reglab/statecodes huggingface dataset:
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 10. Comprehensive Health Insurance › 27-8-10-3.5. Chronic Disease and Pharmaceutical Management Programs

Sec. 3.5. (a) The association shall:
(1) approve and implement chronic disease management and pharmaceutical management programs based on:
(A) an analysis of the highest cost health care services covered under association policies;
(B) a review of chronic disease management and pharmaceutical management programs used in populations similar to insureds; and
(C) a determination of the chronic disease management and pharmaceutical management programs expected to best improve health outcomes in a cost effective manner;
(2) consider recommendations of the drug utilization review board established by IC 12-15-35-19 concerning chronic disease management and pharmaceutical management programs;
(3) when practicable, coordinate programs adopted under this section with comparable programs implemented by the state; and
(4) implement a copayment structure for prescription drugs covered under an association policy.
(b) A program approved and implemented under this section may not require prior authorization for a prescription drug that is prescribed for the treatment of:
(1) human immunodeficiency virus (HIV) or acquired immune deficiency syndrome (AIDS) and is included on the AIDS drug assistance program formulary adopted by the Indiana department of health under the federal Ryan White CARE Act (42 U.S.C. 300ff et seq.); or
(2) hemophilia according to recommendations of the:
(A) Advisory Committee on Blood Safety and Availability of the United States Department of Health and Human Services; or
(B) Medical and Scientific Advisory Council of the National Hemophilia Foundation.
(c) The copayment structure implemented under subsection (a) must be based on an annual actuarial analysis.
(d) A disease management program for which federal funding is available is considered to be approved by the association under this section.
(e) An insured who has a chronic disease for which at least one (1) chronic disease management program is approved under this section shall participate in an approved chronic disease management program for the chronic disease as a condition of coverage of treatment for the chronic disease under an association policy.
As added by P.L.193-2003, SEC.5. Amended by P.L.56-2023, SEC.246.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 10. Comprehensive Health Insurance › 27-8-10-3.6. Mail Order or Internet Based Pharmacy

Sec. 3.6. (a) The association shall approve a mail order or Internet based pharmacy (as defined in IC 25-26-18-1) through which an insured may obtain prescription drugs covered under an association policy.
(b) A prescription drug that is covered under an association policy is covered if the prescription drug is obtained from:
(1) a pharmacy approved under subsection (a); or
(2) a pharmacy that:
(A) is not approved under subsection (a); and
(B) agrees to sell the prescription drug at the same price as a pharmacy approved under subsection (a).
(c) A prescription drug that is:
(1) covered under an association policy; and
(2) obtained from a pharmacy not described in subsection (b);
is covered for an amount equal to the price at which a pharmacy described in subsection (b) will sell the prescription drug, with the remainder of the charge for the prescription drug to be paid by the insured.
As added by P.L.193-2003, SEC.6.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 10. Comprehensive Health Insurance › 27-8-10-4. Policies; Deductible and Coinsurance Requirements; Limitations

Sec. 4. (a) Subject to the limitation provided in subsection (c), an association policy offered in accordance with this chapter must impose a five hundred dollar ($500) deductible on a per person per policy year basis. The deductible must be applied to the first five hundred dollars ($500) of eligible expenses incurred by the covered person.
(b) Subject to the limitation provided in subsection (c), a mandatory coinsurance requirement shall be imposed at the rate of twenty percent (20%) of eligible expenses in excess of the mandatory deductible.
(c) The maximum aggregate out-of-pocket payments for eligible expenses by the insured in the form of deductibles and coinsurance may not exceed one thousand five hundred dollars ($1,500) per individual or two thousand five hundred dollars ($2,500) per family, per policy year.
As added by Acts 1981, P.L.249, SEC.1. Amended by P.L.253-1989, SEC.4.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 10. Comprehensive Health Insurance › 27-8-10-5. Repealed

As added by Acts 1981, P.L.249, SEC.1. Amended by P.L.253-1989, SEC.5; P.L.254-1989, SEC.2. Repealed by P.L.1-1990, SEC.263.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 10. Comprehensive Health Insurance › 27-8-10-6. Policies; Renewal Provisions; Election to Continue Coverage Upon Death of Policyholder

Sec. 6. (a) An association policy offered under this chapter must contain provisions under which the association is obligated to renew the contract until:
(1) the date on which coverage terminates under section 5.1 of this chapter; or
(2) the day on which the individual in whose name the contract is issued first becomes eligible for Medicare coverage, except that in a family policy covering both husband and wife, the age of the younger spouse must be used as the basis for meeting the durational requirement of this subdivision.
(b) The association may not change the rates for association policies or Medicare supplement policies except on a class basis with a clear disclosure in the policy of the association's right to do so.
(c) An association policy offered under this chapter must provide that upon the death of the individual in whose name the contract is issued, every other individual then covered under the contract may elect, within a period specified in the contract, to continue coverage under the same or a different contract until such time as he would have ceased to be entitled to coverage had the individual in whose name the contract was issued lived.
As added by Acts 1981, P.L.249, SEC.1. Amended by P.L.116-1994, SEC.68; P.L.193-2003, SEC.8.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 10. Comprehensive Health Insurance › 27-8-10-7. Rules; Adoption

