reglab/statecodes huggingface dataset:
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 7. Requirements for Group Contracts, Individual Contracts, and Evidence of Coverage › 27-13-7-7.5. Prohibition on Coverage of Abortion; Exceptions; Coverage Through Rider or Endorsement

Sec. 7.5. (a) A health maintenance organization that provides coverage for basic health care services and that is entered into, delivered, amended, or renewed after December 31, 2014, under a group contract or an individual contract may not provide coverage for abortion unless the abortion is permitted under IC 16-34-2-1.
(b) A health maintenance organization that enters into a group contract or an individual contract described in subsection (a) may offer coverage for an abortion permitted under IC 16-34-2-1 through a rider or an endorsement.
As added by P.L.124-2014, SEC.2. Amended by P.L.179-2022(ss), SEC.47.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 7. Requirements for Group Contracts, Individual Contracts, and Evidence of Coverage › 27-13-7-8. Readability Standards

Sec. 8. The commissioner may adopt rules under IC 4-22-2 establishing readability standards for individual contracts and evidence of coverage forms.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 7. Requirements for Group Contracts, Individual Contracts, and Evidence of Coverage › 27-13-7-9. Approval of Forms by Commissioner

Sec. 9. Subject to sections 10 and 11 of this chapter:
(1) a group or an individual contract;
(2) an evidence of coverage; or
(3) an amendment to:
(A) a group or an individual contract; or
(B) an evidence of coverage;
may not be delivered or issued for delivery in Indiana unless the form has been filed with and approved by the commissioner.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 7. Requirements for Group Contracts, Individual Contracts, and Evidence of Coverage › 27-13-7-10. Coverage Outside Indiana; Commissioner's Approval Not Required

Sec. 10. If:
(1) an evidence of coverage that is issued under and incorporated into a contract issued in Indiana is intended for delivery in another state;
(2) the evidence of coverage has been approved for use in the state in which it is to be delivered; and
(3) the evidence of coverage is not delivered in Indiana;
the evidence of coverage need not be submitted to the commissioner in Indiana for approval.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 7. Requirements for Group Contracts, Individual Contracts, and Evidence of Coverage › 27-13-7-11. Filing of Form With Commissioner; Review Period; Approval; Withdrawal of Approval; Hearing

Sec. 11. (a) A form required by this chapter must be filed with the commissioner at least thirty (30) days before the form is:
(1) delivered; or
(2) issued for delivery;
in Indiana.
(b) At any time during the thirty (30) day period referred to in subsection (a), the commissioner may extend the period for review for an additional thirty (30) days.
(c) The commissioner must give notice in writing of an extension of a review period under subsection (b).
(d) If the commissioner does not take action on a form submitted to the commissioner within the thirty (30) day period and any period of extension, the form is considered approved.
(e) At any time after notice and for cause shown, the commissioner may withdraw approval of any form, effective thirty (30) days after notice of the withdrawal of the approval is issued.
(f) When the commissioner:
(1) disapproves a filing; or
(2) withdraws approval of a form;
under this section, the commissioner shall give the health maintenance organization written notice of the reasons for the disapproval or withdrawal of approval. The notice must inform the health maintenance organization that it may, not more than thirty (30) days after it receives the notice, request a hearing concerning the disapproval or withdrawal of approval. If the health maintenance organization requests a hearing not more than thirty (30) days after it receives the notice, the commissioner shall hold a hearing upon not less than ten (10) days notice to the health maintenance organization.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 7. Requirements for Group Contracts, Individual Contracts, and Evidence of Coverage › 27-13-7-12. Additional Information Required by Commissioner

Sec. 12. The commissioner may require the submission of any information the commissioner considers necessary to determine whether to approve or disapprove a filing under this chapter.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 7. Requirements for Group Contracts, Individual Contracts, and Evidence of Coverage › 27-13-7-13. Continuation of Coverage Statement

