CHAPTER 34. LIMITED SERVICE HEALTH MAINTENANCE ORGANIZATIONS
IC 27-13-34
Chapter 34. Limited Service Health Maintenance Organizations
IC 27-13-34-1
"Enrollee" defined
Sec. 1. (a) As used in this chapter, "enrollee" means an individualwho is entitled to limited health services under a contract with anentity authorized to provide or arrange for limited health servicesunder this chapter.
(b) The term includes the dependent of an individual described insubsection (a).
As added by P.L.26-1994, SEC.25.
IC 27-13-34-2
"Evidence of coverage" defined
Sec. 2. As used in this chapter, "evidence of coverage" means thecertificate, agreement, or contract issued under section 13 of thischapter setting forth the coverage to which an enrollee is entitled.
As added by P.L.26-1994, SEC.25.
IC 27-13-34-3
"Limited health services" defined
Sec. 3. (a) As used in this chapter, "limited health services" refersto:
(1) dental care services;
(2) vision care services;
(3) mental health services;
(4) substance abuse services;
(5) pharmaceutical services;
(6) podiatric care services; and
(7) other services that the commissioner determines to belimited health services.
(b) The term does not include hospital or emergency services,except as those services are provided incident to a limited healthservice.
As added by P.L.26-1994, SEC.25.
IC 27-13-34-4
"Limited service health maintenance organization" defined
Sec. 4. (a) As used in this chapter, "limited service healthmaintenance organization" means a corporation, partnership, limitedliability company, or other entity that undertakes to provide orarrange a limited health service on a prepayment basis or other basis.
(b) The term does not include a provider or an entity whenproviding or arranging for the provision of limited health servicesunder a contract with a limited service health maintenanceorganization.
As added by P.L.26-1994, SEC.25.
IC 27-13-34-5 "Provider" defined
Sec. 5. As used in this chapter, "provider" means a physician, adentist, an optometrist, a health facility, or other person or institutionthat is licensed or otherwise authorized to deliver or furnish limitedhealth service.
As added by P.L.26-1994, SEC.25.
IC 27-13-34-6
"Subscriber" defined
Sec. 6. As used in this chapter, "subscriber" means a personwhose employment status or other status, except for familydependency, is the basis for eligibility for limited health servicesunder a contract with an entity authorized to provide or arrange forlimited health services under this chapter.
As added by P.L.26-1994, SEC.25.
IC 27-13-34-7
Certificate of authority required; foreign entities
Sec. 7. (a) After December 31, 1994, a person, corporation,partnership, limited liability company, or other entity may notoperate a limited service health maintenance organization in Indianawithout obtaining and maintaining a certificate of authority from thecommissioner under this chapter.
(b) A for-profit or nonprofit corporation organized under the lawsof another state, other than a foreign corporation defined underIC 27-1-2-3, may obtain a certificate of authority to operate a limitedservice health maintenance organization in Indiana if the foreigncorporation is authorized to do business in Indiana under IC 23-1-49or IC 23-17-26 and complies with this chapter.
(c) A foreign corporation (as defined in IC 27-1-2-3) may obtaina certificate of authority to operate a limited service healthmaintenance organization in Indiana if the foreign corporationcomplies with this chapter.
(d) A foreign or alien limited service health maintenanceorganization granted a certificate of authority under this chapter hasthe same but not greater rights and privileges than a domestic limitedservice health maintenance organization.
As added by P.L.26-1994, SEC.25. Amended by P.L.203-2001,SEC.32.
IC 27-13-34-8
Application for certificate of authority; requirements
Sec. 8. (a) An application for a certificate of authority to operatea limited service health maintenance organization must be filed withthe commissioner on a form prescribed by the commissioner. Anapplication must be verified by an officer or authorizedrepresentative of the applicant and must set forth, or be accompaniedby, the following:
(1) A copy of the applicant's basic organizational document,such as the articles of incorporation, articles of association,
partnership agreement, trust agreement, articles of organization,or other applicable documents, and all amendments to thosedocuments.
(2) A copy of all bylaws, rules and regulations, or similardocuments, if any, regulating the conduct of the internal affairsof the applicant.
(3) A list of the names, addresses, official positions, andbiographical information of the individuals who are to beresponsible for conducting the affairs and daily operations ofthe applicant, including the following:
(A) All members of the board of directors, board of trustees,executive committee, or other governing board orcommittee.
(B) The principal officers.