Sec. 7. The commissioner may adopt rules, under IC 4-22-2, that:
(1) provide for disclosure by carriers of the availability of insurance coverage from the association; and
(2) implement this chapter.
As added by Acts 1981, P.L.249, SEC.1.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 10. Comprehensive Health Insurance › 27-8-10-8. Civil or Criminal Liability of Association or Members

Sec. 8. Neither the participation by carriers or members in the association, the establishment of rates, forms, or procedures for coverages issued by the association, nor any joint or collective action required by this chapter shall be the basis of any legal action, civil, or criminal liability against the association or members of it either jointly or separately.
As added by Acts 1981, P.L.249, SEC.1.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 10. Comprehensive Health Insurance › 27-8-10-9. Medicare Supplement Policies

Sec. 9. (a) The association may issue Medicare supplement policies to individuals who reside in Indiana.
(b) A Medicare supplement policy issued under this section:
(1) must be based on a model policy adopted by the commissioner under IC 27-8-13-10.1; and
(2) must meet the standards for Medicare supplement policy benefits established under IC 27-8-13-10.1.
(c) A Medicare supplement policy issued under this section is not subject to the deductible and coinsurance requirements and the eligibility restrictions applying to association policies under sections 4 and 5.1 of this chapter. However, the association may provide that an individual is not eligible for a Medicare supplement policy issued under this section unless the individual has applied to one (1) carrier for a Medicare supplement policy and the application of the individual has been rejected.
As added by P.L.116-1994, SEC.69.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 10. Comprehensive Health Insurance › 27-8-10-10. Eligibility Guidelines

Sec. 10. Before January 1, 1996, the board of directors of the association shall establish eligibility guidelines for the issuance of an association policy under this chapter to prohibit an:
(1) employer;
(2) insurance producer; or
(3) insurance broker;
from placing in or referring to the association an individual who works for an employer who offers employees an employee welfare benefit plan (as defined in 29 U.S.C. 1002).
As added by P.L.93-1995, SEC.9. Amended by P.L.178-2003, SEC.64.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 10. Comprehensive Health Insurance › 27-8-10-11.2. Use of Diagnostic or Procedure Codes

Sec. 11.2. (a) Not more than ninety (90) days after the date of the version specified in IC 27-1-1.5 of a diagnostic or procedure code described in this subsection:
(1) the association shall begin using the version specified in IC 27-1-1.5 of the:
(A) Current Procedural Terminology (CPT);
(B) International Classification of Diseases (ICD);
(C) American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM);
(D) Current Dental Terminology (CDT);
(E) Healthcare Common Procedure Coding System (HCPCS); and
(F) third party administrator (TPA);
codes under which the association pays claims for services provided under an association policy; and
(2) a health care provider shall begin using the version specified in IC 27-1-1.5 of the:
(A) Current Procedural Terminology (CPT);
(B) International Classification of Diseases (ICD);
(C) American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM);
(D) Current Dental Terminology (CDT);
(E) Healthcare Common Procedure Coding System (HCPCS); and
(F) third party administrator (TPA);
codes under which the health care provider submits claims for payment for services provided under an association policy.
(b) If a health care provider provides services that are covered under an association policy:
(1) after the date of the version specified in IC 27-1-1.5 of a diagnostic or procedure code described in subsection (a); and
(2) before the association begins using the version of the diagnostic or procedure code;
the association shall reimburse the health care provider under the version of the diagnostic or procedure code that was specified in IC 27-1-1.5 on the date that the services were provided.
As added by P.L.161-2001, SEC.3. Amended by P.L.66-2002, SEC.15; P.L.124-2018, SEC.78.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 10. Comprehensive Health Insurance › 27-8-10-14. Repealed

As added by P.L.193-2003, SEC.11. Amended by P.L.97-2004, SEC.101; P.L.51-2004, SEC.9. Repealed by P.L.1-2007, SEC.248.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 11. Accident and Sickness Insurance─reimbursement Agreements › 27-8-11-0.1. Application of Certain Amendments to Chapter

Sec. 0.1. The addition of section 9 of this chapter by P.L.74-2007 applies to an agreement between an insurer and a provider that is entered into, amended, or renewed on or after April 26, 2007.
As added by P.L.220-2011, SEC.441.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 11. Accident and Sickness Insurance─reimbursement Agreements › 27-8-11-1. Definitions