Sec. 13. (a) A health maintenance organization must include in each contract a written statement that if the contract is terminated by the health maintenance organization, an enrollee who is hospitalized for a medical or surgical condition on the date of termination will have continuation of coverage for inpatient covered services.
(b) The continuation of coverage referred to in subsection (a) is not required after one (1) of the following occurs:
(1) The discharge of the enrollee from the hospital.
(2) Sixty (60) days pass after the contract is terminated by the health maintenance organization.
(3) The hospitalized enrollee obtains from another carrier coverage that includes the coverage provided by the terminating health maintenance organization.
(4) A contract holder terminates the contract with the health maintenance organization, as determined by:
(A) the effective date specified in written communication sent by the contract holder to the health maintenance organization, which effective date shall be at least fifteen (15) days after the date the written communication is placed in the United States mail or sent by facsimile transmission; or
(B) the failure to pay a premium within the grace period permitted under the contract.
(5) Termination of an enrollee by a health maintenance organization due to:
(A) the enrollee knowingly providing false information to the health maintenance organization;
(B) the enrollee's failure to comply with the rules of the health maintenance organization stated in the contract; or
(C) the enrollee's failure to pay a premium within the grace period permitted under contract.
(c) In order to satisfy the requirements of subsection (a), a health maintenance organization may provide benefits that exceed the continuation of coverage required by this section, either in the types or time period of health care services covered, or both.
(d) If an enrollee terminates the enrollee's coverage, the health maintenance organization is not required to provide continuation of coverage to that enrollee under this section after the termination.
(e) This section does not apply to a termination of coverage as the result of the receivership of a health maintenance organization.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 7. Requirements for Group Contracts, Individual Contracts, and Evidence of Coverage › 27-13-7-14. Post-Mastectomy Coverage

Sec. 14. (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 contract with a health maintenance organization that provides coverage for a mastectomy must provide 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 health maintenance organization contract 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 services under the contract.
(e) A health maintenance organization shall provide to an enrollee, at the time that an individual contract or a group contract is entered into and annually thereafter, written notice of the coverage required under this section. Notice that is sent by the health maintenance organization 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 contract with a health maintenance organization that provides coverage for a mastectomy, regardless of whether an individual who:
(1) underwent a mastectomy; and
(2) is covered under the contract;
was covered under the contract at the time of the mastectomy.
(g) Except as provided in subsection (c), this section does not require a health maintenance organization 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.5. Amended by P.L.2-1998, SEC.71; P.L.96-2002, SEC.3; P.L.204-2003, SEC.2; P.L.67-2020, SEC.3.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 7. Requirements for Group Contracts, Individual Contracts, and Evidence of Coverage › 27-13-7-14.5. Coverage for Nonexperimental, Surgical Treatment of Morbid Obesity

Sec. 14.5. (a) As used in this section, "health care provider" means a:
(1) physician licensed under IC 25-22.5; or
(2) hospital licensed under IC 16-21;
that provides health care services for surgical treatment of morbid obesity.
(b) As used in this section, "morbid obesity" means:
(1) a body mass index of at least thirty-five (35) kilograms per meter squared with comorbidity or coexisting medical conditions such as hypertension, cardiopulmonary conditions, sleep apnea, or diabetes; or
(2) a body mass index of at least forty (40) kilograms per meter squared without comorbidity.
For purposes of this subsection, body mass index equals weight in kilograms divided by height in meters squared.
(c) Except as provided in subsection (d), a health maintenance organization that provides coverage for basic health care services under a group contract shall offer coverage for nonexperimental, surgical treatment by a health care provider of morbid obesity:
(1) that has persisted for at least five (5) years; and
(2) for which nonsurgical treatment that is supervised by a physician has been unsuccessful for at least six (6) consecutive months.
(d) A health maintenance organization that provides coverage for basic health care services may not provide coverage for surgical treatment of morbid obesity for an enrollee who is less than twenty-one (21) years of age unless two (2) physicians licensed under IC 25-22.5 determine that the surgery is necessary to:
(1) save the life of the enrollee; or
(2) restore the enrollee's ability to maintain a major life activity (as defined in IC 4-23-29-6);
and each physician documents in the enrollee's medical record the reason for the physician's determination.
As added by P.L.78-2000, SEC.3. Amended by P.L.196-2005, SEC.6; P.L.102-2006, SEC.5.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 7. Requirements for Group Contracts, Individual Contracts, and Evidence of Coverage › 27-13-7-14.7. Coverage for Autism Spectrum Disorders

