Title 27, INSURANCE

Sec. 12.3. (a) An administrator that is licensed under section 11.1 of this chapter shall, not later than July 1 of each year unless the commissioner grants an extension of time for good cause, file a report for the previous calendar year that complies with the following: (1) The…

Sec. 12.4. (a) The commissioner shall deny, suspend, or revoke a license issued under this chapter if the commissioner determines that the administrator: (1) is in unsound financial condition; (2) engages in methods or practices in the conduct of the administrator's business so a…

Sec. 13. (a) Except as provided by section 4(b) of this chapter, and except that all provisions of the written agreement between the administrator and an insurer shall be treated by the commissioner as confidential and shall not be open to any member of the public for inspection …

Sec. 14. The commissioner may, under IC 4-22-2, adopt regulations necessary to implement this chapter. As added by Acts 1980, P.L.168, SEC.2.

Sec. 15. (a) An administrator acting without a license issued under this chapter commits a Class C infraction. (b) The commissioner shall notify the prosecuting attorney or the attorney general of Indiana of violations under subsection (a). As added by Acts 1980, P.L.168, SEC.2. …

Sec. 16. (a) A presumption of control arising under section 1(e) of this chapter may be rebutted by a showing made in the manner provided under IC 27-1-23-3(k) that control does not exist in fact. (b) In the absence of a presumption that control exists in fact, the commissioner m…

Sec. 2. (a) An administrator may act only if there is a written agreement between the administrator and an insurer. This agreement must conform to the requirements of this chapter, which apply to the functions performed by the administrator. (b) An agreement between an administra…

Sec. 3. (a) If an insurer utilizes the services of an administrator: (1) premiums or charges for coverage paid by or on behalf of the covered individual are considered to have been received by the insurer when paid to the administrator; and (2) claims or return premiums paid by t…

Sec. 4. (a) An administrator: (1) shall maintain at its principal administrative office books and records of all transactions between the administrator and insurers for at least five (5) years after the creation of the books and records; or (2) may transfer the books and records …

Sec. 5. An administrator may use advertising relating to the business underwritten by an insurer only to the extent that the advertising has been approved in writing by that insurer before the advertising is used. As added by Acts 1980, P.L.168, SEC.2. Amended by P.L.160-2003, SE…

Sec. 5.5. (a) If an insurer uses the services of an administrator, the insurer is responsible for: (1) determining the: (A) benefits; (B) premium rates; (C) underwriting criteria; and (D) claims payment procedures; that apply to the coverage; and (2) securing reinsurance. (b) An …

Sec. 6. (a) An administrator is a fiduciary in collecting or returning premiums or charges for the insurer with whom it has a written agreement for administrative services. (b) Funds collected by the administrator shall be immediately remitted to the person entitled to the funds …

Sec. 7. All claims paid by an administrator from funds collected on behalf of an insurer shall be paid: (1) by draft or check; or (2) via electronic payment; as authorized by the insurer. As added by Acts 1980, P.L.168, SEC.2. Amended by Acts 1982, P.L.165, SEC.5; P.L.160-2003, S…

Sec. 8. (a) An administrator may not enter into an agreement or understanding with an insurer if the effect of the agreement or understanding is to make the amount of a: (1) commission; (2) fee; or (3) charge; that is payable to the administrator contingent on savings effected in…

Sec. 9. Policies, certificates, booklets, termination notices, or other written communications delivered by an insurer to an administrator for delivery to its covered individuals shall be delivered by the administrator promptly after receipt of instructions from the insurer to do…

Sec. 0.5. Nothing in this chapter prohibits: (1) a self-funded health benefit plan that complies with the federal Employee Retirement Income Security Act (ERISA) of 1974 (29 U.S.C. 1001 et seq.); or (2) a: (A) self-insurance program established to provide group health coverage as…

Sec. 1. As used in this chapter, "coverage" means the right of an individual to receive: (1) health care services; or (2) payment or reimbursement for health care services; from a health carrier. As added by P.L.93-2020, SEC.13.

Sec. 10. As used in this chapter, "provider" means: (1) a provider facility; or (2) a practitioner. As added by P.L.93-2020, SEC.13.

