Indiana § 27-1-2-4 - Violation of Indiana Insurance Law

§ 27-1-2-4. Violation of Indiana Insurance Law

Sec. 4. A person who recklessly violates the Indiana Insurance Law (chapters 2 through 20 of this article) commits a Class C infraction, except as otherwise provided. However, except as otherwise provided, the violation is a Class C misdemeanor if the person has a prior unrelated adjudication or conviction for a violation under this section within the previous five (5) years.

As added by Acts 1978, P.L.2, SEC.2701. Amended by P.L.82-1998, SEC.1; P.L.32-2019, SEC.22.

IC 27-1-2.1Chapter 2.1. Health Care Sharing Ministries

27-1-2.1-1"Health care sharing ministry" 27-1-2.1-2Health care sharing ministry not engaged in the business of insurance

IC 27-1-2.1-1"Health care sharing ministry" Sec. 1. (a) As used in this chapter, "health care sharing ministry" means a nonprofit organization that:

(1) is comprised only of participants who share similar and sincerely held religious beliefs;

(2) is tax exempt under Section 501(c)(3) of the Internal Revenue Code;

(3) acts as a facilitator among participants who have financial or medical needs that are qualified in accordance with the organization's criteria, matching those participants with other participants who have the present ability to assist with financial or medical needs;

(4) provides for the financial or medical needs of a participant through contributions from one (1) participant to another participant;

(5) provides information about amounts that participants, with no assumption of risk or promise to pay, may contribute for distribution:

(A) among the participants; or

(B) by the organization to participants;

(6) provides a written monthly statement to all participants that specifies:

(A) the total dollar amount of qualified needs submitted to the organization; and

(B) the amount actually published or assigned to participants for their contribution; and

(7) includes the following statement, in writing, on or accompanying all applications and guideline materials:

"Notice: The organization facilitating the sharing of medical expenses is not an insurance company, and neither its guidelines nor its plan of operation is an insurance policy. Any assistance you receive with your medical bills will be totally voluntary. Neither the organization nor any other participant can be compelled by law to contribute toward your medical bills. As such, participation in the organization or a subscription to any of its documents should never be considered to be insurance. Whether or not you receive any payments for medical expenses and whether or not this organization continues to operate, you are always personally responsible for the payment of your own medical bills.".

(b) The term does not include a fraternal benefit society described in IC 27-11-1-1.

As added by P.L.13-2012, SEC.1.

IC 27-1-2.1-2Health care sharing ministry not engaged in the business of insurance Sec. 2. A health care sharing ministry is not considered to be engaged in the business of insurance under this title or any other provision of Indiana law.

As added by P.L.13-2012, SEC.1.

IC 27-1-2.2Chapter 2.2. Nonprofit Agricultural Organization Coverage

27-1-2.2-1"Nonprofit agricultural organization" 27-1-2.2-2"Nonprofit agricultural organization coverage" 27-1-2.2-3Filing of certification 27-1-2.2-4Coverage not considered insurance 27-1-2.2-5Annual filing 27-1-2.2-6Reinsurance 27-1-2.2-7Complaint procedure 27-1-2.2-8Acknowledgment that coverage is not considered insurance 27-1-2.2-9Membership requirement 27-1-2.2-10Coverage requirements 27-1-2.2-11Severability

IC 27-1-2.2-1"Nonprofit agricultural organization" Sec. 1. As used in this chapter, "nonprofit agricultural organization" means an organization:

(1) that is exempt from taxation under Section 501(c)(5) of the Internal Revenue Code;

(2) that is domiciled in Indiana;

(3) that was in existence before 1950; and

(4) the members of which include residents of every county in Indiana.

As added by P.L.136-2020, SEC.1.

IC 27-1-2.2-2"Nonprofit agricultural organization coverage" Sec. 2. As used in this chapter, "nonprofit agricultural organization coverage" means health benefit coverage that is:

(1) sponsored by:

(A) a nonprofit agricultural organization; or

(B) an affiliate of a nonprofit agricultural organization;

(2) offered only to:

(A) members of the nonprofit agricultural organization; and

(B) families of the members of the nonprofit agricultural organization;

(3) deemed by the nonprofit agricultural organization to be important in assisting its members to live long and productive lives; and

(4) offered to members of the nonprofit agricultural organization in every county in Indiana.

As added by P.L.136-2020, SEC.1.

IC 27-1-2.2-3Filing of certification Sec. 3. Before an organization may offer health benefit coverage under this chapter, the organization must file with the insurance commissioner a certification that:

(1) the organization qualifies as a nonprofit agricultural organization under section 1 of this chapter; and

(2) the health benefit coverage that the organization will offer qualifies as nonprofit agricultural organization coverage under section 2 of this chapter.