Sec. 1. (a) The definitions in this section apply throughout this chapter.
(b) "Credentialing" means a process through which an insurer makes a determination:
(1) based on criteria established by the insurer; and
(2) concerning whether a provider is eligible to:
(A) provide health care services to an insured; and
(B) receive reimbursement for the health care services;
under an agreement entered into between the provider and the insurer under section 3 of this chapter.
(c) "Health care services":
(1) means health care related services or products rendered or sold by a provider within the scope of the provider's license or legal authorization; and
(2) includes hospital, medical, surgical, dental, vision, and pharmaceutical services or products.
(d) "Insured" means an individual entitled to reimbursement for expenses of health care services under a policy issued or administered by an insurer.
(e) "Insurer" means an insurance company authorized in this state to issue policies that provide reimbursement for expenses of health care services.
(f) "Person" means an individual, an agency, a political subdivision, a partnership, a corporation, an association, or any other entity.
(g) "Preferred provider plan" means an undertaking to enter into agreements with providers relating to terms and conditions of reimbursements for the health care services of insureds, members, or enrollees relating to the amounts to be charged to insureds, members, or enrollees for health care services.
(h) "Provider" means an individual or entity duly licensed or legally authorized to provide health care services.
As added by P.L.140-1984, SEC.1. Amended by P.L.31-1988, SEC.22; P.L.26-2005, SEC.1.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 11. Accident and Sickness Insurance─reimbursement Agreements › 27-8-11-2. Conflicting Provisions

Sec. 2. To the extent of any conflict between this chapter and IC 27-4-1-4, IC 27-8-5-15, IC 27-8-6-1, or any other statutory provision, this chapter prevails over the conflicting provision. Agreements may be entered into under section 3(a)(1) of this chapter notwithstanding any contradictory policy provision prescribed under IC 27-8-5-3(a)(9).
As added by P.L.140-1984, SEC.1. Amended by P.L.1-2010, SEC.111.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 11. Accident and Sickness Insurance─reimbursement Agreements › 27-8-11-4. Accessibility and Availability Terms; Reasonable Standards

Sec. 4. Policies issued under section 3(a)(3) or section 3.1 of this chapter (before its repeal) may not contain terms or conditions that would operate unreasonably to restrict the access and availability of health care services for the insured. The commissioner of insurance may, under IC 4-22-2, adopt rules binding upon insurers prescribing reasonable standards relating to the accessibility and availability of health care services for persons insured under policies described in section 3(a)(3) or section 3.1 of this chapter (before its repeal).
As added by P.L.140-1984, SEC.1. Amended by P.L.134-1994, SEC.3; P.L.1-1999, SEC.61.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 11. Accident and Sickness Insurance─reimbursement Agreements › 27-8-11-4.5. Permitted Disclosures by Providers; Coverage of Benefit or Service; Payment of Provider; Application

Sec. 4.5. (a) An agreement between an insurer and provider under section 3 of this chapter may not prohibit a provider from disclosing:
(1) financial incentives to the provider;
(2) all treatment options available to an insured, including those not covered by the insured's policy.
(b) An insurer may not penalize a provider financially or in any other manner for making a disclosure permitted under subsection (a).
(c) An insured is not entitled to coverage of a benefit or service under a health insurance policy unless that benefit or service is included in the insured's health insurance policy.
(d) A provider is not entitled to payment under a policy for benefits or services provided to an insured unless the provider has a contract or an agreement with the insurer.
(e) This section applies to a contract entered, renewed, or modified after June 30, 1996.
As added by P.L.192-1996, SEC.1.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 11. Accident and Sickness Insurance─reimbursement Agreements › 27-8-11-5. Preferred Provider Plans; Filing Sworn Statement

Sec. 5. Each person that organizes a preferred provider plan under this chapter shall file with the commissioner before March 1 of each year a statement, under oath, upon a form prescribed by the commissioner that covers the preceding calendar year and includes the following:
(1) The name and address of each person that has organized a preferred provider plan.
(2) The names and addresses of the providers with whom the preferred provider plan has entered into agreements under section 3 of this chapter.
(3) The geographical area, by counties, within which the preferred provider plan provides or arranges for health care services for insureds, members or enrollees.
(4) The number of insureds, members or enrollees covered by the agreements listed in subdivision (2).
As added by P.L.31-1988, SEC.23.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 11. Accident and Sickness Insurance─reimbursement Agreements › 27-8-11-6. Preferred Provider Plans; Hospital Accreditation

Sec. 6. (a) A preferred provider plan 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 preferred provider plan 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.2.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 11. Accident and Sickness Insurance─reimbursement Agreements › 27-8-11-7.5. Provisional Credentialing for Independent Primary Care Practice Physicians; Criteria

