reglab/statecodes huggingface dataset:
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 15. Participating Providers; Contracts and Legal Actions › 27-13-15-1. Contract Requirements; Enrollee Coverage; Payment of Provider; Rate Schedule

Sec. 1. (a) A contract between a health maintenance organization and a participating provider of health care services:
(1) must be in writing;
(2) may not prohibit the participating provider from disclosing:
(A) the terms of the contract as it relates to financial or other incentives to limit medical services by the participating provider; or
(B) all treatment options available to an insured, including those not covered by the insured's policy;
(3) may not provide for a financial or other penalty to a provider for making a disclosure permitted under subdivision (2); and
(4) must provide that in the event the health maintenance organization fails to pay for health care services as specified by the contract, the subscriber or enrollee is not liable to the participating provider for any sums owed by the health maintenance organization.
(b) An enrollee is not entitled to coverage of a health care service under a group or an individual contract unless that health care service is included in the enrollee's contract.
(c) A provider is not entitled to payment under a contract for health care services provided to an enrollee unless the provider has a contract or an agreement with the carrier.
(d) This subsection does not apply to a rate schedule maintained by state or federal government payers. A health maintenance organization that enters into a contract with a participating provider must provide the participating provider with a current reimbursement rate schedule:
(1) every two (2) years; and
(2) when three (3) or more CPT code (as defined in IC 27-1-37.5-3) rates under the contract change in a twelve (12) month period.
As added by P.L.26-1994, SEC.25. Amended by P.L.195-1996, SEC.7; P.L.192-1996, SEC.3; P.L.190-2023, SEC.33.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 15. Participating Providers; Contracts and Legal Actions › 27-13-15-2. Contract Requirements Not Met; Collection of Money Owed by Health Maintenance Organization Prohibited

Sec. 2. If:
(1) the contract between a health maintenance organization and a participating provider has not been reduced to writing as required by this chapter; or
(2) the contract fails to contain the provision required by section 1(a)(4) of this chapter;
the participating provider may not collect or attempt to collect from the subscriber or enrollee any sums that are owed by the health maintenance organization.
As added by P.L.26-1994, SEC.25. Amended by P.L.203-2001, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 15. Participating Providers; Contracts and Legal Actions › 27-13-15-3. Actions Against Subscribers; Costs and Attorney's Fees

Sec. 3. (a) A:
(1) participating provider; or
(2) trustee, an agent, a representative, or an assignee of a participating provider;
may not bring or maintain any legal action against a subscriber or an enrollee of a health maintenance organization to collect sums owed by the health maintenance organization.
(b) Except as provided in subsection (c), if a participating provider of a health maintenance organization brings or maintains a legal action against a subscriber or enrollee for an amount owed to the participating provider by the health maintenance organization, the participating provider is liable to the subscriber or enrollee for costs and attorney's fees incurred by the subscriber or enrollee in defending the legal action.
(c) A participating provider shall not be liable to the subscriber or enrollee for costs and attorney's fees described in subsection (b) if the participating provider can demonstrate a reasonable basis for believing at the time the legal action was brought and while the legal action was maintained that the health maintenance organization did not owe the sums the participating provider sought to collect from the subscriber or enrollee.
As added by P.L.26-1994, SEC.25. Amended by P.L.203-2001, SEC.26.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 15. Participating Providers; Contracts and Legal Actions › 27-13-15-4. Participating Provider Agreement Prohibitions

Sec. 4. (a) As used in this section, "health maintenance organization" includes the following:
(1) A limited service health maintenance organization.
(2) A person that pays or administers claims on behalf of a health maintenance organization or a limited service health maintenance organization.
(b) An agreement between a health maintenance organization and a participating provider under this chapter may not contain a provision that:
(1) prohibits, or grants the health maintenance organization an option to prohibit, the participating provider from contracting with another health maintenance organization to accept lower payment for health care services than the payment specified in the agreement;
(2) requires, or grants the health maintenance organization an option to require, the participating provider to accept a lower payment from the health maintenance organization if the participating provider agrees with another health maintenance organization to accept lower payment for health care services;
(3) requires, or grants the health maintenance organization an option of, termination or renegotiation of the agreement if the participating provider agrees with another health maintenance organization to accept lower payment for health care services; or
(4) requires the participating provider to disclose the participating provider's reimbursement rates under contracts with other health maintenance organizations.
(c) A contract provision that violates this section is void.
As added by P.L.74-2007, SEC.2.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 15. Participating Providers; Contracts and Legal Actions › 27-13-15-5. Coverage for Dialysis Treatment