(C) Any person or entity owning or having the right toacquire at least ten percent (10%) of the voting securities ofthe applicant.
(D) In the case of a partnership or an association, thepartners or members of the partnership or association.
(E) In the case of a limited liability company, the managersor members of the limited liability company.
(4) A statement generally describing the applicant, the facilitiesand personnel of the applicant, and the limited health service orservices that the applicant will offer.
(5) A copy of the form of any contract that has been made or isto be made between the applicant and any providers regardingthe provision of limited health services to enrollees.
(6) A copy of the form of any contract that has been made or isto be made between the applicant and any person referred to insubdivision (3).
(7) A copy of the form of any contract that has been made or isto be made between the applicant and any person, corporation,partnership, or other entity for the performance of any functionson behalf of the applicant, including the following:
(A) Marketing.
(B) Administration.
(C) Enrollment.
(D) Investment management.
(E) Subcontracting for the provision of limited healthservices to enrollees.
(8) A copy of the form of any contract that is to be issued toemployers, unions, trustees, or other organizations orindividuals, and a copy of any form of evidence of coverage tobe issued to subscribers.
(9) Subject to subsection (b), a copy of the most recent financialstatements of the applicant, audited by an independent certifiedpublic accountant.
(10) A copy of the financial plan of the applicant, including:
(A) a projection of anticipated operating results for at leastthree (3) years; and (B) a statement of the sources of working capital and anyother sources of funding and provisions for contingencies.
(11) A description of the proposed method of marketing.
(12) A statement acknowledging that all lawful process in anylegal action or proceeding against the applicant on a cause ofaction arising in Indiana is valid if served in accordance withthe Indiana Rules of Trial Procedure.
(13) A description of the complaint procedures to be establishedand maintained under IC 27-13-10.
(14) A description of the quality assessment and utilizationreview procedures to be used by the applicant.
(15) A description of how the applicant will comply withsections 16 and 17 of this chapter.
(16) The fee for the issuance of a certificate of authorityrequired by section 23 of this chapter.
(17) A written waiver of the applicant's rights under federalbankruptcy laws.
(18) Other information that the commissioner reasonablyrequires to make the determinations required by this chapter.
(19) 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 limited service healthmaintenance organization on a cause of action arising in Indianamay be served.
(b) If the financial affairs of the parent company of the applicantare audited by independent certified public accountants but those ofthe applicant are not, an applicant may satisfy the requirement setforth in subsection (a)(9) by including with the application the mostrecent audited financial statement of the applicant's parent company,certified by an independent certified public accountant, attached towhich shall be consolidating financial statements of the applicant,unless the commissioner determines that additional or more recentfinancial information is required for the proper administration of thischapter.
As added by P.L.26-1994, SEC.25.
IC 27-13-34-9
Issuance of certificate of authority; application deficiencies; denialof application
Sec. 9. (a) After receiving an application filed under section 8 ofthis chapter, the commissioner shall review the application and notifythe applicant of any deficiencies in the application.
(b) The commissioner shall issue a certificate of authority to anapplicant if the following conditions are met:
(1) The requirements of section 8 of this chapter have beenfulfilled.
(2) The individuals responsible for conducting the affairs of the
applicant are competent, trustworthy, possess good reputations,and have had appropriate experience, training, or education.
(3) The applicant is financially responsible and may reasonablybe expected to meet its obligations to enrollees and toprospective enrollees. In making this determination, thecommissioner may consider:
(A) the financial soundness of the arrangements of theapplicant for limited health services;
(B) the adequacy of the applicant's working capital, othersources of funding, and provisions for contingencies;
(C) any agreement for paying the cost of the limited healthservices or for alternative coverage in the event ofinsolvency of the limited service health maintenanceorganization; and
(D) the manner in which the requirements of sections 16 and17 of this chapter have been fulfilled.
(4) The agreements with providers for the provision of limitedhealth services contain the provisions required by section 15 ofthis chapter.
(5) Any deficiencies identified by the commissioner have beencorrected.
(c) If an application for a certificate of authority is denied, thecommissioner shall notify the applicant and shall specify in thenotice the reasons for the denial of the application. Within thirty (30)days after receiving the notice, the applicant may request a hearingbefore the commissioner under IC 4-21.5.
As added by P.L.26-1994, SEC.25.
