetic devices; and
(2) reconstructive surgery incident to a mastectomy including:
(A) all stages of reconstruction of the breast on which the mastectomy has been performed; and
(B) surgery and reconstruction of the other breast to produce symmetry;
in the manner determined by the attending physician and the patient to be appropriate.
(c) In addition to the coverage required by 29 U.S.C. 1185b, a policy of accident and sickness insurance that provides coverage for a mastectomy must provide coverage for:
(1) custom fabricated breast prostheses; and
(2) one (1) additional breast prosthesis per breast affected by the mastectomy.
(d) Coverage required under this section is subject to:
(1) the deductible and coinsurance provisions applicable to a mastectomy; and
(2) all other terms and conditions applicable to other benefits.
(e) An insurer that issues a policy of accident and sickness insurance shall provide to an insured, at the time the policy is issued and annually thereafter, written notice of the coverage required under this section. Notice that is sent by the insurer that meets the requirements set forth in 29 U.S.C. 1185b constitutes compliance with this subsection.
(f) The coverage required under this section applies to a policy of accident and sickness insurance that provides coverage for a mastectomy, regardless of whether an individual who:
(1) underwent a mastectomy; and
(2) is covered under the policy;
was covered under the policy at the time of the mastectomy.
(g) Except as provided in subsection (c), this section does not require an insurer to provide coverage related to post mastectomy care that exceeds the coverage required for post mastectomy care under federal law.
As added by P.L.150-1997, SEC.3. Amended by P.L.96-2002, SEC.2; P.L.204-2003, SEC.1; P.L.67-2020, SEC.2.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 5. Accident and Sickness Insurance─policy Provisions › 27-8-5-28. Coverage of Child to 26 Years of Age

Sec. 28. A policy of accident and sickness insurance may not be issued, delivered, amended, or renewed unless the policy provides for coverage of a child of the policyholder or certificate holder, upon request of the policyholder or certificate holder, until the date that the child becomes twenty-six (26) years of age.
As added by P.L.218-2007, SEC.48. Amended by P.L.160-2011, SEC.19.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 5. Accident and Sickness Insurance─policy Provisions › 27-8-5-29. Health Plans Offered Through Health Benefit Exchange

Sec. 29. (a) The definitions in IC 27-19-2 apply throughout this section.
(b) A health plan may not be offered to any person in Indiana through a health benefit exchange unless:
(1) the form of the policy, classification of risks, and premium rates that apply to the health plan have been filed with and reviewed and approved by the commissioner under this chapter; and
(2) the insurer is authorized under this title to engage in the business of insurance in Indiana.
(c) An insurer that offers a multistate health plan under Section 1334 of PPACA through a health benefit exchange shall file, for review and approval, the form of the policy, classification of risks, and premium rates that apply to the multistate health plan with the commissioner within five (5) business days of the date on which the same filing is made with the federal government.
(d) This title, in conformity with PPACA, applies to a health plan offered through a health benefit exchange to the same extent that this title would apply if the health plan were offered independently of a health benefit exchange.
As added by P.L.278-2013, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 5.5. Accident and Sickness Insurance─claim Forms › 27-8-5.5-1. Definitions

Sec. 1. As used in this chapter:
(a) "Commissioner" means the insurance commissioner of Indiana.
(b) "Accident and sickness insurance" means any policy or contract of insurance described in classes 1(b), 2(a), 2(b), or 2(l), as defined in IC 27-1-5-1.
As added by Acts 1977, P.L.288, SEC.1.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 5.5. Accident and Sickness Insurance─claim Forms › 27-8-5.5-2. Promulgation of Forms; Requisites; Contents; Acceptance of Claims; Explanation of Benefits Paid Statements or Claims Summary Statements