Sec. 5. (a) Notwithstanding IC 27-13-1-12, as used in this section, "enrollee" refers only to an enrollee who requires dialysis treatment.
(b) As used in this section, "health maintenance organization" includes the following:
(1) A limited service health maintenance organization.
(2) An agent of a health maintenance organization or a limited service health maintenance organization.
(c) A health maintenance organization shall not require an enrollee, as a condition of coverage or reimbursement, to:
(1) if the nearest dialysis facility is located within thirty (30) miles of the enrollee's home, travel more than thirty (30) miles from the enrollee's home to obtain dialysis treatment; or
(2) if the nearest dialysis facility is located more than thirty (30) miles from the enrollee's home, travel a greater distance than the distance to the nearest dialysis facility to obtain dialysis treatment;
regardless of whether the enrollee chooses to receive dialysis treatment at a dialysis facility that is a participating provider or a dialysis facility that is not a participating provider.
As added by P.L.111-2008, SEC.6.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 15. Participating Providers; Contracts and Legal Actions › 27-13-15-6. Right to Provide Prescription Cost Information; Point of Sale Cost Limit; Pharmacist May Not Be Required to Collect Higher Copayment

Sec. 6. (a) As used in this section, "drug" means a prescription drug.
(b) As used in this section, "health maintenance organization" refers to a health maintenance organization that provides coverage for drugs. The term includes the following:
(1) A limited service health maintenance organization.
(2) A person that administers drug benefits on behalf of a health maintenance organization or a limited service health maintenance organization.
(c) As used in this section, "pharmacy" refers to a pharmacist or pharmacy that is a participating provider.
(d) A pharmacy or pharmacist shall have the right to provide an enrollee with information concerning the amount of the enrollee's cost share for a prescription drug. Neither a pharmacy nor a pharmacist shall be proscribed by a health maintenance organization from discussing this information or from selling to the enrollee a more affordable alternative if an affordable alternative is available.
(e) A health maintenance organization that covers prescription drugs may not include a provision that requires an enrollee 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 health maintenance organization at the point of sale.
This subsection does not prohibit the adjudication of claims in accordance with an individual contract or group contract issued or administered by a health maintenance organization. The enrollee is not liable for any additional charges or entitled to any credits as a result of the adjudicated claim.
(f) The health maintenance organization or a pharmacy benefit manager may not require a pharmacy or pharmacist to collect a higher copayment for a prescription drug from an enrollee than the health maintenance organization or pharmacy benefit manager allows the pharmacy or pharmacist to retain.
As added by P.L.209-2018, SEC.13. Amended by P.L.114-2020, SEC.21; P.L.9-2022, SEC.53.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 17. Protection Against Insolvency; Notice of Termination › 27-13-17-1. Notice Requirements Before Termination of Agreement by Provider

Sec. 1. An agreement between a provider and a health maintenance organization under which the provider agrees to provide health care services must require the provider to give the organization at least sixty (60) days advance notice before terminating the agreement unless the provider or the group of providers provide thirty percent (30%) or more of the health maintenance organization services, in which case the provider must give at least one hundred twenty (120) days advance notice.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 19. Replacement Coverage in Event of Receivership › 27-13-19-1. "Discontinuance" Defined

Sec. 1. As used in this chapter, "discontinuance" means the termination of the contract between a group contract holder and a health maintenance organization due to the receivership of the health maintenance organization. The term does not refer to the termination of an individual contract.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 19. Replacement Coverage in Event of Receivership › 27-13-19-2. Replacement Coverage; Challenge of Enrollee

Sec. 2. (a) A carrier that provides replacement coverage with respect to group health care services after the discontinuance of the prior health maintenance organization contract or policy providing health care services must, immediately upon beginning to provide the replacement coverage, cover all enrollees who were covered under the previous health maintenance organization contract or policy on the date of discontinuance.
(b) A carrier that provides replacement coverage under this section may challenge whether an individual designated as an enrollee under the previous health maintenance organization contract qualified as an enrollee under the previous health maintenance organization contract.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 19. Replacement Coverage in Event of Receivership › 27-13-19-3. Provisions Reducing or Excluding Benefits