IC 27-13-34-10
Powers of limited service health maintenance organization
Sec. 10. (a) Subject to subsection (b), the powers of a limitedservice health maintenance organization include the following:
(1) The purchase, lease, construction, renovation, operation, ormaintenance of:
(A) medical facilities that will provide limited healthservices;
(B) equipment for medical facilities providing limited healthservices; and
(C) other property reasonably required for the principaloffice of the limited service health maintenance organizationor for purposes necessary in the transaction of the businessof the organization.
(2) Engaging in transactions between affiliated entities,including loans and the transfer of responsibility under any orall contracts:
(A) between affiliates; or
(B) between the limited service health maintenanceorganization and the parent organization of the limitedservice health maintenance organization.
(3) The furnishing of limited health services through the
following:
(A) Providers.
(B) Provider associations.
(C) Agents for providers who are under contract with or areemployed by the limited service health maintenanceorganization. The contracts with providers, providerassociations, or agents for providers may include fee forservice, cost plus, capitation, or other payment orrisk-sharing agreements.
(4) Contracting with any person for the performance on behalfof the limited service health maintenance organization ofcertain functions, including:
(A) marketing;
(B) enrollment; and
(C) administration.
(5) Contracting with:
(A) an insurance company licensed in Indiana; or
(B) an authorized reinsurer for the provision of insurance,indemnity, or reimbursement against the cost of health careservices provided by the limited service health maintenanceorganization.
(6) The offering of point-of-service products for the limitedhealth services for which the limited service health maintenanceorganization is licensed so long as the limited service healthmaintenance organization complies with the reinsurance or ratiorequirements of IC 27-13-13-8.
(7) The joint marketing of products with:
(A) an insurance company that is licensed in Indiana; or
(B) a health maintenance organization that is authorized toconduct business in Indiana;
if the company that is offering each product is clearly identified.
(8) Providing limited health services at the expense of aself-funded plan.
(b) Nothing in this section qualifies an asset of a prepaid limitedhealth service organization as an admitted asset.
As added by P.L.26-1994, SEC.25.
IC 27-13-34-11
Modification of documents; filing; disapproval
Sec. 11. (a) Before making any material modification of anymatter or document furnished under section 8 of this chapter, alimited service health maintenance organization shall file with thecommissioner:
(1) a notice of the modification; and
(2) supporting documents that are necessary to fully explain themodification.
(b) If a limited service health maintenance organization desires toadd one (1) or more limited health services, it must:
(1) file a notice with the commissioner;
(2) submit the information required by section 8 of this chapter
concerning each limited health service to be added, if thatinformation is different from the information filed with theapplication of the limited service health maintenanceorganization; and
(3) demonstrate compliance with sections 16, 17, 18, and 23 ofthis chapter with respect to each limited health service to beadded by the organization.
(c) If the commissioner does not disapprove a filing undersubsection (a) or (b) within thirty (30) days after the commissionerreceives the filing, or within any period of extension granted by thecommissioner, the filing shall be deemed approved.
(d) If a filing under subsection (a) or (b) is disapproved, thecommissioner shall:
(1) notify the limited service health maintenance organizationof the disapproval of the filing in writing deposited in theUnited States mail addressed to the limited service healthmaintenance organization; and
(2) specify the reasons for disapproval of the filing in thenotice.
(e) Within thirty (30) days after it receives a notice of disapprovalunder subsection (d), the limited service health maintenanceorganization may request a hearing before the commissioner underIC 4-21.5 concerning the disapproval of the filing. If, not more thanthirty (30) days after receiving the notice from the commissioner, thelimited service health maintenance organization requests a hearing,the commissioner shall hold a hearing upon not less than ten (10)days notice to the limited service health maintenance organization.
As added by P.L.26-1994, SEC.25.
IC 27-13-34-12
Applicable statutes
Sec. 12. A limited service health maintenance organizationoperated under this chapter is subject to the following:
(1) IC 27-1-36 concerning risk based capital, unless exemptedby the commissioner under IC 27-1-36-1.
(2) IC 27-13-8, except for IC 27-13-8-2(a)(6) concerningreports.
(3) IC 27-13-9-3 concerning termination of providers.
(4) IC 27-13-10-1 through IC 27-13-10-3 concerning grievanceprocedures.
(5) IC 27-13-11 concerning investments.
(6) IC 27-13-15-1(a)(2) through IC 27-13-15-1(a)(3) concerninggag clauses in contracts.
(7) IC 27-13-21 concerning producers.
