Title 27, INSURANCE

Sec. 15. "Grievance" means a written complaint submitted in accordance with the formal grievance procedure of a health maintenance organization by or on behalf of: (1) the enrollee or subscriber regarding any aspect of the health maintenance organization relative to the enrollee …

Sec. 16. "Group contract" means a contract for health care services which by the contract's terms limits eligibility to members of a specified group. A group contract may include coverage for dependents. As added by P.L.26-1994, SEC.25.

Sec. 17. "Group contract holder" means the person to whom a group contract has been issued. As added by P.L.26-1994, SEC.25.

Sec. 18. (a) "Health care services" means: (1) any services provided by individuals licensed under IC 25-5.1, IC 25-10, IC 25-13, IC 25-14, IC 25-22.5, IC 25-23, IC 25-24, IC 25-26, IC 25-27, IC 25-29, IC 25-33, or IC 25-35.6; (2) services provided as a result of hospitalization;…

Sec. 19. "Health maintenance organization" means a person that undertakes to provide or arrange for the delivery of health care services to enrollees on a prepaid basis, except for enrollee responsibility for copayments or deductibles. As added by P.L.26-1994, SEC.25.

Sec. 2. "Admitted asset" means an asset that may be included in a health maintenance organization's total assets for the purpose of computing the net worth of the health maintenance organization. As added by P.L.26-1994, SEC.25.

Sec. 20. "In-plan covered services" means the following: (1) Covered health care services that are obtained from a provider who: (A) is employed by; (B) is under contract with; (C) provides health care services to an enrollee referred by; or (D) is otherwise affiliated with; the …

Sec. 21. (a) "Individual contract" means a contract for health care services that: (1) is issued to; and (2) covers; an individual. (b) An individual contract may include coverage for a dependent of the subscriber. As added by P.L.26-1994, SEC.25.

Sec. 21.3. "Insurance producer" means a person who is a licensed insurance producer under IC 27-1-15.6 and who: (1) solicits, negotiates, effects, procures, delivers, renews, or continues a policy or contract for membership in a health maintenance organization or a prepaid limite…

Sec. 21.5. "Managed hospital payment basis" means agreements in which the financial risk is primarily related to the degree of utilization rather than to cost of services. As added by P.L.255-1995, SEC.13.

Sec. 22. (a) "Net worth" means the excess of total admitted assets over total liabilities. (b) For the purposes of subsection (a), "liabilities" does not include fully subordinated debt. As added by P.L.26-1994, SEC.25.

Sec. 23. (a) "Out-of-plan covered services" means nonemergency, self-referred covered health care services that: (1) are obtained from a provider who is: (A) not otherwise employed by; (B) not under contract with; and (C) not otherwise affiliated with; the health maintenance orga…

Sec. 24. "Participating provider" means a provider who, under an express or implied contract with: (1) the health maintenance organization; or (2) a contractor of the health maintenance organization or any subcontractor of a contractor of the health maintenance organization; has …

Sec. 25. "Person" includes the following: (1) An individual. (2) A partnership. (3) An association. (4) A trust. (5) A limited liability company. (6) A corporation. As added by P.L.26-1994, SEC.25.

Sec. 26. "Point-of-service product" means a product that covers both: (1) in-plan covered services; and (2) out-of-plan covered services. As added by P.L.26-1994, SEC.25.

Sec. 27. "Limited service health maintenance organization" has the meaning set forth in IC 27-13-34-4. As added by P.L.26-1994, SEC.25. Amended by P.L.2-1998, SEC.70.

Sec. 27.5. "Primary care provider" means a provider under contract with a health maintenance organization who is designated by the health maintenance organization to coordinate, supervise, or provide ongoing care to an enrollee. As added by P.L.69-1998, SEC.4.

Sec. 28. (a) "Provider" means a physician, a hospital, or any other person licensed or authorized to furnish health care services. (b) The term includes an entity that: (1) is owned in whole or in part by one (1) or more physicians, hospitals, or other persons licensed or authori…

Sec. 28.5. "Quality assurance" means the ongoing evaluation of the quality of health care services provided to enrollees. As added by P.L.69-1998, SEC.5.

Sec. 29. "Receivership" means that the health maintenance organization has been placed in receivership under an order of rehabilitation or liquidation by a court with jurisdiction. As added by P.L.26-1994, SEC.25.

Sec. 30. "Replacement coverage" means the coverage provided to a person whose last preceding carrier has ceased providing coverage to that person. As added by P.L.26-1994, SEC.25.

Sec. 31. "Service area" means the geographic area within which a health maintenance organization licensed under this article provides or arranges for the delivery of health care services to enrollees. As added by P.L.26-1994, SEC.25.