Sec. 2. (a) The commissioner shall prescribe by rule, after consultation with providers of health care or treatment, accident and sickness insurers, hospital, medical, and dental service corporations and other prepayment organizations, such accident and sickness insurance claim forms as the commissioner determines will provide for uniformity and simplicity in insurance reporting. The forms shall include, but need not be limited to, information regarding the medical diagnosis, treatment and prognosis of the patient, together with the details of charges incident to the providing of care, treatment or services, sufficient for the purpose of meeting the proof requirements of an accident or sickness insurance policy or a hospital, medical, or dental service contract.
(b) An accident and sickness insurer may not refuse to accept a claim submitted on duly promulgated uniform claim forms. However, an insurer may accept claims submitted on any other form.
(c) Accident and sickness insurer explanation of benefits paid statements or claims summary statements sent to an insured by the accident and sickness insurer may be sent in electronic or paper form and shall be in a format and written in a manner that promotes understanding by the insured by setting forth:
(1) the total dollar amount submitted to the insurer for payment;
(2) any reduction in the amount paid due to the application of any co-payment or deductible, along with an explanation of the amount of the co-payment or deductible applied under the insured's policy;
(3) any reduction in the amount paid due to the application of any other policy limitation or exclusion as set forth in the insured's policy along with an explanation thereof;
(4) the total dollar amount paid; and
(5) the total dollar amount remaining unpaid.
In addition, the explanation shall clearly set forth a toll free number that the insured may call to obtain additional information about any of the items contained in the explanation of benefits paid or claims summary statement.
(d) The commissioner may issue an order under IC 27-1-3-19(a) directing an accident and sickness insurer to comply with subsection (c).
(e) An accident and sickness insurer does not violate subsection (c) by using a document that the accident and sickness insurer has been required to use by the federal government or the state.
(f) An accident and sickness insurer shall:
(1) inform an insured that the insured may request that the statements described in subsection (c) be sent in paper form; and
(2) send the statements in paper form upon the request of the insured.
As added by Acts 1977, P.L.288, SEC.1. Amended by P.L.252-1989, SEC.1; P.L.125-2005, SEC.4.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 5.5. Accident and Sickness Insurance─claim Forms › 27-8-5.5-3. Obtaining Additional Information Regarding Claims

Sec. 3. The adoption of uniform claim forms by the commissioner pursuant to this chapter does not preclude an insurer, hospital, medical, or dental service corporation or other pre-payment organization, from obtaining any necessary additional information regarding a claim from the claimant, provider of health care or treatment, or certifier of coverage, as may be required.
As added by Acts 1977, P.L.288, SEC.1.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 5.6. Accident and Sickness Insurance─coverage for Newborns › 27-8-5.6-0.1. Application of Certain Amendments to Chapter

Sec. 0.1. The amendments made to section 2 of this chapter by P.L.189-1997 apply only to a policy or contract of accident and sickness insurance that is issued or renewed after June 30, 1997.
As added by P.L.220-2011, SEC.436.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 5.6. Accident and Sickness Insurance─coverage for Newborns › 27-8-5.6-1. "Accident and Sickness Insurance"

Sec. 1. (a) As used in this chapter, the term "accident and sickness insurance" means any policy or contract covering one (1) or more of the kinds of insurance described in classes 1(b) or 2(a) of IC 27-1-5-1, as governed by IC 27-8-5.
(b) The term does not include the following:
(1) Accident only, credit, dental, vision, Medicare supplement, long term care, or disability income insurance.
(2) Coverage issued as a supplement to liability insurance.
(3) Worker's compensation or similar insurance.
(4) Automobile medical payment insurance.
(5) A specified disease policy.
(6) A short term insurance plan that:
(A) may be renewed for the greater of:
(i) thirty-six (36) months; or
(ii) the maximum period permitted under federal law;
(B) has a term of not more than three hundred sixty-four (364) days; and
(C) has an annual limit of at least two million dollars ($2,000,000).
(7) A policy that provides indemnity benefits not based on any expense incurred requirement, including a plan that provides coverage for:
(A) hospital confinement, critical illness, or intensive care; or
(B) gaps for deductibles or copayments.
(8) A supplemental plan that always pays in addition to other coverage.
(9) A student health plan.
(10) An employer sponsored health benefit plan that is:
(A) provided to individuals who are eligible for Medicare; and
(B) not marketed as, or held out to be, a Medicare supplement policy.
Formerly: Acts 1975, P.L.282, SEC.1. As amended by P.L.173-2007, SEC.28; P.L.86-2018, SEC.207; P.L.288-2019, SEC.5.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 5.6. Accident and Sickness Insurance─coverage for Newborns › 27-8-5.6-2. Policy Provisions