Sec. 7.5. (a) A physician licensed under IC 25-22.5 who was credentialed to provide services under Medicaid within the previous twelve (12) months shall be considered provisionally credentialed if the physician:
(1) is in good standing with the office or a managed care organization or contractor of the office; and
(2) establishes or joins an independent primary care practice.
(b) The insurer shall complete the credentialing process for an individual who is provisionally credentialed under subsection (a).
As added by P.L.203-2023, SEC.23.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 11. Accident and Sickness Insurance─reimbursement Agreements › 27-8-11-8. Provider Directories

Sec. 8. (a) An insurer may provide to an insured in electronic or paper form a directory of providers with which the insurer has entered into an agreement under section 3 of this chapter.
(b) An insurer that provides a directory described in subsection (a) shall:
(1) inform the insured that the insured may request the directory in paper form; and
(2) provide the directory in paper form upon the request of the insured.
As added by P.L.125-2005, SEC.5.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 11. Accident and Sickness Insurance─reimbursement Agreements › 27-8-11-9. Preferred Provider Agreement Prohibitions

Sec. 9. (a) As used in this section, "insurer" includes the following:
(1) An administrator licensed under IC 27-1-25.
(2) A person that pays or administers claims on behalf of an insurer.
(b) An agreement between an insurer and a provider under this chapter may not contain a provision that:
(1) prohibits, or grants the insurer an option to prohibit, the provider from contracting with another insurer to accept lower payment for health care services than the payment specified in the agreement;
(2) requires, or grants the insurer an option to require, the provider to accept a lower payment from the insurer if the provider agrees with another insurer to accept lower payment for health care services;
(3) requires, or grants the insurer an option of, termination or renegotiation of the agreement if the provider agrees with another insurer to accept lower payment for health care services; or
(4) requires the provider to disclose the provider's reimbursement rates under contracts with other insurers.
(c) A provision that:
(1) is contained in an agreement between an insurer and a provider under this chapter; and
(2) violates this section;
is void.
As added by P.L.74-2007, SEC.1.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 11. Accident and Sickness Insurance─reimbursement Agreements › 27-8-11-10. Coverage for Dialysis Treatment

Sec. 10. (a) As used in this section, "dialysis facility" means an outpatient facility in Indiana at which a dialysis treatment provider provides dialysis treatment.
(b) As used in this section, "contracted dialysis facility" means a dialysis facility that has entered into an agreement with a particular insurer under section 3 of this chapter.
(c) Notwithstanding section 1 of this chapter, as used in this section, "insured" refers only to an insured who requires dialysis treatment.
(d) As used in this section, "insurer" includes the following:
(1) An administrator licensed under IC 27-1-25.
(2) An agent of an insurer.
(e) As used in this section, "non-contracted dialysis facility" means a dialysis facility that has not entered into an agreement with a particular insurer under section 3 of this chapter.
(f) An insurer shall not require an insured, as a condition of coverage or reimbursement, to:
(1) if the nearest dialysis facility is located within thirty (30) miles of the insured's home, travel more than thirty (30) miles from the insured's home to obtain dialysis treatment; or
(2) if the nearest dialysis facility is located more than thirty (30) miles from the insured's home, travel a greater distance than the distance to the nearest dialysis facility to obtain dialysis treatment;
regardless of whether the insured chooses to receive dialysis treatment at a contracted dialysis facility or a non-contracted dialysis facility.
As added by P.L.111-2008, SEC.4.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 11. Accident and Sickness Insurance─reimbursement Agreements › 27-8-11-11. Insurer Payment to Insured for Service Rendered by Noncontracted Provider; Requirements

Sec. 11. (a) As used in this section, "noncontracted provider" means a provider that has not entered into an agreement with an insurer under section 3 of this chapter.
(b) After September 30, 2009, if an insurer makes a payment to an insured for a health care service rendered by a noncontracted provider, the insurer shall include with the payment instrument written notice to the insured that includes the following:
(1) A statement specifying the claims covered by the payment instrument.
(2) The name and address of the provider submitting each claim.
(3) The amount paid by the insurer for each claim.
(4) Any amount of a claim that is the insured's responsibility.
(5) A statement in at least 24 point bold type that:
(A) instructs the insured to use the payment to pay the noncontracted provider if the insured has not paid the noncontracted provider in full;
(B) specifies that paying the noncontracted provider is the insured's responsibility; and
(C) states that the failure to make the payment violates the law and may result in collection proceedings or criminal penalties.
As added by P.L.144-2009, SEC.2.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 11. Accident and Sickness Insurance─reimbursement Agreements › 27-8-11-12. Right to Provide Prescription Cost Information; Point of Sale Cost Limit; Pharmacist May Not Be Required to Collect Higher Copayment