Sec. 14.7. (a) As used in this section, "autism spectrum disorder" means a neurological condition, including Asperger's syndrome and autism, as defined in the Diagnostic and Statistical Manual of Mental Disorders.
(b) A group contract with a health maintenance organization that provides basic health care services must provide services for the treatment of an autism spectrum disorder of an enrollee. Services provided to an enrollee under this subsection are limited to services that are prescribed by the enrollee's treating physician in accordance with a treatment plan. A health maintenance organization may not deny or refuse to provide services to, or refuse to renew, refuse to reissue, or otherwise terminate or restrict coverage under a group contract to services to an individual solely because the individual is diagnosed with an autism spectrum disorder.
(c) The services required under subsection (b) may not be subject to dollar limits, deductibles, copayments, or coinsurance provisions that are less favorable to an enrollee than the dollar limits, deductibles, copayments, or coinsurance provisions that apply to physical illness generally under the contract with the health maintenance organization.
(d) A health maintenance organization that enters into an individual contract that provides basic health care services must offer to provide services for the treatment of an autism spectrum disorder of an enrollee. Services provided to an enrollee under this subsection are limited to services that are prescribed by the enrollee's treating physician in accordance with a treatment plan. A health maintenance organization may not deny or refuse to provide services to, or refuse to renew, refuse to reissue, or otherwise terminate or restrict coverage under an individual contract to services to an individual solely because the individual is diagnosed with an autism spectrum disorder.
(e) The services that must be offered under subsection (d) may not be subject to dollar limits, deductibles, copayments, or coinsurance provisions that are less favorable to an enrollee than the dollar limits, deductibles, copayments, or coinsurance provisions that apply to physical illness generally under the contract with the health maintenance organization.
As added by P.L.148-2001, SEC.3. Amended by P.L.188-2013, SEC.24; P.L.124-2018, SEC.88.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 7. Requirements for Group Contracts, Individual Contracts, and Evidence of Coverage › 27-13-7-14.8. Treatment Limitations or Financial Requirements on Coverage of Services for Mental Illness

Sec. 14.8. (a) As used in this section, "coverage of services for a mental illness" includes the services defined under the contract with the health maintenance organization. However, the term does not include services for the treatment of substance abuse or chemical dependency.
(b) This section applies to a group or individual contract with a health maintenance organization that:
(1) is issued, entered into, or renewed after December 31, 1999; and
(2) is issued to an employer that employs more than fifty (50) full-time employees.
(c) This section does not apply to a legal business entity that has obtained an exemption under IC 27-8-5-15.7.
(d) A group or individual contract with a health maintenance organization may not permit treatment limitations or financial requirements on the coverage of services for a mental illness if similar limitations or requirements are not imposed on the coverage of services for other medical or surgical conditions.
(e) A health maintenance organization that enters into an individual contract or a group contract that provides coverage of services for the treatment of substance abuse and chemical dependency when the services are required in the treatment of a mental illness shall offer to provide the coverage without treatment limitations or financial requirements if similar limitations or requirements are not imposed on the coverage of services for other medical or surgical conditions.
(f) This section does not require a group or individual contract with a health maintenance organization to offer mental health benefits.
As added by P.L.42-1997, SEC.3. Amended by P.L.81-1999, SEC.5; P.L.226-2003, SEC.2.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 7. Requirements for Group Contracts, Individual Contracts, and Evidence of Coverage › 27-13-7-15. Dental Care Provisions Required

Sec. 15. (a) As used in this section, "child" means an individual who is less than nineteen (19) years of age.
(b) As used in this section, "enrollee" means an enrollee who is a child or an individual:
(1) with a physical or mental impairment that substantially limits one (1) or more of the major life activities of the individual; and
(2) who:
(A) has a record of; or
(B) is regarded as;
having an impairment described in subdivision (1).
(c) A health maintenance organization that provides basic health care services shall include coverage under the terms and conditions of the benefits contract for anesthesia and hospital charges for an enrollee for dental care if the mental or physical condition of the enrollee requires dental treatment to be rendered in a hospital or an ambulatory outpatient surgical center. The Indications for General Anesthesia, as published in the reference manual of the American Academy of Pediatric Dentistry, are the utilization standards for determining whether performing dental procedures necessary to treat the enrollee's condition under general anesthesia constitutes appropriate treatment.
(d) A health maintenance organization may:
(1) require prior authorization for hospitalization or treatment in an ambulatory outpatient surgical center for dental care procedures in the same manner that prior authorization is required for hospitalization or treatment of other covered medical conditions; and
(2) restrict coverage to include only procedures performed by a licensed dentist who has privileges at the hospital or ambulatory outpatient surgical center.
(e) This section does not apply to treatment rendered for temporal mandibular joint disorders (TMJ).
As added by P.L.189-1999, SEC.3.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 7. Requirements for Group Contracts, Individual Contracts, and Evidence of Coverage › 27-13-7-15.3. Breast Cancer Screening Mammography