Sec. 3. (a) Except as provided in subsection (b), a provision in a succeeding carrier's contract of replacement coverage that would operate to reduce or exclude benefits on the basis that the condition giving rise to the benefits preexisted the effective date of the succeeding carrier's contract may not be applied with respect to those enrollees who were covered under the prior carrier's contract or policy on the date of discontinuance.
(b) A provision in a succeeding carrier's contract of replacement coverage may operate to reduce or exclude benefits on the basis of a preexisting condition to the extent that the prior carrier's contract or policy would have required that benefits for the condition be reduced or excluded.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 20. Filing Requirements › 27-13-20-1. Rates; Approval

Sec. 1. The rates to be used by a health maintenance organization, including the actuarial assumptions underlying those rates, must be filed with the commissioner for approval and:
(1) must be established in accordance with actuarial principles for various categories of enrollees and, in the case of a group contract, shall not be individually determined based on the status of an enrollee's health;
(2) must be developed by an actuary or other qualified person acceptable to the commissioner; and
(3) may not be excessive, inadequate, or unfairly discriminatory.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 20. Filing Requirements › 27-13-20-1.5. Required Considerations for Approval of Rates

Sec. 1.5. (a) Before approving or disapproving an increase or decrease in the rates to be used by a health maintenance organization, the commissioner shall review the following:
(1) The products affected, by line of business.
(2) The number of covered lives affected.
(3) Whether the product is open or closed to new members in the product block.
(4) Applicable median cost sharing for the product, as allowed by state or federal law.
(5) The benefits provided and the underlying costs of the health services rendered.
(6) The implementation date of the increase or decrease.
(7) The overall percent premium rate increase or decrease that is requested.
(8) The actual percent premium rate increase or decrease to be approved.
(9) Incurred claims paid each year for the past three (3) years, if applicable.
(10) Earned premiums for each of the past three (3) years, if applicable.
(11) Projected medical cost trends in the geographic service region, if the product for which a rate increase or decrease is requested is not a product offered statewide.
(12) If applicable, historical rebates paid to the enrollee from the most recent health plan year under the federal Patient Protection and Affordable Care Act (P.L. 111-148), as amended by the federal Health Care and Education Reconciliation Act of 2010 (P.L. 111-152).
(13) The median cost sharing amount for a member enrolled in the product, or the actuarial value information as required under the Patient Protection and Affordable Care Act, if applicable.
(b) The commissioner shall not approve a rate increase or decrease for an existing product unless the commissioner has, at a minimum, considered the matters set forth in subsection (a)(1) through (a)(13).
(c) The information compiled, prepared, and considered by the commissioner under subsection (a)(1) through (a)(13) is subject to the requirements of IC 5-14-3. However, the commissioner's approval of a rate increase or decrease may take effect before the information compiled, prepared, and considered by the commissioner under subsection (a)(1) through (a)(13) is made accessible to the public under IC 5-14-3.
(d) When considering whether to approve a premium rate increase, the commissioner shall consider whether the current rate is appropriate for achieving the target loss ratio of the health maintenance organization.
(e) To the extent authorized by the Patient Protection and Affordable Care Act and other federal law, the commissioner, under this section, may:
(1) consider network adequacy;
(2) conduct form review to ensure:
(A) minimum essential health benefits; and
(B) nondiscriminatory benefit design;
(3) perform accreditation confirmation; and
(4) confirm quality measures.
As added by P.L.190-2023, SEC.34.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 20. Filing Requirements › 27-13-20-2. Approval of Documents by Commissioner

Sec. 2. (a) Except as provided in subsection (b), a document submitted to the commissioner under this chapter is deemed approved when one (1) of the following conditions is met:
(1) The health maintenance organization receives a written communication of approval from the commissioner.
(2) Thirty (30) days pass after the commissioner receives the document.
(b) A document is not deemed approved under subsection (a)(2) if, within thirty (30) days after the commissioner receives the document, or within any period of extension granted by the commissioner, the commissioner deposits in the United States mail addressed to the health maintenance organization a written communication to the contrary. Not more than thirty (30) days after receiving the written communication from the commissioner, the health maintenance organization may request a hearing. If, not more than thirty (30) days after receiving the communication from the commissioner, the health maintenance organization requests a hearing, 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 21. Insurance Producers of Health Maintenance Organizations and Limited Service Health Maintenance Organizations › 27-13-21-1. Licensing of Insurance Producer