Sec. 2. (a) Except as provided in subsection (b), all individual and group accident and sickness insurance policies or contracts which provide coverage on an expense incurred basis or a provision of service basis for:
(1) an individual insured, certificate holder, or subscriber; or
(2) a family member or child of the insured, certificate holder, or subscriber;
shall, as to such individual or family members' coverage, also provide that the insurance benefits applicable for the individual or family member shall be payable with respect to a newly born child of the insured, certificate holder, or subscriber from the moment of birth.
(b) Subsection (a) does not require the coverage of a newly born child of an insured or a subscriber under an individual accident and sickness policy or contract if the pregnancy resulting in the birth of the newly born child was a condition that existed prior to the issuance of the policy or contract. If the pregnancy resulting in the birth of a newly born child was a condition that existed prior to the issuance of the policy or contract, coverage for the newly born child under the policy or contract is subject to the underwriting practices followed by the insurer at the time of the birth of the child.
(c) The coverage for newly born children required by subsection (a) shall consist of coverage of injury or sickness, including the necessary care and treatment of medically diagnosed congenital defects and birth abnormalities. Coverage for newly born children required by subsection (a) shall include but not be limited to benefits for inpatient or outpatient expenses arising from medical and dental treatment (including orthodontic and oral surgery treatment) involved in the management of birth defects known as cleft lip and cleft palate.
Formerly: Acts 1975, P.L.282, SEC.1. As amended by P.L.259-1985, SEC.1; P.L.267-1987, SEC.6; P.L.257-1995, SEC.1; P.L.189-1997, SEC.1.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 5.6. Accident and Sickness Insurance─coverage for Newborns › 27-8-5.6-3. Payment of Specific Premium; Notification of Birth

Sec. 3. If payment of a specific premium or subscription fee is required to provide coverage for a child, the policy or contract may require that notification of birth of a newly born child and payment of the required premium or fees must be furnished to the insurer or nonprofit service or indemnity corporation within thirty-one (31) days after the date of birth in order to have the coverage continue beyond the thirty-one (31) day period.
Formerly: Acts 1975, P.L.282, SEC.1.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 5.6. Accident and Sickness Insurance─coverage for Newborns › 27-8-5.6-4. Application of Chapter

Sec. 4. This chapter applies to accident and sickness insurance policies and contracts delivered or issued for delivery in Indiana after October 1, 1975.
As added by P.L.5-1988, SEC.148.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 5.7. Accident and Sickness Insurance; Provider Payment › 27-8-5.7-1. "Accident and Sickness Insurance Policy" Defined

Sec. 1. As used in this chapter, "accident and sickness insurance policy" has the meaning set forth in IC 27-8-5-1.
As added by P.L.162-2001, SEC.5.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 5.7. Accident and Sickness Insurance; Provider Payment › 27-8-5.7-2. "Clean Claim" Defined

Sec. 2. As used in this chapter, "clean claim" means a claim submitted by a provider for payment under an accident and sickness insurance policy issued in Indiana that has no defect, impropriety, or particular circumstance requiring special treatment preventing payment.
As added by P.L.162-2001, SEC.5.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 5.7. Accident and Sickness Insurance; Provider Payment › 27-8-5.7-2.5. "Cpt Code"

Sec. 2.5. As used in this chapter, "CPT code" refers to the medical billing code that applies to a specific health care service, as published in the Current Procedural Terminology code set maintained by the American Medical Association.
As added by P.L.190-2023, SEC.26.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 5.7. Accident and Sickness Insurance; Provider Payment › 27-8-5.7-3. "Insurer" Defined

Sec. 3. As used in this chapter, "insurer" means an insurance company issued a certificate of authority in Indiana to issue accident and sickness insurance policies. The term includes:
(1) a preferred provider plan (as defined in IC 27-8-11-1); and
(2) an insurance administrator that:
(A) collects charges or premiums; and
(B) adjusts or settles claims;
in connection with coverage under an accident and sickness insurance policy.
As added by P.L.162-2001, SEC.5.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 5.7. Accident and Sickness Insurance; Provider Payment › 27-8-5.7-4. "Provider" Defined

Sec. 4. As used in this chapter, "provider" has the meaning set forth in IC 27-8-11-1.
As added by P.L.162-2001, SEC.5.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 5.7. Accident and Sickness Insurance; Provider Payment › 27-8-5.7-5. Notice of Deficiencies in Claims