Sec. 11. As used in this chapter, "provider facility" means any of the following: (1) A hospital licensed under IC 16-21-2. (2) An ambulatory outpatient surgical center licensed under IC 16-21-2. (3) A birthing center licensed under IC 16-21-2. (4) Except for an urgent care facil…

Sec. 12. (a) A covered individual may request from the health carrier a good faith estimate of: (1) the amount of the cost of the nonemergency health care service that the health carrier will: (A) pay for; or (B) reimburse to; the covered individual; or (2) the applicable benefit…

Sec. 13. A health carrier may provide a good faith estimate to an individual under this chapter: (1) in a writing delivered to the individual; (2) by electronic mail; or (3) through a mobile application or other Internet web based method, if available; according to the preference…

Sec. 14. (a) A good faith estimate provided by a health carrier to an individual under this chapter must: (1) in the case of an insurer or another health carrier that pays or reimburses the cost of health care services: (A) provide a summary of the services and material items tha…

Sec. 15. A health carrier that provides a website for the use of its covered individuals shall ensure that the website includes a printed notice that: (1) is designed, lettered, and featured on the website so as to be conspicuous to and readable by any individual with normal visi…

Sec. 16. (a) If a health carrier fails or refuses: (1) to provide a good faith estimate as required by this chapter; or (2) to provide notice on the health carrier's Internet web site as required by section 15 of this chapter; the insurance commissioner may, after notice and hear…

Sec. 2. As used in this chapter, "covered individual" means an individual who is entitled to coverage from a health carrier. As added by P.L.93-2020, SEC.13.

Sec. 2.5. As used in this chapter, "episode of care" means the medical care ordered to be provided for a specific medical procedure, condition, or illness. As added by P.L.93-2020, SEC.13.

Sec. 3. As used in this chapter, "good faith estimate" means a health carrier's reasonable estimate of: (1) the amount of the cost of a nonemergency health care service that the health carrier will: (A) pay for; or (B) reimburse to; a covered individual; or (2) the applicable ben…

Sec. 4. (a) As used in this chapter, "health carrier" means an entity: (1) that is subject to this title and the administrative rules adopted under this title; and (2) that enters into a contract to: (A) provide health care services; (B) deliver health care services; (C) arrange …

Sec. 5. As used in this chapter, "in network", when used in reference to a practitioner, means that the health care services provided by the practitioner are subject to a health carrier's network plan. As added by P.L.93-2020, SEC.13.

Sec. 6. (a) As used in this chapter, "network" means a group of provider facilities and practitioners that: (1) provide health care services to covered individuals; and (2) have agreed to, or are otherwise subject to, maximum limits on the prices for the health care services to b…

Sec. 7. As used in this chapter, "network plan" means a plan of a health carrier that: (1) requires a covered individual to receive; or (2) creates incentives, including financial incentives, for a covered individual to receive; health care services from one (1) or more providers…

Sec. 8. As used in this chapter, "nonemergency health care service" means a discrete service or series of services ordered by a practitioner for an episode of care for the: (1) diagnosis; (2) prevention; (3) treatment; (4) cure; or (5) relief; of a physical, mental, or behavioral…

Sec. 9. (a) As used in this chapter, "practitioner" means: (1) an individual who holds: (A) an unlimited license, certificate, or registration; (B) a limited or probationary license, certificate, or registration; (C) a temporary license, certificate, registration, or permit; (D) …

Sec. 9.5. As used in this chapter, "price" means the negotiated rate between the: (1) provider facility and practitioner; and (2) covered individual's primary health carrier; minus the amount that the health carrier will pay. As added by P.L.93-2020, SEC.13.

Sec. 1. As used in this chapter, "care method" means the use of a particular drug or device in a particular manner. As added by P.L.109-2009, SEC.3.

Sec. 2. As used in this chapter, "clinical trial" means a Phase I, II, III, or IV research study: (1) that is conducted: (A) using a particular care method to prevent, diagnose, or treat a cancer for which: (i) there is no clearly superior, noninvestigational alternative care met…

Sec. 3. As used in this chapter, "contracted provider" means a health care provider that has entered into an agreement under IC 27-8-11-3 with an insurer that issues a policy of accident and sickness insurance. As added by P.L.109-2009, SEC.3.

Sec. 4. As used in this chapter, "covered individual" means an individual entitled to coverage under a policy of accident and sickness insurance. As added by P.L.109-2009, SEC.3.

Sec. 5. As used in this chapter, "noncontracted provider" means a health care provider that has not entered into an agreement to serve as a contracted provider. As added by P.L.109-2009, SEC.3.

Sec. 6. As used in this chapter, "policy of accident and sickness insurance" has the meaning set forth in IC 27-8-5-1. As added by P.L.109-2009, SEC.3.

Sec. 7. As used in this chapter, "routine care cost" means the cost of medically necessary services related to the care method that is under evaluation in a clinical trial. The term does not include the following: (1) The health care service, item, or investigational drug that is…

Sec. 8. (a) A policy of accident and sickness insurance must provide coverage for routine care costs that are incurred in the course of a clinical trial if the policy of accident and sickness insurance would provide coverage for the same routine care costs not incurred in a clini…

Sec. 9. This chapter does not create a cause of action against a person for any harm to a covered individual resulting from a clinical trial. As added by P.L.109-2009, SEC.3.

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.

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 commiss…

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…