(8) IC 27-13-29 concerning statutory construction andrelationship to other laws.
(9) IC 27-13-30 concerning public records.
(10) IC 27-13-31 concerning confidentiality of medicalinformation and limitation of liability.
(11) IC 27-13-36-5 and IC 27-13-36-6 concerning referrals to
out of network providers and continuation of care.
(12) IC 27-13-40 concerning comparison sheets of servicesprovided by the limited service health maintenanceorganization.
As added by P.L.26-1994, SEC.25. Amended by P.L.191-1997,SEC.14; P.L.69-1998, SEC.12; P.L.133-1999, SEC.8; P.L.51-2002,SEC.12.
IC 27-13-34-13
Evidence of coverage; required information
Sec. 13. (a) Every subscriber of a limited service healthmaintenance organization shall be issued an evidence of coverage inelectronic or paper form, which must contain a clear and completestatement of the following:
(1) The limited health services to which each enrollee isentitled.
(2) Any limitation of the services, kinds of services, or benefitsto be provided.
(3) Any exclusions, including any copayment or other charges.
(4) Where and in what manner information is available as towhere and how services may be obtained.
(5) The method for resolving complaints.
(b) Any amendment to the evidence of coverage may be providedto the subscriber in a separate document in electronic or paper form.
(c) A limited service health maintenance organization shall issuethe evidence of coverage described in subsection (a) and anamendment described in subsection (b) in paper form upon therequest of the subscriber.
(d) A limited service health maintenance organization shallinclude in the limited service health maintenance organization'senrollment materials information concerning the manner in which asubscriber may:
(1) obtain an evidence of coverage; and
(2) request the evidence of coverage in paper form.
As added by P.L.26-1994, SEC.25. Amended by P.L.125-2005,SEC.8.
IC 27-13-34-14
Examinations by commissioner
Sec. 14. (a) The commissioner may examine a limited servicehealth maintenance organization as often as is reasonably necessaryto protect the interests of Indiana citizens. However, an examinationof a limited service health maintenance organization domiciled inIndiana must be conducted at least one (1) time every three (3) years.
(b) A limited service health maintenance organization:
(1) shall make its relevant books and records, and the books andrecords in its custody and control, available for examinationunder this section; and
(2) in every way cooperate with the commissioner to facilitatethe examination. (c) The expenses of an examination under this section shall bepaid by the organization being examined.
(d) Instead of conducting an examination of a limited servicehealth maintenance organization that is not domiciled in Indiana, thecommissioner may accept the report of an examination made by thechief administrative officer who regulates insurance in another state,if the other state is accredited by the National Association ofInsurance Commissioners.
As added by P.L.26-1994, SEC.25.
IC 27-13-34-15
Required contract terms and conditions; exemptions
Sec. 15. All contracts with providers or with entitiessubcontracting for the provision of limited health services toenrollees on a prepayment basis or other basis must contain, or shallbe construed to contain, the following terms and conditions:
(1) If the limited service health maintenance organization failsto pay for limited health services for any reason whatsoever,including insolvency or breach of this contract, the enrolleesshall not be liable to the provider for any sums owed to theprovider under this contract.
(2) No provider or agent, trustee, representative, or assignee ofa provider may maintain an action at law or attempt to collectfrom the enrollee sums that the limited service healthmaintenance organization owes to the provider.
(3) These provisions do not prohibit the collection of:
(A) uncovered charges consented to by enrollees; or
(B) copayments;
from enrollees.
(4) The contract may not provide for a financial or other penaltyto a primary care provider for making a referral permitted underIC 27-13-36-5(a), but may provide for reasonable cost sharingbetween the primary care provider and the limited servicehealth maintenance organization for the additional costsincurred as a result of services provided by an out of networkprovider.
(5) These provisions survive the termination of this contract,regardless of the reason for the termination.
(6) For not more than ninety (90) days after the termination ofthis contract, the provider must complete procedures in progresson an enrollee receiving treatment for a specific condition, atthe same schedule of copayment or other applicable charge thatis in effect on the effective date of termination of the contract.
(7) An amendment to the provisions of this contract set forth insubdivisions (1) through (6) must be:
(A) submitted to; and
(B) approved by;
the commissioner before it becomes effective.
As added by P.L.26-1994, SEC.25. Amended by P.L.69-1998,SEC.13.