Sec. 1. To qualify to represent a health maintenance organization or a limited service health maintenance organization, an insurance producer shall be licensed with an accident and health or sickness qualification under IC 27-1-15.6-7.
As added by P.L.26-1994, SEC.25. Amended by P.L.132-2001, SEC.18; P.L.178-2003, SEC.86.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 22. Powers of Insurers and Hospital Corporations › 27-13-22-1. Operation of Health Maintenance Organization by Insurer or Hospital

Sec. 1. (a) A licensed insurer or a hospital authorized to conduct business in Indiana may, through a subsidiary or an affiliate, organize and operate a health maintenance organization under this article.
(b) This section does not apply to a health maintenance organization granted a certificate of authority under this article before July 1, 2001.
As added by P.L.26-1994, SEC.25. Amended by P.L.203-2001, SEC.28.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 22. Powers of Insurers and Hospital Corporations › 27-13-22-2. Joint Organization or Operation as Health Maintenance Organization

Sec. 2. Notwithstanding any other law:
(1) insurers;
(2) hospitals; or
(3) subsidiaries or affiliates of entities referred to in subdivisions (1) and (2);
may jointly organize and operate 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 22. Powers of Insurers and Hospital Corporations › 27-13-22-3. Business of Insurance Including Health Care Maintenance Organizations

Sec. 3. For the purposes of IC 27-1-2-2, the business of insurance includes the providing of health care services by a health care maintenance organization owned or operated by an insurer or a subsidiary of an insurer.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 22. Powers of Insurers and Hospital Corporations › 27-13-22-4. Contracting With Health Maintenance Organizations to Provide Insurance Coverage

Sec. 4. An insurer or a hospital may contract with a health maintenance organization to provide to the health maintenance organization:
(1) insurance coverage or similar protection against the cost of health care services provided through the health maintenance organization; or
(2) insurance coverage in the event of the failure of the health maintenance organization to meet its obligations to enrollees or providers.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 22. Powers of Insurers and Hospital Corporations › 27-13-22-5. Benefit Payments to Health Maintenance Organization; Contract Provisions

Sec. 5. Under a contract between an insurer or a hospital and a health maintenance organization under section 4 of this chapter, the insurer or hospital may make benefit payments to the health maintenance organization for health care services for which the health maintenance organization is liable.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 23. Examinations › 27-13-23-1. Health Maintenance Organization Examination

Sec. 1. The commissioner may make an examination of a health maintenance organization whenever necessary for the protection of the interests of the citizens of Indiana. However, an examination of a health maintenance organization domiciled in Indiana must be conducted at least once every five (5) years.
As added by P.L.26-1994, SEC.25. Amended by P.L.226-2023, SEC.27.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 23. Examinations › 27-13-23-2. Quality Management Program Examination

Sec. 2. The commissioner may make an examination concerning the quality management program of a health maintenance organization whenever necessary for the protection of the citizens of Indiana. However, an examination of the quality management program of a health maintenance organization domiciled in Indiana must be conducted at least once every five (5) years.
As added by P.L.26-1994, SEC.25. Amended by P.L.226-2023, SEC.28.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 23. Examinations › 27-13-23-3. Availability of Books and Records

Sec. 3. Each health maintenance organization that is subject to an examination under this chapter shall make its books and records, and the books and records in its custody or control, available for examination and otherwise facilitate the completion of the examination.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 23. Examinations › 27-13-23-4. Officers and Agents; Oaths and Examination by Commissioner

Sec. 4. When conducting an examination of a health maintenance organization, the commissioner:
(1) may administer oaths to; and
(2) examine;
the officers and agents of the health maintenance organization concerning the business of the organization.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 23. Examinations › 27-13-23-6. Health Maintenance Organizations Outside Indiana; Reports of Other Insurance Commissioners

Sec. 6. Instead of conducting an examination of a health maintenance organization that is not domiciled in Indiana, the commissioner may accept the report of an examination made by the insurance commissioner of another state if the other state is accredited by the NAIC.
As added by P.L.26-1994, SEC.25. Amended by P.L.124-2018, SEC.94.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 23. Examinations › 27-13-23-7. Annual Review of Hedis Data

Sec. 7. (a) Beginning July 1, 1999, the commissioner shall review each health maintenance organization's Health Plan Employer Data and Information Set (HEDIS) data on an annual basis.
(b) The commissioner may contract with an appropriate entity to conduct the reviews required under this section.
As added by P.L.69-1998, SEC.9.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 23. Examinations › 27-13-23-8. Filing Examination Reports of Other States