Sec. 5. (a) An insurer shall pay or deny each clean claim in accordance with sections 6 and 6.5 of this chapter.
(b) An insurer shall notify a provider of any deficiencies in a submitted claim not more than:
(1) thirty (30) days for a claim that is filed electronically; or
(2) forty-five (45) days for a claim that is filed on paper;
and describe any remedy necessary to establish a clean claim.
(c) Failure of an insurer to notify a provider as required under subsection (b) establishes the submitted claim as a clean claim.
As added by P.L.162-2001, SEC.5. Amended by P.L.137-2002, SEC.2; P.L.190-2023, SEC.27.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 5.7. Accident and Sickness Insurance; Provider Payment › 27-8-5.7-6. Payment or Denial of Claims; Interest

Sec. 6. (a) An insurer shall pay or deny each clean claim as follows:
(1) If the claim is filed electronically, within thirty (30) days after the date the claim is received by the insurer.
(2) If the claim is filed on paper, within forty-five (45) days after the date the claim is received by the insurer.
(b) If:
(1) an insurer fails to pay or deny a clean claim in the time required under subsection (a); and
(2) the insurer subsequently pays the claim;
the insurer shall pay the provider that submitted the claim interest on the accident and sickness insurance policy allowable amount of the claim paid under this section.
(c) Interest paid under subsection (b):
(1) accrues beginning:
(A) thirty-one (31) days after the date the claim is filed under subsection (a)(1); or
(B) forty-six (46) days after the date the claim is filed under subsection (a)(2); and
(2) stops accruing on the date the claim is paid.
(d) In paying interest under subsection (b), an insurer shall use the same interest rate as provided in IC 12-15-21-3(7)(A).
As added by P.L.162-2001, SEC.5.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 5.7. Accident and Sickness Insurance; Provider Payment › 27-8-5.7-6.5. Prohibition on Altering Cpt Code for Claim; Exceptions

Sec. 6.5. (a) An insurer may not alter the CPT code submitted for a clean claim or pay for a CPT code of lesser monetary value unless:
(1) the CPT code submitted is not in accordance with correct coding guidelines and rules, clinical care guidelines, or the terms and conditions of the participating provider's agreement or contract with the insurer; or
(2) the medical record of the clean claim has been reviewed by an employee or contractor of the insurer.
(b) An insurer may not alter a clean claim to only pay for the CPT codes necessary for an individual's final diagnosis, if the CPT codes billed were deemed medically necessary according to generally accepted clinical care guidelines to reach the final diagnosis.
(c) This section does not prohibit a provider from appealing a claim.
As added by P.L.190-2023, SEC.28.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 5.7. Accident and Sickness Insurance; Provider Payment › 27-8-5.7-7. Permitted Forms

Sec. 7. A provider shall submit only the following forms for payment by an insurer:
(1) CMS-1500.
(2) CMS-1450 (UB-04).
(3) American Dental Association (ADA) claim form.
As added by P.L.162-2001, SEC.5. Amended by P.L.208-2018, SEC.10.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 5.7. Accident and Sickness Insurance; Provider Payment › 27-8-5.7-8. Civil Penalties

Sec. 8. (a) If the commissioner finds that an insurer has failed during any calendar year to process and pay clean claims in compliance with this chapter, the commissioner may assess an aggregate civil penalty against the insurer according to the following schedule:
(1) If the insurer has paid at least eighty-five percent (85%) but less than ninety-five percent (95%) of all clean claims received from all providers during the calendar year in compliance with this chapter, a civil penalty of up to ten thousand dollars ($10,000).
(2) If the insurer has paid at least sixty percent (60%) but less than eighty-five percent (85%) of all clean claims received from all providers during the calendar year in compliance with this chapter, a civil penalty of at least ten thousand dollars ($10,000) but not more than one hundred thousand dollars ($100,000).
(3) If the insurer has paid less than sixty percent (60%) of all clean claims received from all providers during the calendar year in compliance with this chapter, a civil penalty of at least one hundred thousand dollars ($100,000) but not more than two hundred thousand dollars ($200,000).
(b) In determining the amount of a civil penalty under this section, the commissioner shall consider whether the insurer's failure to achieve the standards established by this chapter is due to circumstances beyond the insurer's control.
(c) An insurer may contest a civil penalty imposed under this section by requesting an administrative hearing under IC 4-21.5 not more than thirty (30) days after the insurer receives notice of the assessment of the fine.
(d) If the commissioner imposes a civil penalty under this section, the commissioner may not impose a penalty against the insurer under IC 27-4-1 for the same activity.
(e) Civil penalties collected under this section shall be deposited in the state general fund.
As added by P.L.162-2001, SEC.5.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 5.7. Accident and Sickness Insurance; Provider Payment › 27-8-5.7-10. Claim Payment Errors

