CHAPTER 1. DEFINITIONS
IC 27-13
ARTICLE 13. HEALTH MAINTENANCEORGANIZATIONS
IC 27-13-1
Chapter 1. Definitions
IC 27-13-1-1
Applicability of definitions
Sec. 1. The definitions in this chapter apply throughout thisarticle.
As added by P.L.26-1994, SEC.25.
IC 27-13-1-2
"Admitted asset"
Sec. 2. "Admitted asset" means an asset that may be included ina health maintenance organization's total assets for the purpose ofcomputing the net worth of the health maintenance organization.
As added by P.L.26-1994, SEC.25.
IC 27-13-1-3
Repealed
(Repealed by P.L.97-2004, SEC.133.)
IC 27-13-1-4
"Basic health care services"
Sec. 4. (a) "Basic health care services" means the followingmedically 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) The term does not include the following:
(1) Mental health services.
(2) Services for alcohol and drug abuse.
(3) Dental services.
(4) Vision services.
(5) Long term rehabilitation treatment.
As added by P.L.26-1994, SEC.25.
IC 27-13-1-5
"Capitated basis"
Sec. 5. "Capitated basis" means fixed per member per monthpayment or percentage of premium payment under which theprovider assumes the full risk for the cost of contracted serviceswithout regard to type, value, or frequency of services provided. Forpurposes of this definition, capitated basis includes the costassociated with operating staff model facilities.
As added by P.L.26-1994, SEC.25.
IC 27-13-1-6
"Carrier"
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 Class2(A) lines of insurance.
(3) Any other entity responsible for the payment of benefits orprovision of services under a group contract.
As added by P.L.26-1994, SEC.25.
IC 27-13-1-7
"Commissioner"
Sec. 7. "Commissioner" refers to the insurance commissionerappointed under IC 27-1-1-2.
As added by P.L.26-1994, SEC.25.
IC 27-13-1-8
"Copayment"
Sec. 8. "Copayment" means an amount, or a percentage of thecharge, that an enrollee must pay to receive a specific service that isnot fully prepaid.
As added by P.L.26-1994, SEC.25.
IC 27-13-1-9
"Coverage"
Sec. 9. "Coverage" means the health care services to which aperson is contractually entitled, either directly or indirectly, under acontract with a carrier.
As added by P.L.26-1994, SEC.25.
IC 27-13-1-10
"Covered by a health maintenance organization"
Sec. 10. "Covered by a health maintenance organization" meansthat a person is contractually entitled, either directly or indirectly, tohealth care services from the health maintenance organization.
As added by P.L.26-1994, SEC.25.
IC 27-13-1-10.5
"Credentialing"
Sec. 10.5. "Credentialing" means a process through which a healthmaintenance organization makes a determination:
(1) based on criteria established by the health maintenanceorganization; and
(2) concerning whether a provider may serve as a participatingprovider.
As added by P.L.26-2005, SEC.3.
IC 27-13-1-11
"Deductible"
Sec. 11. "Deductible" means the amount that an enrollee is
responsible to pay out-of-pocket before the health maintenanceorganization begins to pay the costs associated with the health careservices.
As added by P.L.26-1994, SEC.25.
IC 27-13-1-11.3
"Department"
Sec. 11.3. "Department" refers to the department of insurance.
As added by P.L.69-1998, SEC.1.
IC 27-13-1-11.5
"Dialysis facility"
Sec. 11.5. "Dialysis facility" means an outpatient facility inIndiana at which a dialysis treatment provider provides dialysistreatment.
As added by P.L.111-2008, SEC.5.
IC 27-13-1-11.7
"Emergency"
Sec. 11.7. "Emergency" means a medical condition that arisessuddenly and unexpectedly and manifests itself by acute symptomsof such severity, including severe pain, that the absence of immediatemedical attention could reasonably be expected by a prudent layperson who possesses an average knowledge of health and medicineto:
(1) place an individual's health in serious jeopardy;
(2) result in serious impairment to the individual's bodilyfunctions; or
(3) result in serious dysfunction of a bodily organ or part of theindividual.
As added by P.L.69-1998, SEC.2.