Sec. 15.3. (a) As used in this section, "breast cancer screening mammography" has the meaning set forth in IC 27-8-14-2.
(b) As used in this section, "woman at risk" has the meaning set forth in IC 27-8-14-5.
(c) Except as provided in subsection (g), a health maintenance organization issued a certificate of authority in Indiana shall provide breast cancer screening mammography as a covered service under every group contract that provides coverage for basic health care services.
(d) Except as provided in subsection (g), the coverage that a health maintenance organization must provide under this section must include the following:
(1) If the enrollee is at least thirty-five (35) years of age but less than forty (40) years of age and a female, coverage for at least one (1) baseline breast cancer screening mammography performed upon the enrollee before the enrollee becomes forty (40) years of age.
(2) If the enrollee is less than forty (40) years of age and a woman at risk, one (1) breast cancer screening mammography performed upon the enrollee every year.
(3) If the enrollee is at least forty (40) years of age and a female, one (1) breast cancer screening mammography performed upon the enrollee every year.
(4) Any additional mammography views that are required for proper evaluation.
(5) Ultrasound services, if determined medically necessary by the physician treating the enrollee.
(e) Except as provided in subsection (g), the coverage that a health maintenance organization must provide under this section may not be subject to a contract provision that is less favorable to an enrollee or a subscriber than contract provisions applying to physical illness generally under the health maintenance organization contract.
(f) Except as provided in subsection (g), the coverage that a health maintenance organization must provide under this section is in addition to services specifically provided for x-rays, laboratory testing, or wellness examinations.
(g) In the case of coverage that is not employer based, the health maintenance organization must offer to provide the coverage described in subsections (c) through (f).
As added by P.L.170-1999, SEC.5.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 7. Requirements for Group Contracts, Individual Contracts, and Evidence of Coverage › 27-13-7-16. Prostate Specific Antigen Test

Sec. 16. (a) As used in this section, "prostate specific antigen test" means a standard blood test performed to determine the level of prostate specific antigen in the blood.
(b) Except as provided in subsection (f), a health maintenance organization issued a certificate of authority in Indiana shall provide prostate specific antigen testing as a covered service under every group contract that provides coverage for basic health care services.
(c) Except as provided in subsection (f), the coverage required under subsection (b) must include the following:
(1) At least one (1) prostate specific antigen test annually for a male enrollee who is at least fifty (50) years of age.
(2) At least one (1) prostate specific antigen test annually for a male enrollee who is less than fifty (50) years of age and who is at high risk for prostate cancer according to the American Cancer Society guidelines.
(d) Except as provided in subsection (f), the coverage that a health maintenance organization must provide under this section may not be subject to a contract provision that is less favorable to an enrollee than a contract provision applying to physical illness generally under the health maintenance organization contract.
(e) Except as provided in subsection (f), the coverage that a health maintenance organization must provide under this section is in addition to services specifically provided for x-rays, laboratory testing, or wellness examinations.
(f) In the case of coverage that is not employer based, the health maintenance organization must offer to provide the coverage described in subsections (b) through (e).
As added by P.L.170-1999, SEC.6. Amended by P.L.124-2018, SEC.89.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 7. Requirements for Group Contracts, Individual Contracts, and Evidence of Coverage › 27-13-7-17. Coverage for Colorectal Cancer Screening; Exception for Grandfathered Health Plans