IC 27-13-34-16
"Net worth" and "uncovered expense" defined; computation of networth; minimum net worth
Sec. 16. (a) As used in this section, "net worth" means the excessof total assets over total liabilities, excluding liabilities that havebeen subordinated in a manner acceptable to the commissioner.
(b) For the purposes of computing net worth, the total assets mustbe reduced by the value assigned to the following intangible assets:
(1) Goodwill.
(2) Going concern value.
(3) Organizational expense.
(4) Start-up costs.
(5) Long term prepayments of deferred charges.
(6) Nonreturnable deposits.
(7) Obligations of officers, directors, owners, or affiliates,except short term obligations of affiliates for goods or servicesthat:
(A) arise in the normal course of business;
(B) are payable on the same terms as equivalent transactionswith nonaffiliates; and
(C) are not past due.
(c) As used in this section, "uncovered expense" means the costof health care services:
(1) that are the obligation of a limited service healthmaintenance organization;
(2) for which an enrollee may be liable in the event of theinsolvency of the organization; and
(3) for which alternative arrangements acceptable to thecommissioner have not been made to cover the costs.
(d) For purposes of the definition of "uncovered expense" setforth in subsection (c), costs incurred by a provider who has agreedin writing not to bill enrollees, except for permissible supplementalcharges, shall be considered a covered expense.
(e) Each limited service health maintenance organization must, atall times, have and maintain net worth equal to the greater of:
(1) fifty thousand dollars ($50,000); or
(2) two and one-half percent (2.5%) of the annual grosssubscription income of the organization, up to a maximum oftwo hundred fifty thousand dollars ($250,000).
(f) A limited service health maintenance organization shallmaintain as a claim or loss reserve, in cash or obligations of theUnited States government, assets sufficient to discharge all liabilitieson all uncovered expenses arising under policies issued.
(g) The commissioner may adopt rules under IC 4-22-2 to furtherdefine whether and to what extent the assets of a limited servicehealth maintenance organization may be considered to be admittedassets for the purposes of complying with the requirements of thischapter.
As added by P.L.26-1994, SEC.25.
IC 27-13-34-17
Required deposit
Sec. 17. (a) Each limited service health maintenance organizationshall deposit in a joint-name account with:
(1) the commissioner; or
(2) any bank or bank and trust company or other financialinstitution acceptable to the commissioner through which acustodial or controlled account is used;
cash, securities acceptable to the commissioner, or any combinationof these, in an amount equal to fifty thousand dollars ($50,000).
(b) For the purposes of section 16 of this chapter:
(1) a deposit made by an organization under this section shall betreated as an admitted asset of the organization in thedetermination of net worth; and
(2) all income from deposits of an organization under thissection shall be an asset of the organization.
(c) An organization may withdraw:
(1) a deposit made under this section; or
(2) any part of the deposit;
after making a substitute deposit of equal amount and value.
(d) Any obligations of the United States government depositedwith the commissioner under this section must be approved by thecommissioner before being substituted under subsection (c).
(e) The deposit made by a limited service health maintenanceorganization under this section shall be used to protect the interest ofthe enrollees of the organization and to assure continuation of limitedhealth care services to enrollees of a limited service healthmaintenance organization that is in rehabilitation or conservation.
(f) If a limited service health maintenance organization is placedin rehabilitation or liquidation, the deposit made by the organizationunder this section shall be an asset subject to IC 27-9.
(g) The commissioner is not required to but may reduce oreliminate the deposit requirement of this section for a limited servicehealth maintenance organization if the organization:
(1) has made an acceptable deposit with the state or jurisdictionin which the organization is domiciled for the protection of allenrollees, wherever located; and
(2) delivers to the commissioner a certificate to that effect,authenticated by the appropriate state official holding thedeposit.
As added by P.L.26-1994, SEC.25.
IC 27-13-34-18
Fidelity bonds; deposit in place of bond
Sec. 18. (a) Except as provided in subsection (c), a limited servicehealth maintenance organization shall maintain in force a fidelitybond in its own name on its officers and employees:
(1) in an amount not less than fifty thousand dollars ($50,000);or
(2) in any other amount prescribed by the commissioner. (b) The fidelity bond required by this section must be issued by aninsurance company not affiliated in any way with the limited servicehealth maintenance organization, that is licensed to do business inIndiana. However, if a fidelity bond is not available from aninsurance company that holds a certificate of authority in Indiana, alimited service health maintenance organization may satisfy therequirement of this section by maintaining a fidelity bond procuredby a surplus lines insurance producer not affiliated in any way withthe limited service health maintenance organization who holds alicense issued under IC 27-1-15.8.