Sec. 8. A health maintenance organization shall file a copy of any examination report filed by the insurance commissioner of another state during the preceding calendar year with the annual statement required under IC 27-13-8-1.
As added by P.L.203-2001, SEC.29.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 24. Suspension, Revocation, or Denial of Certificate of Authority › 27-13-24-1. Grounds for Suspension or Revocation

Sec. 1. (a) The commissioner may suspend or revoke a certificate of authority issued under this article or deny an application submitted under this article if the commissioner finds that any of the following conditions exists:
(1) The health maintenance organization is operating:
(A) significantly in contravention of its basic organizational document; or
(B) in a manner contrary to that described in any other information submitted under IC 27-13-2;
unless amendments to the basic organizational document or other submissions that are consistent with the operations of the organization have been filed with and approved by the commissioner.
(2) The health maintenance organization:
(A) issues an evidence of coverage;
(B) enters into a contract with a participating provider; or
(C) uses a schedule of charges for health care services;
that does not comply with the requirements of IC 27-13-7, IC 27-13-15, and IC 27-13-20.
(3) The health maintenance organization does not provide or arrange for basic health care services.
(4) The commissioner determines that the health maintenance organization is unable to fulfill its obligations to furnish health care coverage.
(5) The health maintenance organization is no longer financially responsible and may reasonably be expected to be unable to meet its obligations to enrollees or prospective enrollees.
(6) The health maintenance organization has failed to correct, within the time prescribed by section 2 of this chapter, any deficiency occurring due to the impairment of the prescribed minimum net worth of the health maintenance organization.
(7) The health maintenance organization has failed to implement the grievance procedures required by IC 27-13-10 in a reasonable manner to resolve valid complaints.
(8) The health maintenance organization or any person acting on behalf of the organization has intentionally advertised or merchandised the services of the organization in an untrue, a misrepresentative, a misleading, a deceptive, or an unfair manner.
(9) The continued operation of the health maintenance organization would be hazardous to the enrollees of the organization.
(10) The health maintenance organization fails to comply with the requirements provided under IC 27-13-36 through IC 27-13-40.
(11) The health maintenance organization has otherwise failed substantially to comply with this article.
(b) The commissioner, in a proceeding under IC 4-21.5-3-8, may impose a civil penalty of not more than twenty-five thousand dollars ($25,000) against a health maintenance organization for each cause listed in subsection (a). The civil penalties may not exceed one hundred thousand dollars ($100,000) for any one (1) health maintenance organization in one (1) calendar year. The penalty may be imposed in addition to or instead of a suspension or revocation of the certificate of authority of the health maintenance organization.
As added by P.L.26-1994, SEC.25. Amended by P.L.69-1998, SEC.10.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 24. Suspension, Revocation, or Denial of Certificate of Authority › 27-13-24-2. Deficient Net Worth

Sec. 2. (a) If the commissioner finds that the net worth maintained by a health maintenance organization subject to this article is less than the minimum net worth required by IC 27-13-12, the commissioner shall:
(1) give written notice to the health maintenance organization of the amount of the deficiency; and
(2) require the health maintenance organization to:
(A) file with the commissioner a plan for correction of the deficiency that is acceptable to the commissioner; and
(B) correct the deficiency within a reasonable time, not to exceed sixty (60) days, unless an extension of time, not to exceed an additional sixty (60) days, is granted by the commissioner.
(b) A deficiency described in subsection (a) is an impairment, and the failure of a health maintenance organization to correct the impairment in the time prescribed by the commissioner under subsection (a) is grounds for:
(1) the suspension or revocation of the certificate of authority of the organization; or
(2) placing the health maintenance organization in rehabilitation or liquidation.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 24. Suspension, Revocation, or Denial of Certificate of Authority › 27-13-24-4. Action by Commissioner After Hearing

Sec. 4. (a) After a hearing, or upon failure of the health maintenance organization or applicant to appear at the hearing, the commissioner shall:
(1) take whatever action the commissioner finds necessary and appropriate based on written findings; and
(2) mail the decision to the health maintenance organization or applicant.
(b) The action of the commissioner under this chapter is subject to review under IC 4-21.5.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 24. Suspension, Revocation, or Denial of Certificate of Authority › 27-13-24-5. Application of Ic 4-21.5