Sec. 17. (a) As used in this section, "colorectal cancer testing" means examinations and laboratory tests for cancer for any nonsymptomatic enrollee.
(b) As used in this section, "follow-up colonoscopy" means a colonoscopy that is performed as a follow-up to a colorectal cancer screening test, other than a colonoscopy, that is assigned a grade of "A" or "B" by the United States Preventive Services Task Force and for which the result was positive.
(c) Except as provided in subsection (f), a health maintenance organization issued a certificate of authority in Indiana shall provide colorectal cancer testing, including:
(1) a colorectal cancer screening test assigned either an "A" or "B" grade by the United States Preventive Services Task Force; and
(2) a follow-up colonoscopy;
as a covered service under every group contract that provides coverage for basic health care services.
(d) For an enrollee who is:
(1) at least forty-five (45) years of age; or
(2) less than forty-five (45) years of age and at high risk for colorectal cancer;
the colorectal cancer testing required under this section must meet the requirements set forth in subsection (e), except as provided in subsection (g).
(e) An enrollee may not be required to pay a copayment for the colorectal cancer testing benefit required by this section that is greater than a copayment established for similar benefits under the group contract under which the enrollee is entitled to services. If the group contract does not cover a similar covered service, the copayment for the colorectal cancer testing benefit may not be set at a level that materially diminishes the value of the colorectal cancer testing benefit.
(f) In the case of coverage that is not employer based, the health maintenance organization is required only to offer to provide colorectal cancer testing as a covered service under a proposed group contract providing coverage for basic health care services.
(g) The requirements imposed under subsection (c)(2) do not apply to grandfathered health plans as defined in 45 CFR 147.140.
As added by P.L.54-2000, SEC.3. Amended by P.L.1-2001, SEC.34; P.L.124-2018, SEC.90; P.L.36-2020, SEC.3; P.L.165-2022, SEC.13.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 7. Requirements for Group Contracts, Individual Contracts, and Evidence of Coverage › 27-13-7-18. Inherited Metabolic Disease Coverage

Sec. 18. (a) As used in this section, "inherited metabolic disease" means a disease:
(1) caused by inborn errors of amino acid, organic acid, or urea cycle metabolism; and
(2) treatable by the dietary restriction of one (1) or more amino acids.
(b) As used in this section, "medical food" means a formula that is:
(1) intended for the dietary treatment of a disease or condition for which nutritional requirements are established by medical evaluation; and
(2) formulated to be consumed or administered enterally under the direction of a physician.
(c) A group health maintenance organization contract that provides coverage for basic health care services must provide coverage for medical food that is:
(1) medically necessary; and
(2) prescribed for an enrollee by the enrollee's treating physician for treatment of the enrollee's inherited metabolic disease.
(d) The coverage that must be provided under this section shall not be subject to dollar limits, copayments, or deductibles that are less favorable to an enrollee than the dollar limits, copayments, or deductibles that apply to coverage for:
(1) prescription drugs generally under the group contract, if prescription drugs are covered under the group contract; or
(2) physical illness generally under the group contract, if prescription drugs are not covered under the group contract.
As added by P.L.166-2003, SEC.3.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 7. Requirements for Group Contracts, Individual Contracts, and Evidence of Coverage › 27-13-7-19. Coverage for Orthotic Devices and Prosthetic Devices

Sec. 19. (a) As used in this section, "orthotic device" means a medically necessary custom fabricated brace or support that is designed as a component of a prosthetic device.
(b) As used in this section, "prosthetic device" means an artificial leg or arm.
(c) An individual contract or a group contract that provides coverage for basic health care services must provide coverage for orthotic devices and prosthetic devices, including repairs or replacements, that:
(1) are provided or performed by a person that is:
(A) accredited as required under 42 U.S.C. 1395m(a)(20); or
(B) a qualified practitioner (as defined in 42 U.S.C. 1395m(h)(1)(F)(iii));
(2) are determined by the enrollee's physician to be medically necessary to restore or maintain the enrollee's ability to perform activities of daily living or essential job related activities; and
(3) are not solely for comfort or convenience.
(d) The:
(1) coverage required under subsection (c) must be equal to the coverage that is provided for the same device, repair, or replacement under the federal Medicare program (42 U.S.C. 1395 et seq.); and
(2) reimbursement under the coverage required under subsection (c) must be equal to the reimbursement that is provided for the same device, repair, or replacement under the federal Medicare reimbursement schedule, unless a different reimbursement rate is negotiated.
This subsection does not require a deductible under an individual contract or a group contract to be equal to a deductible under the federal Medicare program.
(e) Except as provided in subsections (f) and (g), the coverage required under subsection (c):
(1) may be subject to; and
(2) may not be more restrictive than;
the provisions that apply to other benefits under the individual contract or group contract.
(f) The coverage required under subsection (c) may be subject to utilization review, including periodic review, of the continued medical necessity of the benefit.
(g) Any lifetime maximum coverage limitation that applies to prosthetic devices and orthotic devices:
(1) must not be included in; and
(2) must be equal to;
the lifetime maximum coverage limitation that applies to all other items and services generally under the individual contract or group contract.
(h) For purposes of this subsection, "items and services" does not include preventive services for which coverage is provided under a high deductible health plan (as defined in 26 U.S.C. 220(c)(2) or 26 U.S.C. 223(c)(2)). The coverage required under subsection (c) may not be subject to a deductible, copayment, or coinsurance provision that is less favorable to an enrollee than the deductible, copayment, or coinsurance provisions that apply to other items and services generally under the individual contract or group contract.
As added by P.L.109-2008, SEC.3.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 7. Requirements for Group Contracts, Individual Contracts, and Evidence of Coverage › 27-13-7-20. Prohibition on Chemotherapy Coverage Limitations