Sec. 12. (a) As used in this section, "drug" means a prescription drug.
(b) As used in this section, "insurer" refers to an insurer that provides coverage for drugs. The term includes a person that administers drug benefits on behalf of an insurer.
(c) As used in this section, "pharmacy" refers to a pharmacist or pharmacy that has entered into an agreement with an insurer under section 3 of this chapter.
(d) A pharmacy or pharmacist shall have the right to provide an insured with information concerning the amount of the insured's cost share for a prescription drug. Neither a pharmacy nor a pharmacist shall be proscribed by an insurer from discussing this information or from selling to the insured a more affordable alternative if an affordable alternative is available.
(e) An insurer that covers prescription drugs may not include a provision that requires an insured to make payment for a prescription drug at the point of sale in an amount that exceeds the lesser of:
(1) the contracted copayment amount; or
(2) the amount of total approved charges by the insurer at the point of sale.
This subsection does not prohibit the adjudication of claims in accordance with an accident and sickness insurance policy issued or administered by an insurer. The insured is not liable for any additional charges or entitled to any credits as a result of the adjudicated claim.
(f) The insurer or a pharmacy benefit manager may not require a pharmacy or pharmacist to collect a higher copayment for a prescription drug from an insured than the insurer or pharmacy benefit manager allows the pharmacy or pharmacist to retain.
As added by P.L.209-2018, SEC.12. Amended by P.L.114-2020, SEC.20; P.L.9-2022, SEC.52.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 11. Accident and Sickness Insurance─reimbursement Agreements › 27-8-11-13. Fully Credentialed Provider Reimbursement; Requirements

Sec. 13. (a) A fully credentialed provider shall be reimbursed for eligible services provided at any in-network hospital if the following conditions are met:
(1) The provider submits the documentation required by the insurer to be loaded under the provider group or hospital.
(2) The provider, provider group, or hospital is a network provider with the insurer.
(3) The services are provided in accordance with all terms and conditions of the provider's, group provider's, or hospital's agreement or contract with the insurer.
(4) Prior authorization is obtained in accordance with IC 27-1-37.5 when required by the insurer for an eligible service.
(b) The insurer shall reimburse the provider or hospital for services described in subsection (a) at the rates determined by the contract between the provider and the insurer.
(c) An insurer is not required to credential a provider. However, if:
(1) a provider is employed by a hospital that is part of the hospital's network that is covered by the insurer; and
(2) the provider meets the insurer's credentialing requirements;
the insurer shall reimburse the provider for any reimbursable services from the date that the provider was employed by the hospital.
As added by P.L.50-2020, SEC.8.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 12. Long Term Care Insurance › 27-8-12-1. "Applicant" Defined

Sec. 1. As used in this chapter, "applicant" means:
(1) an individual who applies for long term care insurance through an individual insurance policy; or
(2) a prospective holder of a certificate issued under a group long term care insurance policy.
As added by P.L.275-1987, SEC.1.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 12. Long Term Care Insurance › 27-8-12-2. "Certificate" Defined

Sec. 2. As used in this chapter, "certificate" means a document issued to a member of the group covered under a group insurance policy, which policy has been delivered or issued for delivery in Indiana, to signify that the individual named in the certificate is covered under the policy.
As added by P.L.275-1987, SEC.1.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 12. Long Term Care Insurance › 27-8-12-4. "Insurance Policy" Defined

Sec. 4. As used in this chapter, "insurance policy" means any policy, contract, subscriber agreement, rider, or endorsement delivered or issued for delivery in Indiana by an insurer, a fraternal benefit society, a nonprofit corporation, a health maintenance organization (as defined in IC 27-13-1-19), a limited service health maintenance organization (as defined in IC 27-13-34-4), a preferred provider arrangement, or any other organization.
As added by P.L.275-1987, SEC.1. Amended by P.L.26-1994, SEC.16.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 12. Long Term Care Insurance › 27-8-12-4.5. "Long Term Care Facility" Defined

Sec. 4.5. As used in this chapter, "long term care facility" has the meaning set forth in IC 12-15-39.6-2.
As added by P.L.75-1994, SEC.9. Amended by P.L.24-1997, SEC.63.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 12. Long Term Care Insurance › 27-8-12-5. "Long Term Care Insurance Policy" Defined