Sec. 5. IC 4-21.5 applies to proceedings under this chapter to the extent IC 4-21.5 does not conflict with any section of this chapter.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 24. Suspension, Revocation, or Denial of Certificate of Authority › 27-13-24-6. Prohibited Activity During Suspension

Sec. 6. A health maintenance organization whose certificate of authority is suspended may not, during the period of suspension:
(1) enroll any additional enrollees, except newborn children or other newly acquired dependents of existing enrollees; or
(2) engage in any advertising or solicitation.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 24. Suspension, Revocation, or Denial of Certificate of Authority › 27-13-24-7. Conclusion of Affairs Following Revocation of Certificate of Authority

Sec. 7. (a) A health maintenance organization whose certificate of authority is revoked:
(1) shall proceed, immediately following the effective date of the order of revocation, to wind up the affairs of the organization; and
(2) may not conduct further business, except as essential to the orderly conclusion of the affairs of the organization.
(b) After the certificate of authority of a health maintenance organization is revoked, the health maintenance organization may not engage in further advertising or solicitation.
(c) Notwithstanding subsection (a), the commissioner may, by written order, permit further operation of a health maintenance organization after the certificate of authority of the organization is revoked if the commissioner finds the further operation of the organization to be in the best interest of enrollees.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 24. Suspension, Revocation, or Denial of Certificate of Authority › 27-13-24-8. Prohibited Activities Before Hearing

Sec. 8. If the commissioner issues an order under section 3(b)(1) of this chapter and the health maintenance organization requests a hearing under section 3(d) of this chapter within the time period specified, the health maintenance organization may not:
(1) enroll any additional enrollees, except newborn children or other newly acquired dependents of existing enrollees; or
(2) engage in any advertising or solicitation;
until the commissioner takes action under section 4 of this chapter.
As added by P.L.26-1994, SEC.25. Amended by P.L.195-1996, SEC.9.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 25. Rehabilitation or Liquidation of Health Maintenance Organizations › 27-13-25-1. Rehabilitation or Liquidation as an Insurance Company; Applicability of Ic 27-9

Sec. 1. The rehabilitation or liquidation of a health maintenance organization:
(1) shall be considered to be the rehabilitation or liquidation of an insurance company; and
(2) shall be conducted under IC 27-9.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 25. Rehabilitation or Liquidation of Health Maintenance Organizations › 27-13-25-2. Appointment of Commissioner as Rehabilitator or Liquidator; Grounds

Sec. 2. The commissioner may apply for an order appointing the commissioner as rehabilitator or liquidator to rehabilitate or liquidate a health maintenance organization:
(1) upon at least one (1) of the grounds set forth in IC 27-9-3-1 or IC 27-9-3-6; or
(2) when, in the commissioner's opinion, the continued operation of the health maintenance organization would be hazardous to the enrollees of the organization or the people of Indiana.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 25. Rehabilitation or Liquidation of Health Maintenance Organizations › 27-13-25-3. Claims Against Health Maintenance Organization

Sec. 3. (a) In the liquidation of a health maintenance organization, the claims against the health maintenance organization by enrollees, beneficiaries, and providers qualify as class 3 claims under IC 27-9-3-40(3).
(b) If an enrollee is liable to a provider for services provided under and covered by a health maintenance organization, that liability has the status of an enrollee claim in the liquidation of a health maintenance organization. If the health maintenance organization in liquidation pays the provider the amount of a claim under this subsection, then the claim of the enrollee is extinguished.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 26. Summary of Orders and Supervision › 27-13-26-1. Hazardous Financial Condition; Corrective Action Ordered by Commissioner

Sec. 1. (a) If the commissioner determines that:
(1) the financial condition of a health maintenance organization is such that the continued operation of the organization might be hazardous to:
(A) the subscribers, enrollees, or creditors of the organization; or
(B) the general public; or
(2) the organization has violated any provision of this article;
the commissioner may, after notice and hearing, order the health maintenance organization to take action reasonably necessary to rectify the condition or violation.
(b) An order of the commissioner under subsection (a) may require a health maintenance organization to do one (1) or more of the following:
(1) Reduce the total amount of present and potential liability for benefits by reinsurance or another method acceptable to the commissioner.
(2) Reduce the volume of new business being accepted.
(3) Reduce expenses by specified methods.
(4) Suspend or limit the writing of new business for a period of time.
(5) Increase the capital and surplus of the health maintenance organization by contribution.
(6) Take other steps the commissioner considers appropriate under the circumstances.
(c) The commissioner's order under this section may require items in addition to those set forth in subsection (b).
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 26. Summary of Orders and Supervision › 27-13-26-2. Violation of Article