Sec. 10. (a) An insurer may not, more than two (2) years after the date on which an overpayment on a provider claim was made to the provider by the insurer:
(1) request that the provider repay the overpayment; or
(2) adjust a subsequent claim filed by the provider as a method of obtaining reimbursement of the overpayment from the provider.
(b) An insurer may not be required to correct a payment error to a provider more than two (2) years after the date on which a payment on a provider claim was made to the provider by the insurer.
(c) This section does not apply in cases of fraud by the provider, the insured, or the insurer with respect to the claim on which the overpayment or underpayment was made.
As added by P.L.55-2006, SEC.1.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 5.7. Accident and Sickness Insurance; Provider Payment › 27-8-5.7-11. Claim Overpayment Adjustment

Sec. 11. Every subsequent claim that is adjusted by an insurer for reimbursement on an overpayment of a previous provider claim made to the provider must be accompanied by an explanation of the reason for the adjustment, including:
(1) an identification of:
(A) the claim on which the overpayment was made; and
(B) if ascertainable, the party financially responsible for the overpaid amount; and
(2) the amount of the overpayment that is being reimbursed to the insurer through the adjusted subsequent claim.
As added by P.L.55-2006, SEC.2.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 5.8. Insurance Benefit Cards › 27-8-5.8-1. "Accident and Sickness Insurance Policy"

Sec. 1. As used in this chapter, "accident and sickness insurance policy" means an insurance policy that provides at least one (1) of the types of insurance described in IC 27-1-5-1, Classes 1(b) and 2(a), and is issued on a group basis. The term does not include the following:
(1) Accident only, credit, dental, vision, Medicare, Medicare supplement, long term care, or disability income insurance.
(2) Coverage issued as a supplement to liability insurance.
(3) Automobile medical payment insurance.
(4) A specified disease policy.
(5) A limited benefit health insurance policy.
(6) A short term insurance plan that:
(A) may be renewed for the greater of:
(i) thirty-six (36) months; or
(ii) the maximum period permitted under federal law;
(B) has a term of not more than three hundred sixty-four (364) days; and
(C) has an annual limit of at least two million dollars ($2,000,000).
(7) A policy that provides a stipulated daily, weekly, or monthly payment to an insured during hospital confinement, without regard to the actual expense of the confinement.
(8) Worker's compensation or similar insurance.
(9) A student health insurance policy.
As added by P.L.230-2001, SEC.2. Amended by P.L.288-2019, SEC.6.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 5.8. Insurance Benefit Cards › 27-8-5.8-3. "Insured" Defined

Sec. 3. As used in this chapter, "insured" means an individual who is entitled to coverage under an accident and sickness insurance policy.
As added by P.L.230-2001, SEC.2.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 5.8. Insurance Benefit Cards › 27-8-5.8-4. Prescription Drug Information Card

Sec. 4. (a) This section applies to an insurer that:
(1) issues an accident and sickness insurance policy that provides coverage for prescription drugs or devices; and
(2) issues a card or other technology for claims processing.
This section also applies to a third party administrator for self-insured plans, a pharmacy benefit manager, or a health benefit plan administered by the state if the administrator, manager, or plan issues a card or other technology described in subdivision (2).
(b) The card or other technology issued by an insurer or another entity referred to in subsection (a) 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 insured'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 the 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) An insurer or an insurer's agents, contractors, or administrators, including pharmacy benefits managers, 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 insurance coverage other than the coverage to which this chapter applies.
As added by P.L.230-2001, SEC.2. Amended by P.L.1-2002, SEC.111.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 5.8. Insurance Benefit Cards › 27-8-5.8-5. "Health Plan Information Card"; Indication of Health Benefits; Rules

Sec. 5. (a) As used in this section, "health plan information card" means a card that:
(1) an insurer of an accident and sickness insurance policy; 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 health benefits or services.
(b) Subject to subsection (c), a health plan information card must indicate that the health benefits and services are provided by:
(1) an insurer of an accident and sickness insurance policy; or
(2) a third party administrator of a self-insured plan.
(c) Subsection (b) applies only to a health plan information card issued:
(1) initially to a new insured; or
(2) to an insured at the time of the insured's policy renewal;
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.11.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 5.8. Insurance Benefit Cards › 27-8-5.8-6. "Insurer"; Electronic Data Base; Required Information; Rules

