CHAPTER 2. ESTABLISHMENT OF HEALTH MAINTENANCE ORGANIZATIONS
IC 27-13-2
Chapter 2. Establishment of Health Maintenance Organizations
IC 27-13-2-1
Persons applying for certificate of authority
Sec. 1. Notwithstanding any other law, any person may apply tothe commissioner for a certificate of authority to establish andoperate a health maintenance organization under this article.
As added by P.L.26-1994, SEC.25.
IC 27-13-2-2
Certificate of authority required
Sec. 2. (a) A person may not establish or operate a healthmaintenance organization without obtaining a certificate of authorityunder this article.
(b) If a participating provider contracts with another providerunder a contract that complies with IC 27-13-15 to provide healthservices on a prepaid basis to enrollees of a health maintenanceorganization that holds a certificate of authority, neither provider,with respect to the contract is:
(1) considered to be engaged in the business of insurance; or
(2) required to obtain a certificate of authority under this article.
As added by P.L.26-1994, SEC.25. Amended by P.L.195-1996,SEC.3.
IC 27-13-2-3
Foreign entities obtaining certificate of authority
Sec. 3. (a) A foreign corporation, other than a foreign corporationdefined under IC 27-1-2-3, may obtain a certificate of authority if theforeign corporation:
(1) is authorized to do business in Indiana under IC 23-1-49 orIC 23-17-26; and
(2) complies with this article.
(b) A foreign corporation (as defined in IC 27-1-2-3) may obtaina certificate of authority if the foreign corporation complies with thisarticle.
(c) A foreign or alien health maintenance organization granted acertificate of authority under this section has the same but no greaterrights and privileges than a domestic health maintenanceorganization.
As added by P.L.26-1994, SEC.25. Amended by P.L.203-2001,SEC.15.
IC 27-13-2-4
Certificate of authority application; verification; form
Sec. 4. An application for a certificate of authority to operate ahealth maintenance organization must be:
(1) verified by an officer or authorized representative of theapplicant; and
(2) submitted on a form prescribed by the commissioner.As added by P.L.26-1994, SEC.25.
IC 27-13-2-5
Certificate of authority application; requirements
Sec. 5. An application for a certificate of authority to operate ahealth maintenance organization must set forth or be accompanied bythe following:
(1) A copy of the organizational documents of the applicant,such as the articles of incorporation, partnership agreement,trust agreement, articles of organization, or any other applicabledocuments, and all amendments to those documents.
(2) A copy of the bylaws, rules and regulations, or similardocument regulating the conduct of the internal affairs of theapplicant.
(3) A list, on a form acceptable to the commissioner, of thenames, addresses, official positions, and biographicalinformation of the persons who are to be responsible for theconduct of the affairs and daily operations of the applicant,including the following:
(A) All members of the board of directors, board of trustees,executive committee, or other governing board or committeeof the applicant.
(B) The principal officers, if the applicant is a corporation.
(C) The partners or members, if the applicant is a partnershipor an association.
(D) The manager or, if there is no manager, all members ofa limited liability company.
(4) A copy of any contract form that has been made or is to bemade between any class of providers and the healthmaintenance organization.
(5) A copy of any contract that has been made or is to be madebetween:
(A) third party administrators, agents, or persons identifiedunder subdivision (3); and
(B) the health maintenance organization.
(6) A copy of the form of evidence of coverage that is to beissued by the health maintenance organization to an enrollee.
(7) A copy of the form of a group contract, if any, that is to beissued by the health maintenance organization to an employer,a union, a trustee, or another entity.
(8) Financial statements showing the assets, liabilities, andsources of financial support of the applicant, including:
(A) a copy of the most recent certified financial statement ofthe applicant; and
(B) an unaudited current financial statement.
(9) A financial feasibility plan that includes the following:
(A) Detailed enrollment projections.
(B) The methodology for determining premium rates to becharged during the first twelve (12) months of operations,certified by an actuary or other qualified person acceptable
to the commissioner.
(C) A projection of:
(i) balance sheets;
(ii) cash flow statements showing any capitalexpenditures, purchase and sale of investments, anddeposits with the state; and
(iii) income and expense statements;
anticipated from the start of operations until the organizationhas had net income for at least one (1) year.