Sec. 2. For purposes of section 1(a)(2) of this chapter, the violation by a health maintenance organization of any Indiana law to which the health maintenance organization is subject is considered a violation of this article.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 26. Summary of Orders and Supervision › 27-13-26-3. Adoption of Rules; Uniform Standards Set by Commissioner

Sec. 3. (a) The commissioner may adopt rules under IC 4-22-2 to do the following:
(1) Set uniform standards and criteria to produce an early warning that the continued operation of a health maintenance organization might be hazardous to the subscribers, enrollees, or creditors of the organization or to the general public.
(2) Set standards for evaluating the financial condition of a health maintenance organization.
(b) The standards set under subsection (a)(2) must be consistent with the purposes expressed in section 1 of this chapter.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 26. Summary of Orders and Supervision › 27-13-26-4. Remedies and Measures

Sec. 4. The remedies and measures available to the commissioner under this chapter are in addition to and not in place of the remedies and measures available to the commissioner under IC 27-9.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 27. Fees › 27-13-27-1. Filing Fees

Sec. 1. Each health maintenance organization subject to this article shall pay to the commissioner for deposit into the department of insurance fund established by IC 27-1-3-28 the following fees:
(1) Three hundred fifty dollars ($350) for filing:
(A) an application for a certificate of authority; or
(B) an application for an amendment to a certificate of authority.
(2) Fifty dollars ($50) for filing each annual report.
As added by P.L.26-1994, SEC.25. Amended by P.L.173-2007, SEC.44; P.L.234-2007, SEC.198.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 27. Fees › 27-13-27-2. Fees Required by Ic 27-1-3-15

Sec. 2. In addition to the fees required by section 1 of this chapter, a health maintenance organization subject to this article must pay the fees required by IC 27-1-3-15. For purposes of IC 27-1-3-15, a contract between a health maintenance organization and a subscriber or enrollee and an evidence of coverage shall constitute a single policy.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 28. Penalties and Enforcement › 27-13-28-1. Augmentation of Penalty; Damages Suffered by Enrollees or Other Members of the Public

Sec. 1. The commissioner may augment a penalty imposed under IC 27-13-24-1(b) by an amount equal to the sum that the commissioner calculates to be the damages suffered by enrollees or other members of the public. The commissioner may direct that any penalty imposed under this section be paid to the enrollees or other members of the public damaged by 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 28. Penalties and Enforcement › 27-13-28-2. Conference to Determine Violations

Sec. 2. If the commissioner has cause to believe that a violation of this article by a health maintenance organization has occurred or is threatened, the commissioner may give notice to:
(1) the health maintenance organization; and
(2) the other persons who appear to be involved in the suspected violation;
to arrange a conference with the alleged violators or their authorized representatives for the purpose of attempting to determine the facts relating to the suspected violation and, if a violation has occurred or is threatened, to determine an adequate and effective means of correcting or preventing the violation.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 28. Penalties and Enforcement › 27-13-28-3. Procedural Requirements

Sec. 3. Proceedings under section 2 of this chapter are not governed by any formal procedural requirements and may be conducted in a manner the commissioner considers appropriate under the circumstances. However, a conference under section 2 of this chapter may not result in a rule or an order until the requirements of section 2 of this chapter are satisfied, unless the health maintenance organization consents to the rule or order.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 28. Penalties and Enforcement › 27-13-28-4. Cease and Desist Orders

Sec. 4. (a) The commissioner may issue an order directing:
(1) a health maintenance organization; or
(2) a representative of a health maintenance organization;
to cease and desist from engaging in any act or practice that violates this article.
(b) Within ten (10) days after a cease and desist order is served under subsection (a), the health maintenance organization or its representative may request a hearing on the question of whether acts or practices in violation of this article have occurred. The hearing must be conducted under IC 4-21.5.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 28. Penalties and Enforcement › 27-13-28-5. Injunctive or Other Relief

Sec. 5. In the case of a violation of this article, if the commissioner elects not to issue a cease and desist order, or in the event of noncompliance with a cease and desist order issued under section 4 of this chapter, the commissioner may institute a proceeding to obtain injunctive relief or other appropriate relief in the Marion County circuit court.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 28. Penalties and Enforcement › 27-13-28-6. Failure to Comply With Net Worth Requirements; Continued Operation