Sec. 6. (a) As used in this section, "insurer" means:
(1) an issuer of an accident and sickness insurance policy; or
(2) a third party administrator of health benefits and services under an accident and sickness insurance policy.
(b) The electronic data base by which an insurer allows an insured or a provider to verify an insured's coverage or benefits under an accident and sickness insurance policy issued or administered by the insurer must include the following information for each insured:
(1) Whether health benefits and services under the accident and sickness insurance policy are provided by:
(A) the issuer of the accident and sickness insurance policy; or
(B) a third party administrator.
(2) Whether the accident and sickness insurance policy is subject to state or federal regulation.
(c) 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.12.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 5.9. Short Term Insurance Plan › 27-8-5.9-2. "Ppaca"

Sec. 2. As used in this chapter, "PPACA" has the meaning set forth in IC 27-19-2-14.
As added by P.L.288-2019, SEC.7.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 5.9. Short Term Insurance Plan › 27-8-5.9-3. "Short Term Insurance Plan"

Sec. 3. As used in this chapter, "short term insurance plan" means a policy of accident and sickness insurance (as defined in IC 27-8-5-1) that:
(1) may be renewed for the greater of:
(A) thirty-six (36) months; or
(B) the maximum period permitted under federal law;
(2) has a term of not more than three hundred sixty-four (364) days; and
(3) has an annual limit of at least two million dollars ($2,000,000).
As added by P.L.288-2019, SEC.7.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 5.9. Short Term Insurance Plan › 27-8-5.9-4. Renewal Requirements

Sec. 4. (a) An insurer may require an applicant for coverage under a short term insurance plan to specify, before issuance of the short term insurance plan, the number of renewals the applicant elects.
(b) After issuance of a short term insurance plan, the insurer may not require underwriting of the short term insurance plan until:
(1) all renewal periods elected under subsection (a) have ended; and
(2) the covered individual renews the short term insurance plan beyond the periods described in subdivision (1).
As added by P.L.288-2019, SEC.7.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 5.9. Short Term Insurance Plan › 27-8-5.9-5. Coverage Requirements

Sec. 5. A short term insurance plan must include coverage for the following:
(1) Ambulatory patient services.
(2) Hospitalization.
(3) Emergency services.
(4) Laboratory services.
As added by P.L.288-2019, SEC.7.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 5.9. Short Term Insurance Plan › 27-8-5.9-6. Use of Preferred Provider Plan

Sec. 6. (a) This section applies to an insurer that issues a short term insurance plan and undertakes a preferred provider plan under IC 27-8-11 to render health care services to covered individuals under the short term insurance plan.
(b) An insurer described in subsection (a) shall ensure that the preferred provider plan meets the following requirements:
(1) The preferred provider plan includes essential community providers in accordance with PPACA.
(2) The preferred provider plan is sufficient in number and types of providers (other than mental health and substance abuse treatment providers) to assure covered individuals' access to all health care services without unreasonable delay.
(3) The preferred provider plan is consistent with the network adequacy requirements that:
(A) apply to qualified health plan issuers under 45 CFR 156.230(a) and 45 CFR 156.230(b); and
(B) are consistent with subdivisions (1) and (2).
As added by P.L.288-2019, SEC.7.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 5.9. Short Term Insurance Plan › 27-8-5.9-7. Disclosures

Sec. 7. (a) An insurer that issues a short term insurance plan shall disclose to an applicant, in bold, 10 point type, the following:
(1) That the short term insurance plan does not include coverage for the ten (10) essential health benefits required under PPACA.
(2) That the short term insurance plan does not provide the coverage that is required under PPACA.
(3) That enrollment in health coverage that provides the coverage that is required under PPACA may be done during the next PPACA open enrollment period.
(4) The dates of the next PPACA open enrollment period during which the applicant may enroll in coverage described in subdivision (3).
(b) An insurer shall obtain the signature of an applicant to whom the disclosures required by subsection (a) are made.
As added by P.L.288-2019, SEC.7.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 5.9. Short Term Insurance Plan › 27-8-5.9-8. Similarly Situated Individuals

Sec. 8. An insurer shall not, as a condition of enrollment or continued enrollment in a short term insurance plan, require an individual to pay a premium or contribution greater than the premium or contribution for a similarly situated individual enrolled in the short term insurance plan on the basis of a health status related factor in relation to the individual or a dependent of the individual.
As added by P.L.288-2019, SEC.7.