(D) A statement of the sources of working capital as well asany other sources of funding.
(10) If the applicant is not domiciled in Indiana, an executedpower of attorney appointing the commissioner, thecommissioner's successors in office, and authorized deputies ofthe commissioner as the true and lawful attorney of theapplicant in and for Indiana upon whom all lawful process inany legal action or proceeding against the health maintenanceorganization on a cause of action arising in Indiana may beserved.
(11) A statement or map reasonably indicating, on acounty-by-county basis, the service area to be served by thehealth maintenance organization.
(12) A description of the internal procedures to be used by thehealth maintenance organization for the investigation andresolution of the complaints and grievances of enrollees.
(13) A description of the proposed quality managementprogram of the applicant, including the following:
(A) The formal organizational structure.
(B) Methods for developing criteria.
(C) Procedures for comprehensive evaluation of the qualityof care rendered to enrollees.
(D) Processes to initiate corrective action and reevaluationwhen deficiencies in provider performance or organizationalperformance are identified.
(14) A description of the procedures to be implemented to meetthe requirements set forth in IC 27-13-12 through IC 27-13-17.
(15) A list of the names, addresses, and license numbers of anyproviders with whom the health maintenance organization hasagreements.
(16) Any other information required by the commissioner tomake the determination required under IC 27-13-3.
As added by P.L.26-1994, SEC.25.
IC 27-13-2-6
Certificate of authority application; modifications or amendments
Sec. 6. (a) An applicant shall submit to the commissioner anymodifications or amendments to the items of information required inan application under section 5 of this chapter.
(b) The commissioner may adopt rules under this section thatprovide that any modifications or amendments to the items of
information in the application required of a health maintenanceorganization:
(1) must be submitted to the commissioner before themodification or amendment takes effect:
(A) for the approval of the commissioner; or
(B) for the information of the commissioner only; or
(2) must be indicated by the health maintenance organization tothe commissioner at the time of the next succeeding site visit orexamination of the organization by the department of insurance.
(c) A health maintenance organization shall file any assumedcorporate name with the department at least thirty (30) days beforeassuming the name.
As added by P.L.26-1994, SEC.25. Amended by P.L.203-2001,SEC.16.
IC 27-13-2-7
Certificate of authority application; approval of modifications oramendments
Sec. 7. Any modification or amendment requiring the approval ofthe commissioner under rules adopted under section 6 of this chapteris considered approved unless the commissioner disapproves themodification or amendment not more than thirty (30) days after themodification or amendment is submitted. However, thecommissioner may postpone the action, if necessary for properconsideration, and if the commissioner gives written notice of thepostponement to the applicant before the expiration of the thirty (30)day period.
As added by P.L.26-1994, SEC.25.
IC 27-13-2-8
Waiver of rights under bankruptcy laws
Sec. 8. The commissioner may not issue a certificate of authorityto operate a health maintenance organization unless the applicant hassubmitted to the commissioner a written waiver of the healthmaintenance organization's rights under the federal bankruptcy laws.
As added by P.L.26-1994, SEC.25.
IC 27-13-2-9
Prohibited names
Sec. 9. (a) A health maintenance organization established underthis article may not:
(1) use as a part of its corporate name the words "UnitedStates", "Federal", "government", "official", or any word thatwould imply that the company is an administrative agency ofthe state of Indiana or of the United States, or that it is subjectto supervision of any department other than the department ofinsurance; or
(2) take or assume a corporate name the same as, or confusinglysimilar to, an existing name of any other insurance company orother entity licensed or regulated under IC 27, unless at the
same time:
(A) the other company changes its corporate name orwithdraws from transacting business in Indiana; and
(B) the written consent of the other company, signed andverified under oath by its secretary, is filed with thedepartment.
(b) This section does not affect the right of any healthmaintenance organization that:
(1) exists under the laws of Indiana as of July 1, 2001;
(2) exists under the laws of Indiana as of July 1, 2001, andthereafter reorganizes or reincorporates under this article; or
(3) is authorized to transact business in Indiana as of July 1,2001;
to continue the use of its corporate name.
As added by P.L.203-2001, SEC.17.