Sec. 5. (a) As used in this chapter, "long term care insurance policy" means an insurance policy providing coverage for at least twelve (12) consecutive months for each covered person on an expense incurred, indemnity, prepaid, or other basis for one (1) or more necessary diagnostic, preventive, therapeutic, rehabilitative, maintenance, or personal care services provided in a setting other than an acute care wing of a hospital.
(b) The term includes the following:
(1) A policy advertised, marketed, or offered as long term care insurance.
(2) A group or individual annuity, a life insurance policy, or riders that provide directly or supplement long term care insurance.
(3) A policy or rider that provides for payment of benefits based upon cognitive impairment or the loss of functional capacity.
(c) The term does not include the following:
(1) An insurance policy that is offered primarily to provide basic hospital expense coverage, basic medical-surgical expense coverage, hospital confinement indemnity coverage, major medical expense coverage, disability income protection coverage, accident only coverage, specified disease or specified accident coverage, comprehensive coverage, catastrophic coverage, or limited benefit health coverage.
(2) A life insurance policy that accelerates the death benefit specifically for terminal illness, a medical condition requiring extraordinary medical intervention, or a permanent institutional confinement, and that provides the option of a lump sum payment for those benefits and in which neither the benefits nor the eligibility for the benefits is conditioned upon the receipt of long term care.
(3) An insurance policy that is offered primarily to provide basic Medicare supplemental coverage (as defined under IC 27-8-13).
As added by P.L.275-1987, SEC.1. Amended by P.L.114-1991, SEC.9.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 12. Long Term Care Insurance › 27-8-12-6. Compliance With Statutory Requirements

Sec. 6. An insurance policy may be marketed, advertised, offered, or sold in Indiana as long term care insurance only if that policy complies with the requirements of this chapter.
As added by P.L.275-1987, SEC.1.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 12. Long Term Care Insurance › 27-8-12-7. Policy Disclosure Standards; Marketing Practices; Continuing Education; Penalties; Reporting Practices; Rules

Sec. 7. (a) The insurance commissioner shall adopt rules under IC 4-22-2 establishing standards of full and fair disclosure concerning long term care insurance policies. The standards must require disclosure of information concerning the following:
(1) The sale of the policies.
(2) Terms of renewability.
(3) Initial and subsequent terms of eligibility.
(4) Nonduplication of coverage provisions.
(5) Coverage of dependents.
(6) Preexisting conditions.
(7) Termination of insurance coverage.
(8) Probationary periods.
(9) Limitations on coverage.
(10) Exceptions to coverage.
(11) Reductions from coverage.
(12) Elimination periods.
(13) Requirements for replacement.
(14) Recurrent conditions.
(15) Definitions of terms.
(16) Continuation or conversion of coverage.
(b) The insurance commissioner shall adopt rules under IC 4-22-2 to establish minimum standards concerning:
(1) marketing practices;
(2) insurance producer continuing education;
(3) penalties; and
(4) reporting practices;
for long term care insurance.
(c) Rules adopted by the insurance commissioner under this section must:
(1) recognize the unique, developing, and experimental nature of long term care insurance; and
(2) where necessary or appropriate, recognize the distinctions between group insurance policies and individual insurance policies.
As added by P.L.275-1987, SEC.1. Amended by P.L.114-1991, SEC.10; P.L.178-2003, SEC.65.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 12. Long Term Care Insurance › 27-8-12-7.1. Qualification of Long Term Care Policies; Rules

Sec. 7.1. The department of insurance shall adopt rules under IC 4-22-2 that establish standards for the qualification of a long term care policy under IC 12-15-39.6. The rules must include the following:
(1) The standards adopted under section 7 of this chapter.
(2) The requirement that an insurer or other person who issues a qualified long term care policy must at a minimum offer to each policyholder or prospective policyholder a policy that provides both:
(A) long term care facility coverage; and
(B) home and community care coverage.
(3) A provision that an insurer or other person who complies with subdivision (2) may elect to also offer a qualified long term care policy that provides only long term care facility coverage.
(4) The submission of data by insurers that will allow the department of insurance, the office of Medicaid policy and planning, and the division of aging to administer the Indiana long term care program under IC 12-15-39.6.
(5) Other standards needed to administer the Indiana long term care program.
As added by P.L.114-1991, SEC.11. Amended by P.L.9-1991, SEC.94; P.L.2-1992, SEC.786; P.L.4-1993, SEC.260; P.L.5-1993, SEC.273; P.L.75-1994, SEC.10; P.L.24-1997, SEC.64; P.L.141-2006, SEC.109.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 12. Long Term Care Insurance › 27-8-12-8. Loss Ratio Standards Rule

Sec. 8. The insurance commissioner may not adopt a rule establishing loss ratio standards that apply to long term care insurance policies unless the rule exclusively concerns long term care insurance.
As added by P.L.275-1987, SEC.1.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 12. Long Term Care Insurance › 27-8-12-9. Termination of Policy on Grounds of Age or Deteriorated Health

Sec. 9. An insurer that issues a long term care insurance policy may not cancel, decline to renew, or otherwise terminate the policy solely on the grounds of the age or deterioration in mental or physical health of the insured individual or certificate holder.
As added by P.L.275-1987, SEC.1.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 12. Long Term Care Insurance › 27-8-12-10. "Preexisting Condition" Defined; Exclusion of Coverage; Limitations