Sec. 20. (a) This section applies to an individual contract or a group contract that provides coverage for both of the following:
(1) Orally administered cancer chemotherapy.
(2) Cancer chemotherapy that is administered intravenously or by injection.
(b) As used in this section, "cancer chemotherapy" means medication that is prescribed by a physician to kill or slow the growth of cancer cells.
(c) Coverage for orally administered cancer chemotherapy under an individual contract or a group contract must not be subject to dollar limits, copayments, deductibles, or coinsurance provisions that are less favorable to an enrollee than the dollar limits, copayments, deductibles, or coinsurance provisions that apply to coverage for cancer chemotherapy that is administered intravenously or by injection under the individual contract or group contract.
As added by P.L.46-2009, SEC.2.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 7. Requirements for Group Contracts, Individual Contracts, and Evidence of Coverage › 27-13-7-20.1. Individual or Group Contract Providing Coverage for Prescription Eye Drops; Refill of Prescription Eye Drops; Requirements

Sec. 20.1. (a) This section applies to an individual contract or a group contract that provides coverage for prescription eye drops.
(b) An individual contract or a group contract must provide coverage for a refill of prescription eye drops if the following are met:
(1) For a thirty (30) day supply, the enrollee requests the refill not earlier than twenty-five (25) days from the date the prescription eye drops were last dispensed to the enrollee.
(2) For a ninety (90) day supply, the enrollee requests the refill not earlier than seventy-five (75) days from the date the prescription eye drops were last dispensed to the enrollee.
(3) The prescribing practitioner has indicated on the prescription that the prescription eye drops are refillable and the refill requested by the enrollee does not exceed the refillable amount remaining on the prescription.
(c) The coverage required by subsection (b) must not be subject to dollar limits, copayments, deductibles, or coinsurance provisions that are less favorable to an enrollee than the dollar limits, copayments, deductibles, or coinsurance provisions that apply to coverage for prescription drugs generally under the individual contract or group contract.
(d) This section applies to an individual contract or a group contract issued, delivered, amended, or renewed after December 31, 2015.
As added by P.L.43-2015, SEC.3.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 7. Requirements for Group Contracts, Individual Contracts, and Evidence of Coverage › 27-13-7-20.4. Applicability; Coverage for Methadone for Treatment of Pain

Sec. 20.4. (a) This section applies to an individual contract or a group contract that is entered into, amended, or renewed after June 30, 2015.
(b) An individual contract or a group contract may provide coverage for methadone if the drug is prescribed for the treatment of pain or pain management only as follows:
(1) If the daily dosage is not more than sixty (60) milligrams.
(2) If the daily dosage is more than sixty (60) milligrams, only if:
(A) prior authorization is obtained; and
(B) a determination of medical necessity has been shown by the provider.
As added by P.L.209-2015, SEC.20.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 7. Requirements for Group Contracts, Individual Contracts, and Evidence of Coverage › 27-13-7-21. High Breast Density

Sec. 21. (a) As used in this section, "high breast density" means a condition in which there is a greater amount of breast and connective tissue in comparison to fat in the breast.
(b) An individual contract or a group contract that provides coverage for basic health care services must provide coverage for an appropriate medical screening, test, or examination for a female enrollee who is at least forty (40) years of age and who has been determined to have high breast density.
As added by P.L.126-2013, SEC.5.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 7. Requirements for Group Contracts, Individual Contracts, and Evidence of Coverage › 27-13-7-22. Coverage of Telehealth Services; Prohibition on Requiring Use of Specific Information Technology Application