(c) Instead of maintaining a fidelity bond under subsection (a), alimited service health maintenance organization may deposit with thecommissioner:
(1) cash;
(2) certificates of deposit;
(3) United States government obligations acceptable to thecommissioner;
(4) any other securities acceptable to the commissioner of thetypes referred to in IC 27-13-11-1; or
(5) a combination of the items described in subdivisions (1)through (4).
A deposit made under this subsection is in addition to any otherrequired deposit, and must also be maintained in joint custody withthe commissioner in the amount and subject to the same conditionsrequired for a fidelity bond under this section.
As added by P.L.26-1994, SEC.25. Amended by P.L.132-2001,SEC.19; P.L.178-2003, SEC.87.
IC 27-13-34-19
Annual reports; additional reports
Sec. 19. (a) On or before March 1 of each year, a limited servicehealth maintenance organization shall file with the commissioner areport that covers the preceding calendar year. The report must be:
(1) made on forms prescribed by the commissioner; and
(2) verified by at least two (2) principal officers of the limitedservice health maintenance organization.
(b) In addition to the report required by subsection (a), a limitedservice health maintenance organization shall file with thecommissioner on or before June 1 of each year an audited financialstatement of the limited service health maintenance organization forthe preceding calendar year.
(c) The commissioner may require any additional reportsnecessary to enable the commissioner to carry out the duties of thecommissioner under this chapter.
As added by P.L.26-1994, SEC.25.
IC 27-13-34-20
Suspension or revocation of certificate of authority
Sec. 20. (a) The commissioner may suspend or revoke thecertificate of authority issued to a limited service health maintenance
organization under this chapter or deny an application submittedunder this chapter upon determining that any of the followingconditions exist:
(1) The limited service health maintenance organization isoperating:
(A) significantly in contravention of the basic organizationaldocument of the organization; or
(B) in a manner contrary to that described in and reasonablyinferred from any other information submitted under section8 of this chapter;
unless amendments to the organization's submissions have beenfiled and authorized under section 11 of this chapter.
(2) The limited service health maintenance organization issuesan evidence of coverage that does not comply with therequirements of section 13 of this chapter.
(3) The limited service health maintenance organization isunable to fulfill its obligations to furnish limited healthservices.
(4) The limited service health maintenance organization is notfinancially responsible and may reasonably be expected to beunable to meet its obligations to enrollees or prospectiveenrollees.
(5) The net worth of the limited service health maintenanceorganization is less than that required by section 16 of thischapter, or the limited service health maintenance organizationhas failed to correct any deficiency in its net worth as requiredby the commissioner.
(6) The limited service health maintenance organization hasfailed to implement in a reasonable manner the grievancesystem required by IC 27-13-10.
(7) The continued operation of the limited service healthmaintenance organization would be hazardous to the enrolleesof the organization.
(8) The limited service health maintenance organization hasotherwise failed to comply with this chapter.
(b) The commissioner may suspend or revoke a certificate ofauthority or deny an application for a certificate of authority bywritten order sent to the limited service health maintenanceorganization by certified mail or registered mail. The written ordershall state the grounds for the suspension, revocation, or denial. Alimited service health maintenance organization may request inwriting a hearing within thirty (30) days after mailing of the order.If the limited service health maintenance organization requests ahearing within the time specified, the commissioner shall hold ahearing, which may not be less than twenty (20) days or more thansixty (60) days after the date of the notice for a hearing on the matterunder IC 4-21.5.
(c) Immediately after the certificate of authority of a limitedservice health maintenance organization is revoked, the organizationshall proceed to wind up its affairs. An organization whose
certificate is revoked:
(1) shall not conduct further business except as may be essentialto the orderly conclusion of the affairs of the organization; and
(2) shall not engage in further advertising or solicitation.
However, the commissioner may, by written order, permit the furtheroperation of the organization as the commissioner may find to be inthe best interest of enrollees, to the end that enrollees will beafforded the greatest practical opportunity to obtain continuinglimited health services.
As added by P.L.26-1994, SEC.25.