Sec. 10. (a) As used in this section, "preexisting condition" means the existence of:
(1) either:
(A) symptoms that would cause an ordinarily prudent person to seek diagnosis, care, or treatment; or
(B) a condition for which medical advice or treatment was recommended by, or received from, a provider of health care services; within
(2) a period not to exceed either:
(A) twelve (12) months preceding the effective date of coverage of an insured person who is sixty-five (65) years of age or older on the effective date of coverage; or
(B) twenty-four (24) months preceding the effective date of coverage of an insured person who is less than sixty-five (65) years of age on the effective date of coverage.
(b) A long term care insurance policy may exclude coverage for a loss or confinement that is the result of a preexisting condition only if that loss or confinement begins within:
(1) twelve (12) months following the effective date of coverage of an insured person who is sixty-five (65) years of age or older on the effective date of coverage; or
(2) twenty-four (24) months following the effective date of coverage of an insured person who is under sixty-five (65) years of age on the effective date of coverage.
(c) The insurance commissioner may extend the limitation periods set forth in subsections (a)(2)(A), (a)(2)(B), and (b), concerning specific age group categories in specific policies upon a finding that the extension is in the best interest of the public.
As added by P.L.275-1987, SEC.1.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 12. Long Term Care Insurance › 27-8-12-10.5. Loss or Confinement Resulting From a Preexisting Condition; Exclusion of Coverage; Limitation Period; Rules

Sec. 10.5. (a) As used in this section, "preexisting condition" means a condition for which medical advice or treatment was recommended by or received from a provider of health care services within six (6) months preceding the effective date of coverage of an insured individual.
(b) A long term care insurance policy may not use a definition of preexisting condition that is more restrictive than the definition contained in subsection (a).
(c) Except for a group long term care policy under IC 27-8-5-16(1) or IC 27-1-12-37, a long term care insurance policy may not exclude coverage for a loss or confinement that is the result of a preexisting condition unless the loss or confinement begins within six (6) months following the effective date of coverage of an insured individual.
(d) The commissioner may extend the limitation period under subsections (a) and (c) concerning a specific age group category in a specific policy form upon a finding by the commissioner that the extension is in the best interest of the public.
(e) This section does not prohibit an insurer from doing any of the following:
(1) Using an application form designed to elicit the complete health history of an applicant.
(2) Based on an application, underwriting in accordance with the insurer's established underwriting standards.
(f) Unless otherwise provided in the policy or certificate, a preexisting condition, regardless of whether the condition is disclosed on the application, need not be covered until after the waiting period described in subsection (c).
(g) A long term care insurance policy may not exclude or use a waiver or rider to exclude, limit, or reduce coverage or benefits for a specifically named or described preexisting disease or physical condition beyond the waiting period described in subsection (c).
As added by P.L.114-1991, SEC.12.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 12. Long Term Care Insurance › 27-8-12-10.6. Conditions on Eligibility for Benefits; Restrictions

Sec. 10.6. (a) A long term care insurance policy may not be delivered or issued for delivery in Indiana if the policy:
(1) conditions eligibility for any benefits on a prior hospitalization requirement;
(2) conditions eligibility for benefits provided in an institutional care setting on the receipt of a higher level of institutional care; or
(3) conditions eligibility for a benefit other than:
(A) a waiver of premium;
(B) postconfinement;
(C) postacute care; or
(D) recuperative benefits;
on a prior institutionalization requirement.
(b) A long term care insurance policy containing a postconfinement, postacute, or recuperative benefit must clearly label in a separate paragraph of the policy a statement entitled "limitations or conditions on eligibility for benefits". Under the statement, the policy must outline any limitations or conditions for benefits.
(c) A long term care insurance policy or rider that conditions eligibility of noninstitutional benefits on the prior receipt of institutional care must not require a prior institutional stay of more than thirty (30) days.
(d) A long term care insurance policy or rider that provides benefits only following institutionalization may not condition such benefits upon admission to a facility for the same or related conditions within a period of less than thirty (30) days after discharge from the institution.
As added by P.L.114-1991, SEC.13.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 12. Long Term Care Insurance › 27-8-12-11. Establishment of New Waiting Period

Sec. 11. (a) A long term care insurance policy may not:
(1) contain a provision establishing a new waiting period if an existing policy is converted to or replaced by a new form issued by the same insurer, except in the case of an increase in benefits voluntarily selected by the insured individual or group policyholder;
(2) be canceled, nonrenewed, or otherwise terminated on the grounds of age or the deterioration of the mental or physical health of the insured individual or certificate holder;
(3) provide coverage for skilled nursing care only; or
(4) provide significantly more coverage for skilled care than coverage for a lower level of care.
(b) Subsection (a) does not prohibit an insurer from voluntarily waiving any authorized waiting period.
As added by P.L.275-1987, SEC.1. Amended by P.L.114-1991, SEC.14.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 12. Long Term Care Insurance › 27-8-12-12. No Obligation Return Period; Notice