Sec. 6. Notwithstanding any other provision of this article, if a health maintenance organization fails to comply with the net worth requirement of this article, the commissioner may take appropriate action to assure that the continued operation of the health maintenance organization will not be hazardous to the enrollees of the organization.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 28. Penalties and Enforcement › 27-13-28-7. Investigations on Behalf of Enrollees or Providers Not Precluded

Sec. 7. This article does not preclude the department from investigating complaints, grievances, or appeals on behalf of enrollees or providers.
As added by P.L.69-1998, SEC.11.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 29. Statutory Construction and Relationship to Other Laws › 27-13-29-1. Applicability of Provisions

Sec. 1. (a) Except as provided in subsection (b) or as otherwise provided in this article or IC 27:
(1) IC 27; and
(2) the provisions of IC 16 regulating hospitals;
do not apply to any health maintenance organization or limited service health maintenance organization (as defined in IC 27-13-34-4) that is granted a certificate of authority under this article. However, this section does not apply to an insurer or a hospital that is licensed under Indiana law, except with respect to the health maintenance organization activities of the hospital or insurer that are authorized and regulated under this article.
(b) Every:
(1) health maintenance organization; and
(2) limited service health maintenance organization (as defined in IC 27-13-34-4);
authorized to do business in Indiana is subject to IC 27-4-1 relating to unfair methods of competition and unfair or deceptive acts or practices to the extent that IC 27-4-1 does not conflict with this article. If a provision in IC 27-4-1 conflicts with this article, this article governs and controls.
As added by P.L.26-1994, SEC.25. Amended by P.L.255-1995, SEC.14; P.L.91-1998, SEC.23.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 29. Statutory Construction and Relationship to Other Laws › 27-13-29-2. Solicitation of Enrollees

Sec. 2. Provided that the solicitation otherwise complies with IC 27-13-21, the solicitation of enrollees by:
(1) a health maintenance organization or limited service health maintenance organization that is granted a certificate of authority; or
(2) a representative of an organization described in subdivision (1);
may not be construed to violate any provision of law relating to solicitation or advertising by health professionals.
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 29. Statutory Construction and Relationship to Other Laws › 27-13-29-4. Risk Based Capital Requirements

Sec. 4. A:
(1) health maintenance organization; or
(2) limited service health maintenance organization;
that is domiciled in Indiana is subject to the risk based capital requirements of IC 27-1-36, unless exempted by the commissioner under IC 27-1-36-1.
As added by P.L.51-2002, SEC.11.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 30. Filings and Reports as Public Documents › 27-13-30-1. Public Records; Exemptions; Annual Financial Statement

Sec. 1. (a) All applications, filings, and reports required under this article shall be treated as public records under IC 5-14-3, except those that are:
(1) trade secrets; or
(2) privileged or confidential:
(A) quality management information; or
(B) commercial or financial information.
(b) An annual financial statement required under IC 27-13-8 is not exempt from treatment as a public document under subsection (a)(2)(B).
As added by P.L.26-1994, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 31. Confidentiality of Medical Information and Limitation of Liability › 27-13-31-1. Information Treated as Confidential; Exceptions; Privilege Against Disclosure

Sec. 1. (a) Notwithstanding IC 27-13-30, any information:
(1) that pertains to the diagnosis, treatment, or health of any enrollee of a health maintenance organization or limited service health maintenance organization; and
(2) that is obtained from:
(A) the enrollee; or
(B) any provider;
by any health maintenance organization or limited service health maintenance organization;
is confidential and may not be disclosed to any person, except under the circumstances set forth in subsection (b).
(b) Information described in subsection (a) may be disclosed:
(1) to the extent necessary to carry out this article;
(2) upon the express consent of the enrollee;
(3) under a statute or court order for the production of evidence or the discovery of evidence; or
(4) in the event of a claim or litigation between:
(A) the enrollee; and
(B) the health maintenance organization or limited service health maintenance organization;
in which the data or information is pertinent.
(c) A health maintenance organization or limited service health maintenance organization is entitled to claim any statutory privilege against the disclosure of information described in subsection (a) that the provider who furnished the information to the health maintenance organization or limited service health maintenance organization is entitled to claim.
As added by P.L.26-1994, SEC.25.