IC 27-13-34-21
Chapter violations; fines and penalties
Sec. 21. (a) In place of any other penalty specified in this chapter,or when no penalty is specifically provided, whenever any limitedservice health maintenance organization or other person, corporation,partnership, limited liability company, or entity subject to thischapter has been found to have violated any provision of this chapter,the commissioner may:
(1) issue and cause to be served upon the organization, person,or entity charged with the violation a copy of the findings andan order requiring the organization, person, or entity to ceaseand desist from engaging in the act or practice that constitutesthe violation; and
(2) impose a monetary penalty of not more than two thousandfive hundred dollars ($2,500) for each violation, but not toexceed an aggregate penalty of twenty-five thousand dollars($25,000).
(b) A limited service health maintenance organization may appealany action taken by the commissioner under this section within thirty(30) days after receiving notice of the action by requesting a hearingbefore the commissioner under IC 4-21.5.
As added by P.L.26-1994, SEC.25.
IC 27-13-34-22
Supervision, rehabilitation, or liquidation; remedies and measures
Sec. 22. (a) Any supervision, rehabilitation, or liquidation of alimited service health maintenance organization shall be consideredto be the supervision, rehabilitation, or liquidation of an insurancecompany and shall be conducted under IC 27-9.
(b) A limited service health maintenance organization is notsubject to IC 27-6-8 or IC 27-8-8.
(c) The remedies and measures available to the commissionerunder this chapter are in addition to and not in the place of theremedies and measures available to the commissioner under IC 27-9.
As added by P.L.26-1994, SEC.25.
IC 27-13-34-23
Fees
Sec. 23. (a) A limited service health maintenance organization
subject to this chapter shall pay to the commissioner for deposit intothe department of insurance fund established by IC 27-1-3-28 thefollowing fees:
(1) For filing an application for a certificate of authority or anamendment to an application, three hundred fifty dollars ($350).
(2) For filing each annual report, fifty dollars ($50).
(b) In addition to the fees required by subsection (a), a limitedservice health maintenance organization subject to this chapter mustpay the fees required by IC 27-1-3-15.
As added by P.L.26-1994, SEC.25. Amended by P.L.173-2007,SEC.45; P.L.234-2007, SEC.199.
IC 27-13-34-24
Dental care services and director; review of adverse decisions;complaints
Sec. 24. (a) A limited service health maintenance organizationthat provides dental care services shall appoint a dental director whohas an unlimited license to practice dentistry under IC 25-14 or anequivalent license issued by another state.
(b) The dental director appointed under subsection (a) isresponsible for oversight of treatment policies, protocols, qualityassurance activities, credentialing of participating providers, andutilization management decisions of the limited service healthmaintenance organization.
(c) A limited service health maintenance organization thatprovides dental care services shall contract with or employ at leastone (1) individual who holds an unlimited license to practicedentistry under IC 25-14 or an equivalent license issued by anotherstate to do the following:
(1) Develop, in consultation with a group of appropriateproviders, the limited service health maintenance organization'streatment policies, protocols, and quality assurance activities.
(2) Respond when a treating provider requests in writing that adentist reconsider an adverse utilization review decision.
(d) A limited service health maintenance organization thatprovides dental care services that receives a written request forreconsideration of an adverse utilization review decision from atreating provider shall:
(1) review the decision as expeditiously as possible; and
(2) provide a response to the treating provider not more than ten(10) business days after receiving the request.
(e) A limited service health maintenance organization thatprovides dental care services shall provide participating providerswith an opportunity to comment on the following:
(1) Treatment policies.
(2) Protocols.
(3) Quality assurance activities.
(4) Credentialing policies and procedures.
(5) Utilization management policies and procedures.
As added by P.L.91-2000, SEC.1.
IC 27-13-34-26
Complaints; records
Sec. 26. (a) The department shall maintain records concerningcomplaints filed against a limited service health maintenanceorganization that provides dental care services.
(b) The department shall classify complaints described insubsection (a) in categories according to the National Association ofInsurance Commissioners standardized complaint report procedures.
(c) The department shall classify the disposition of complaints ineach category by:
(1) number of complaints for which corrective action isconsidered necessary by the department; and
(2) number of complaints classified by National Association ofInsurance Commissioners disposition codes.
(d) The department shall make information specified in thissection available to the public in a form that does not identify anyspecific individual.
(e) A limited service health maintenance organization thatprovides dental care services may not take any retaliatory action,including cancellation or refusal to renew a participating providercontract, individual contract, or group contract, solely because aparticipating provider, enrollee, or individual or group contractholder files a complaint against the limited service healthmaintenance organization.
As added by P.L.91-2000, SEC.2.