Sec. 32. "Subscriber" means: (1) an individual whose employment status or other status, except family dependency, is the basis for eligibility for enrollment in the health maintenance organization; or (2) in the case of an individual contract, the person in whose name the contrac…

Sec. 33. "Subscriber premiums" means money or any other thing of value paid or given in consideration to a health maintenance organization, agent, or solicitor on account of or in connection with a contract under which a health maintenance organization provides or arranges for th…

Sec. 34. "Telehealth services" means health care services delivered by use of technology allowed under IC 25-1-9.5-6, including the following: (1) Medical exams and consultations. (2) Behavioral health, including substance abuse evaluations and treatment. As added by P.L.185-2015…

Sec. 4. (a) "Basic health care services" means the following medically necessary services: (1) Preventive care. (2) Inpatient and outpatient hospital and physician care. (3) Diagnostic laboratory care. (4) Diagnostic and therapeutic radiological services. (5) Emergency care. (b) …

Sec. 5. "Capitated basis" means fixed per member per month payment or percentage of premium payment under which the provider assumes the full risk for the cost of contracted services without regard to type, value, or frequency of services provided. For purposes of this definition…

Sec. 6. "Carrier" refers to any of the following: (1) A health maintenance organization. (2) An insurer licensed in Indiana to write Class 1(B) or Class 2(A) lines of insurance. (3) Any other entity responsible for the payment of benefits or provision of services under a group co…

Sec. 7. "Commissioner" refers to the insurance commissioner appointed under IC 27-1-1-2. As added by P.L.26-1994, SEC.25.

Sec. 8. "Copayment" means an amount, or a percentage of the charge, that an enrollee must pay to receive a specific service that is not fully prepaid. As added by P.L.26-1994, SEC.25.

Sec. 9. "Coverage" means the health care services to which a person is contractually entitled, either directly or indirectly, under a contract with a carrier. As added by P.L.26-1994, SEC.25.

Sec. 1. This article may be referred to as the Indiana demutualization law. As added by P.L.94-1999, SEC.3.

Sec. 10. "Membership interests" means: (1) the voting rights of members of a domestic mutual insurance company as provided by law and by the company's articles of incorporation and bylaws; and (2) the rights of members of a domestic mutual insurance company to receive cash, stock…

Sec. 11. "Parent company" means a corporation that, upon the effective date of a conversion, owns all of the stock of the former mutual. As added by P.L.94-1999, SEC.3.

Sec. 12. "Plan of conversion" means the plan of conversion described in either IC 27-15-2-2 or IC 27-15-2-3. As added by P.L.94-1999, SEC.3.

Sec. 13. "RBC level" has the meaning set forth in IC 27-1-36-18. As added by P.L.94-1999, SEC.3.

Sec. 14. "Simple plan of conversion" means the plan of conversion described in IC 27-15-2-3. As added by P.L.94-1999, SEC.3.

Sec. 2. (a) Any domestic mutual insurance company that: (1) maintains its executive offices in Indiana; and (2) employs at least five hundred (500) persons or a substantial percentage of its workforce in Indiana; may, by amendment to its articles of incorporation, convert to a st…

Sec. 3. The definitions set forth in this chapter and IC 27-1-2-3 apply throughout this article. As added by P.L.94-1999, SEC.3.

Sec. 4. "Closed block" means an allocation of assets for a defined group of in force policies which, together with the premiums of those policies and related investment earnings, are expected to be sufficient to maintain the payments of guaranteed benefits, certain expenses, and …

Sec. 5. "Company action level RBC" has the meaning set forth in IC 27-1-36-6. As added by P.L.94-1999, SEC.3.

Sec. 6. "Converting mutual" means a domestic mutual insurance company that has adopted a plan of conversion and an amendment to its articles of incorporation under this article that will, upon consummation, result in the domestic mutual insurance company converting into a domesti…

Sec. 7. "Eligible member" means a person who: (1) is a member of the converting mutual on the date the converting mutual's board of directors adopts a resolution proposing a plan of conversion and an amendment to the articles of incorporation; and (2) continues to be a member of …

Sec. 8. "Former mutual" means the domestic stock insurance company resulting from the conversion of a converting mutual to a stock insurance company under a plan of conversion and an amendment to its articles of incorporation under this article. As added by P.L.94-1999, SEC.3.

Sec. 9. "Member" means a person that, according to the: (1) records; (2) articles of incorporation; and (3) bylaws; of a converting mutual, is a member of the converting mutual. As added by P.L.94-1999, SEC.3.

Sec. 1. This article applies after December 31, 2005. As added by P.L.245-2005, SEC.7.