IC 27-13-1-12
"Enrollee"
Sec. 12. "Enrollee" means a subscriber or a subscriber's dependentwho is covered by a health maintenance organization.
As added by P.L.26-1994, SEC.25. Amended by P.L.191-1997,SEC.1.
IC 27-13-1-13
"Evidence of coverage"
Sec. 13. "Evidence of coverage" means a statement of theessential features and services of the coverage provided by a healthmaintenance organization.
As added by P.L.26-1994, SEC.25.
IC 27-13-1-13.5
"Experimental treatment"
Sec. 13.5. "Experimental treatment" means medical technology ora new application of existing medical technology, including medical
procedures, drugs, and devices for treating a medical condition,illness, or diagnosis that:
(1) is not generally accepted by informed health careprofessionals in the United States as effective; or
(2) has not been proven by scientific testing or evidence to beeffective;
in treating the medical condition, illness, or diagnosis for which itsuse is proposed.
As added by P.L.69-1998, SEC.3.
IC 27-13-1-14
"Extension of benefits"
Sec. 14. "Extension of benefits" means the continuation ofcoverage under a particular benefit provided under a contractfollowing the termination of an enrollee with a total disability on thedate of termination.
As added by P.L.26-1994, SEC.25. Amended by P.L.99-2007,SEC.194.
IC 27-13-1-15
"Grievance"
Sec. 15. "Grievance" means a written complaint submitted inaccordance with the formal grievance procedure of a healthmaintenance organization by or on behalf of the enrollee orsubscriber regarding any aspect of the health maintenanceorganization relative to the enrollee or subscriber.
As added by P.L.26-1994, SEC.25.
IC 27-13-1-16
"Group contract"
Sec. 16. "Group contract" means a contract for health careservices which by the contract's terms limits eligibility to membersof a specified group. A group contract may include coverage fordependents.
As added by P.L.26-1994, SEC.25.
IC 27-13-1-17
"Group contract holder"
Sec. 17. "Group contract holder" means the person to whom agroup contract has been issued.
As added by P.L.26-1994, SEC.25.
IC 27-13-1-18
"Health care services"
Sec. 18. (a) "Health care services" means:
(1) any services provided by individuals licensed underIC 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;
(3) services incidental to the furnishing of services described in
subdivision (1) or (2); or
(4) any other services or goods furnished for the purpose ofpreventing, alleviating, curing, or healing human illness,physical disability, or injury.
(b) The term does not include any service provided by, from, orthrough a licensed health care facility in connection with any lifecare, founder's fee, or other type of prepaid fee contract for residencyand health care in a retirement home, community, or facility forelderly persons.
As added by P.L.26-1994, SEC.25.
IC 27-13-1-19
"Health maintenance organization"
Sec. 19. "Health maintenance organization" means a person thatundertakes to provide or arrange for the delivery of health careservices to enrollees on a prepaid basis, except for enrolleeresponsibility for copayments or deductibles.
As added by P.L.26-1994, SEC.25.
IC 27-13-1-20
"In-plan covered services"
Sec. 20. "In-plan covered services" means the following:
(1) Covered health care services that are obtained from aprovider 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 health maintenance organization.
(2) Emergency services.
As added by P.L.26-1994, SEC.25.
IC 27-13-1-21
"Individual contract"
Sec. 21. (a) "Individual contract" means a contract for health careservices that:
(1) is issued to; and
(2) covers;
an individual.
(b) An individual contract may include coverage for a dependentof the subscriber.
As added by P.L.26-1994, SEC.25.
IC 27-13-1-21.3
"Insurance producer"
Sec. 21.3. "Insurance producer" means a person who is a licensedinsurance producer under IC 27-1-15.6 and who:
(1) solicits, negotiates, effects, procures, delivers, renews, orcontinues a policy or contract for membership in a health
maintenance organization or a prepaid limited health serviceorganization;
(2) takes or transmits a membership fee or premium for thepolicy or contract other than for the insurance producer; or
(3) causes the insurance producer to be held out to the public,through advertising or otherwise, as a producer for a healthmaintenance organization or a prepaid limited health serviceorganization.