Sec. 22. (a) An individual contract or a group contract must provide coverage for telehealth services in accordance with the same clinical criteria as the individual contract or the group contract provides coverage for the same health care services delivered to an enrollee in person.
(b) Coverage for telehealth services required by subsection (a) may not be subject to a dollar limit, copayment, or coinsurance requirement that is less favorable to an enrollee than the dollar limit, copayment, or coinsurance requirement that applies to the same health care services delivered to an enrollee in person.
(c) Any annual or lifetime dollar limit that applies to telehealth services must be the same annual or lifetime dollar limit that applies in the aggregate to all items and services covered under the individual contract or the group contract.
(d) This section does not do any of the following:
(1) Require an individual contract or a group contract to provide coverage for a telehealth service that is not a covered health care service under the individual contract or group contract.
(2) Require the use of telehealth services when the treating provider has determined that telehealth services are inappropriate.
(3) Prevent the use of utilization review concerning coverage for telehealth services in the same manner as utilization review is used concerning coverage for the same health care services delivered to an enrollee in person.
(e) A separate consent for telehealth services may not be required.
(f) If a policy provides coverage for telehealth services via:
(1) secure videoconferencing;
(2) store and forward technology; or
(3) remote patient monitoring technology;
between a provider in one (1) location and a patient in another location, the policy may not require the use of a specific information technology application for those services.
As added by P.L.185-2015, SEC.27. Amended by P.L.85-2021, SEC.32.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 7. Requirements for Group Contracts, Individual Contracts, and Evidence of Coverage › 27-13-7-24. Coverage for Anatomical Gifts, Transplantation, or Related Health Care Services

Sec. 24. (a) As used in this section, "disability" has the meaning set forth in 42 U.S.C. 12102.
(b) As used in this section, "enrollee" means an enrollee who has a disability.
(c) As used in this section, "group contract" means a group contract that provides coverage for anatomical gifts, transplantation, or related health care services.
(d) As used in this section, "health maintenance organization" includes an administrator that is licensed under IC 27-1-25 and administers an individual contract or a group contract.
(e) As used in this section, "individual contract" means an individual contract that provides coverage for anatomical gifts, transplantation, or related health care services.
(f) A health maintenance organization shall not deny coverage for anatomical gifts, transplantation, or related health care services under an individual contract or a group contract based solely on the disability of the enrollee.
As added by P.L.2-2019, SEC.10.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 7. Requirements for Group Contracts, Individual Contracts, and Evidence of Coverage › 27-13-7-24.5. Coverage for Chronic Pain Management

Sec. 24.5. (a) This section applies to each of the following:
(1) An individual contract.
(2) A group contract.
(b) As used in this section, "chronic pain" means pain that:
(1) persists beyond the usual course of an acute disease or healing of an injury; or
(2) may be associated with an acute or chronic pathologic process that causes continuous or intermittent pain for a period of months or years.
(c) As used in this section, "chronic pain management" means evidence based health care products and services intended to relieve chronic pain that has lasted for at least three (3) months. The term includes:
(1) prescription drugs;
(2) physical therapy;
(3) occupational therapy;
(4) chiropractic care;
(5) osteopathic manipulative treatment; and
(6) athletic trainer services.
(d) An individual contract and a group contract must provide coverage for medically necessary chronic pain management prescribed by an enrollee's treating practitioner.
(e) The coverage required by this section may not be subject to annual or lifetime limitation, deductible, copayment, or coinsurance provisions that are more restrictive than the annual or lifetime limitation, deductible, copayment, or coinsurance provisions that apply generally under the individual contract or group contract.
As added by P.L.149-2019, SEC.6.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 7. Requirements for Group Contracts, Individual Contracts, and Evidence of Coverage › 27-13-7-26. Coverage for Pediatric Neuropsychiatric Disorders

Sec. 26. (a) An individual contract and a group contract must provide coverage for treatment of:
(1) pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS); and
(2) pediatric acute-onset neuropsychiatric syndrome (PANS);
including treatment with intravenous immunoglobulin therapy.
(b) The coverage required by this section may not be subject to annual or lifetime limitation, deductible, copayment, or coinsurance provisions that are more restrictive than the annual or lifetime limitation, deductible, copayment, or coinsurance provisions that apply generally under the individual contract or group contract.
As added by P.L.130-2020, SEC.16.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 7. Requirements for Group Contracts, Individual Contracts, and Evidence of Coverage › 27-13-7-27. Reimbursement for Emergency Medical Services