Sec. 12. (a) An individual long term care insurance policyholder may return the policy within thirty (30) days of its delivery and have the premium refunded if, after examination of the policy, the policyholder is not satisfied for any reason.
(b) Each individual long term care insurance policy must have prominently printed on, or attached to, its first page a notice setting forth in substance the provisions of subsection (a).
As added by P.L.275-1987, SEC.1. Amended by P.L.114-1991, SEC.15.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 12. Long Term Care Insurance › 27-8-12-13. Direct Response Solicitation Issued Policies; No Obligation Return Period; Notice

Sec. 13. (a) A person insured under a long term care insurance policy or certificate issued under a direct response solicitation may return the policy or certificate within thirty (30) days of its delivery and have the premium refunded if the insured person is not satisfied for any reason.
(b) Each long term care insurance policy or certificate issued under a direct response solicitation must have printed on, or attached to, its first page a notice setting forth in substance the provisions of subsection (a).
As added by P.L.275-1987, SEC.1.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 12. Long Term Care Insurance › 27-8-12-14. Outline of Coverage; Contents

Sec. 14. (a) The insurer shall deliver an outline of the coverage provided by an individual long term care insurance policy to the prospective applicant at the time of initial solicitation through means that prominently direct the attention of the recipient to the document and the document's purpose.
(b) The commissioner shall prescribe a standard format regarding:
(1) style;
(2) arrangement;
(3) overall appearance; and
(4) content;
for an outline of coverage.
(c) An insurance producer who solicits a long term care insurance policy shall deliver the outline of coverage before the presentation of an application or enrollment form.
(d) The outline of coverage must be presented in conjunction with any application or enrollment form when there is a direct response solicitation of long term care insurance.
(e) An outline of coverage required under this section must include the following:
(1) A description of the principal benefits and coverage provided in the policy.
(2) A statement of the principal exclusions, reductions, and limitations set forth in the policy.
(3) A statement of the policy's renewal provisions, including any reservation by the insurer of a right to change premiums.
(4) A statement that the outline of coverage is a summary of the policy issued or applied for, and that the policy should be consulted to determine the exact terms of the coverage provided by the policy.
(5) A description of the terms under which the policy may be returned and the premium refunded.
(6) A brief description of the relationship of the cost of care and benefits.
(7) A statement of the terms under which the policy or certificate may continue or be discontinued, including any reservation in the policy of the right to change the premium.
(8) A specific statement of the provisions for continuation or conversion of group coverage.
As added by P.L.275-1987, SEC.1. Amended by P.L.114-1991, SEC.16; P.L.178-2003, SEC.66.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 12. Long Term Care Insurance › 27-8-12-14.5. Policy Summary; Requirements

Sec. 14.5. (a) A policy summary shall be delivered, at the time of policy delivery, for an individual life insurance policy that provides long term care benefits within the policy or by a rider.
(b) The insurer shall deliver the policy summary upon the applicant's request when there is a direct response solicitation. If there is no request, the insurer shall deliver the policy summary not later than when the policy is delivered.
(c) The policy summary must include the following:
(1) An explanation of how long a long term care benefit interacts with other components of the policy, including deductions from a death benefit.
(2) An illustration of the amount of a benefit, the length of a benefit, and the guaranteed lifetime benefits for each covered person.
(3) Any exclusion, reduction, and limitation on benefits of long term care.
(d) A policy summary required under this section must also include the following information if applicable:
(1) A disclosure of any effect of exercising rights under the policy other than rights referred to in subsection (c).
(2) A disclosure of any guarantee related to long term care costs of insurance charges.
(3) Current and projected maximum lifetime benefits.
As added by P.L.114-1991, SEC.17.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 12. Long Term Care Insurance › 27-8-12-14.6. Benefits Funded Through Life Insurance by Acceleration of Death Benefits; Benefit Payment Status Report; Contents

Sec. 14.6. If a long term care benefit, funded through a life insurance vehicle by the acceleration of the death benefit, is in benefit payment status, a monthly report containing the following shall be provided to the policyholder:
(1) Any long term care benefit paid out during the month.
(2) An explanation of any change in the policy, including a change in death benefit or cash value due to long term care benefits being paid.
(3) The amount of long term care benefits remaining under the policy.
As added by P.L.114-1991, SEC.18.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 12. Long Term Care Insurance › 27-8-12-15. Group Policy Certificate; Contents

Sec. 15. A certificate issued under a group long term care insurance policy that is delivered or issued for delivery in Indiana must include the following:
(1) A description of the principal benefits and coverage provided in the policy.
(2) A statement of the principal exclusions, reductions, and limitations set forth in the policy.
(3) A statement that the group master policy should be consulted to determine the exact terms of the coverage provided by the policy.
As added by P.L.275-1987, SEC.1.