As added by P.L.97-2004, SEC.102.
IC 27-13-1-21.5
"Managed hospital payment basis"
Sec. 21.5. "Managed hospital payment basis" means agreementsin which the financial risk is primarily related to the degree ofutilization rather than to cost of services.
As added by P.L.255-1995, SEC.13.
IC 27-13-1-22
"Net worth"
Sec. 22. (a) "Net worth" means the excess of total admitted assetsover total liabilities.
(b) For the purposes of subsection (a), "liabilities" does notinclude fully subordinated debt.
As added by P.L.26-1994, SEC.25.
IC 27-13-1-23
"Out-of-plan covered services"
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 organization; or
(2) are obtained from a participating provider without a referral.
(b) The term does not include uncovered services.
As added by P.L.26-1994, SEC.25.
IC 27-13-1-24
"Participating provider"
Sec. 24. "Participating provider" means a provider who, under anexpress or implied contract with:
(1) the health maintenance organization; or
(2) a contractor of the health maintenance organization or anysubcontractor of a contractor of the health maintenanceorganization;
has agreed to provide health care services to enrollees with anexpectation of directly or indirectly receiving payment, other thancopayment or deductible, from the health maintenance organization.
As added by P.L.26-1994, SEC.25. Amended by P.L.195-1996,
SEC.1.
IC 27-13-1-25
"Person"
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.
IC 27-13-1-26
"Point-of-service product"
Sec. 26. "Point-of-service product" means a product that coversboth:
(1) in-plan covered services; and
(2) out-of-plan covered services.
As added by P.L.26-1994, SEC.25.
IC 27-13-1-27
"Limited service health maintenance organization"
Sec. 27. "Limited service health maintenance organization" hasthe 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.
IC 27-13-1-27.5
"Primary care provider"
Sec. 27.5. "Primary care provider" means a provider undercontract with a health maintenance organization who is designatedby the health maintenance organization to coordinate, supervise, orprovide ongoing care to an enrollee.
As added by P.L.69-1998, SEC.4.
IC 27-13-1-28
"Provider"
Sec. 28. (a) "Provider" means a physician, a hospital, or any otherperson 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 authorized to furnishhealth care services; and
(2) was established for purposes of furnishing health careservices through:
(A) contracts; or
(B) employment agreements;
with one (1) or more physicians, hospitals, or other personslicensed or authorized to furnish health care services.
As added by P.L.26-1994, SEC.25. Amended by P.L.195-1996,
SEC.2.
IC 27-13-1-28.5
"Quality assurance"
Sec. 28.5. "Quality assurance" means the ongoing evaluation ofthe quality of health care services provided to enrollees.
As added by P.L.69-1998, SEC.5.
IC 27-13-1-29
"Receivership"
Sec. 29. "Receivership" means that the health maintenanceorganization has been placed in receivership under an order ofrehabilitation or liquidation by a court with jurisdiction.
As added by P.L.26-1994, SEC.25.
IC 27-13-1-30
"Replacement coverage"
Sec. 30. "Replacement coverage" means the coverage provided toa person whose last preceding carrier has ceased providing coverageto that person.
As added by P.L.26-1994, SEC.25.
IC 27-13-1-31
"Service area"
Sec. 31. "Service area" means the geographic area within whicha health maintenance organization licensed under this articleprovides or arranges for the delivery of health care services toenrollees.
As added by P.L.26-1994, SEC.25.
IC 27-13-1-32
"Subscriber"
Sec. 32. "Subscriber" means:
(1) an individual whose employment status or other status,except family dependency, is the basis for eligibility forenrollment in the health maintenance organization; or
(2) in the case of an individual contract, the person in whosename the contract is issued.
As added by P.L.26-1994, SEC.25.
IC 27-13-1-33
"Subscriber premiums"
Sec. 33. "Subscriber premiums" means money or any other thingof value paid or given in consideration to a health maintenanceorganization, agent, or solicitor on account of or in connection witha contract under which a health maintenance organization providesor arranges for the delivery of health care benefits to enrollees.
As added by P.L.26-1994, SEC.25.