Sec. 27. (a) This section applies to each of the following:
(1) An individual contract.
(2) A group contract.
(b) As used in this section, "emergency medical services" has the meaning set forth in IC 16-18-2-110.
(c) As used in this section, "emergency medical services provider organization" means a provider of emergency medical services that is certified by the Indiana emergency medical services commission as an advanced life support provider organization under rules adopted under IC 16-31-3.
(d) An individual contract and a group contract that provide coverage for emergency medical services must provide reimbursement for emergency medical services that are:
(1) rendered by an emergency medical services provider organization;
(2) within the emergency medical services provider organization's scope of practice;
(3) performed or provided as advanced life support services; and
(4) performed or provided during a response initiated through the 911 system regardless of whether the patient is transported.
(e) Reimbursement for basic and advanced life support services through a contract to which this section applies must be provided on an equal basis regardless of whether the services involve transportation of the patient by ambulance.
(f) If multiple emergency medical services provider organizations qualify and submit a claim for reimbursement under this section, the health maintenance organization:
(1) may reimburse under this section only for one (1) claim per patient encounter; and
(2) shall reimburse the claim submitted by the emergency medical services provider organization that performed or provided the majority of advanced life support services.
(g) The department may adopt rules under IC 4-22-2, including emergency rules under IC 4-22-2-37.1, to implement this section.
(h) This section does not require an individual contract or a group contract to provide coverage for emergency medical services.
As added by P.L.115-2020, SEC.5. Amended by P.L.170-2022, SEC.39.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 7. Requirements for Group Contracts, Individual Contracts, and Evidence of Coverage › 27-13-7-28. Mental Health Detention as Medically Necessary

Sec. 28. An individual contract and a group contract shall consider services provided to an individual while detained under IC 12-26-5 as medically necessary when provided in accordance with generally accepted clinical care guidelines.
As added by P.L.205-2023, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 7. Requirements for Group Contracts, Individual Contracts, and Evidence of Coverage › 27-13-7-28.5. Coverage for Wearable Cardioverter Defibrillators

Sec. 28.5. (a) This section applies to an individual contract or a group contract that is entered into, amended, or renewed after June 30, 2023.
(b) As used in this section, "wearable cardioverter defibrillator" means a device that:
(1) is worn externally on an individual's body;
(2) continually monitors and analyzes the individual's heart rhythm; and
(3) delivers a shock to the heart when an abnormal heart rhythm is detected.
(c) An individual contract or a group contract must provide coverage for a wearable cardioverter defibrillator, including the cost of the wearable cardioverter defibrillator, any necessary accessory, and ongoing monitoring services.
(d) The coverage required under subsection (c) must be in accordance with a:
(1) local coverage determination; or
(2) national coverage determination;
as defined in 42 U.S.C. 1395ff(f) for Medicare purposes.
(e) The coverage required by this section may not be subject to an annual or lifetime limitation.
As added by P.L.190-2023, SEC.32.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 8. Annual Report › 27-13-8-0.1. Application of Certain Amendments to Chapter

Sec. 0.1. The amendments made to section 2 of this chapter by P.L.133-1999 apply to external grievances filed by enrollees after January 1, 2000.
As added by P.L.220-2011, SEC.458.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 8. Annual Report › 27-13-8-1. Filing

Sec. 1. On or before March 1 of each year, a health maintenance organization must file with the commissioner a report that covers the preceding calendar year. The report must be:
(1) made on forms prescribed by the commissioner; and
(2) verified by at least two (2) principal officers of the health maintenance organization.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 8. Annual Report › 27-13-8-1.5. Preparation of Annual Statement

Sec. 1.5. (a) Each health maintenance organization authorized to conduct business in Indiana and required to file an Annual Statement Blank with the department under this chapter shall prepare the health maintenance organization's statement:
(1) on the Annual Statement Blank;
(2) in accordance with Annual Statement Instructions; and
(3) following practices and procedures prescribed by the Accounting Practices and Procedures Manual.
(b) To the extent that the Annual Statement Instructions require disclosure under subsection (a) of compensation paid to or on behalf of a health maintenance organization's officers, directors, or employees, the information may be filed with the department as an exhibit separate from the Annual Statement Blank. The compensation information described under this subsection shall be maintained by the department as confidential and may not be disclosed to the public under IC 5-14-3.
As added by P.L.203-2001, SEC.20. Amended by P.L.124-2018, SEC.91.