Indiana Code
Chapter 34. Limited Service Health Maintenance Organizations
27-13-34-15. Required Contract Terms and Conditions; Exemptions

Sec. 15. All contracts with providers or with entities subcontracting for the provision of limited health services to enrollees on a prepayment basis or other basis must contain, or shall be construed to contain, the following terms and conditions:
(1) If the limited service health maintenance organization fails to pay for limited health services for any reason whatsoever, including insolvency or breach of this contract, the enrollees shall not be liable to the provider for any sums owed to the provider under this contract.
(2) No provider or agent, trustee, representative, or assignee of a provider may maintain an action at law or attempt to collect from the enrollee sums that the limited service health maintenance 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 penalty to a primary care provider for making a referral permitted under IC 27-13-36-5(a), but may provide for reasonable cost sharing between the primary care provider and the limited service health maintenance organization for the additional costs incurred as a result of services provided by an out of network provider.
(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 of this contract, the provider must complete procedures in progress on an enrollee receiving treatment for a specific condition, at the same schedule of copayment or other applicable charge that is in effect on the effective date of termination of the contract.
(7) An amendment to the provisions of this contract set forth in subdivisions (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.

Structure Indiana Code

Indiana Code

Title 27. Insurance

Article 13. Health Maintenance Organizations

Chapter 34. Limited Service Health Maintenance Organizations

27-13-34-0.1. Application of Certain Amendments to Chapter

27-13-34-1. "Enrollee" Defined

27-13-34-2. "Evidence of Coverage" Defined

27-13-34-3. "Limited Health Services" Defined

27-13-34-4. "Limited Service Health Maintenance Organization" Defined

27-13-34-5. "Provider" Defined

27-13-34-6. "Subscriber" Defined

27-13-34-7. Certificate of Authority Required; Foreign Entities

27-13-34-8. Application for Certificate of Authority; Requirements

27-13-34-9. Issuance of Certificate of Authority; Application Deficiencies; Denial of Application

27-13-34-10. Powers of Limited Service Health Maintenance Organization

27-13-34-11. Modification of Documents; Filing; Disapproval

27-13-34-12. Applicable Statutes

27-13-34-13. Evidence of Coverage; Required Information

27-13-34-14. Examinations by Commissioner

27-13-34-15. Required Contract Terms and Conditions; Exemptions

27-13-34-16. "Net Worth" and "Uncovered Expense" Defined; Computation of Net Worth; Minimum Net Worth

27-13-34-17. Required Deposit

27-13-34-18. Fidelity Bonds; Deposit in Place of Bond

27-13-34-19. Annual Reports; Additional Reports

27-13-34-20. Suspension or Revocation of Certificate of Authority

27-13-34-21. Chapter Violations; Fines and Penalties

27-13-34-22. Supervision, Rehabilitation, or Liquidation; Remedies and Measures

27-13-34-23. Fees

27-13-34-24. Dental Care Services and Director; Review of Adverse Decisions; Complaints

27-13-34-26. Complaints; Records