As added by P.L.136-2020, SEC.1.

IC 27-1-2.2-4Coverage not considered insurance Sec. 4. (a) Nonprofit agricultural organization coverage provided under this chapter:

(1) is not insurance;

(2) shall not be considered to be insurance under this title or any other provision of Indiana law; and

(3) is not subject to the regulatory authority of the department of insurance under this title or any other provision of Indiana law.

(b) Entering into a contract between a nonprofit agricultural organization and an individual for health coverage under this chapter does not constitute the business of insurance.

(c) A nonprofit agricultural organization providing coverage under this chapter is not required to obtain a certificate of authority under IC 27-1-3-20.

As added by P.L.136-2020, SEC.1.

IC 27-1-2.2-5Annual filing Sec. 5. A nonprofit agricultural organization offering coverage under this chapter shall annually file with the department of insurance a written, signed opinion of a qualified actuary that the plan reserves of the nonprofit agricultural organization and its affiliate are adequate and conform to the appropriate actuarial standards of practice.

As added by P.L.136-2020, SEC.1.

IC 27-1-2.2-6Reinsurance Sec. 6. A nonprofit agricultural organization offering coverage under this chapter shall reinsure all or a portion of its risks under this coverage with a company authorized to transact reinsurance business or stop-loss insurance business in Indiana.

As added by P.L.136-2020, SEC.1.

IC 27-1-2.2-7Complaint procedure Sec. 7. A nonprofit agricultural organization offering coverage under this chapter shall adopt a complaint procedure that is materially similar to the procedure used by the department of insurance.

As added by P.L.136-2020, SEC.1.

IC 27-1-2.2-8Acknowledgment that coverage is not considered insurance Sec. 8. (a) When an individual applies for health coverage provided under this chapter, the nonprofit agricultural organization offering the health coverage shall inform the individual that the health coverage:

(1) is not considered insurance; and

(2) is not subject to the administrative rules of the department of insurance.

(b) An individual entering into a contract for health coverage under this chapter must acknowledge that the coverage:

(1) is not considered insurance; and

(2) is not subject to the administrative rules of the department of insurance.

(c) The acknowledgment required by subsection (b) must be in a writing signed by the individual. The nonprofit agricultural organization shall:

(1) keep a copy of the written acknowledgment for the entire duration of the contract under which the individual is provided coverage under this chapter; and

(2) provide a copy of the acknowledgment to the individual at the individual's request.

As added by P.L.136-2020, SEC.1.

IC 27-1-2.2-9Membership requirement Sec. 9. An individual may not apply for health coverage provided under this chapter until the individual has been a member of the nonprofit agricultural organization offering the health coverage for at least thirty (30) days.

As added by P.L.136-2020, SEC.1.

IC 27-1-2.2-10Coverage requirements Sec. 10. Health coverage provided to an individual under this chapter:

(1) must include coverage for:

(A) ambulatory patient services;

(B) hospitalization;

(C) emergency services; and

(D) laboratory services; and

(2) may not be subject to an annual limit of less than two million dollars ($2,000,000) per year.

As added by P.L.136-2020, SEC.1.

IC 27-1-2.2-11Severability Sec. 11. The provisions of this chapter are severable in the manner provided in IC 1-1-1-8(b).

As added by P.L.136-2020, SEC.1.

IC 27-1-2.3Chapter 2.3. Payment for Ambulance Services

27-1-2.3-0.5Application 27-1-2.3-1"Ambulance" 27-1-2.3-2"Ambulance service provider" 27-1-2.3-2.8"Clean claim" 27-1-2.3-3"Covered individual" 27-1-2.3-4"Health plan" 27-1-2.3-5"Health plan operator" 27-1-2.3-6"Nonparticipating" or "participating" 27-1-2.3-7"Person" 27-1-2.3-7.5"State employee health plan" 27-1-2.3-8Fair negotiation of rates and terms for ambulance service; rate negotiations; considerations 27-1-2.3-8.1Health plan operator payment to a nonparticipating ambulance service 27-1-2.3-8.2Health plan operator payment in full to a nonparticipating ambulance service provider; limits on cost sharing amounts that a covered individual pays 27-1-2.3-8.3Procedures for remitting payment to a nonparticipating ambulance provider for claims 27-1-2.3-9Expired

IC 27-1-2.3-0.5Application Sec. 0.5. This chapter does not apply to the following:

(1) The Medicaid program.

(2) Ambulance services owned or operated by a health system (as defined in IC 16-18-2-168.5) that bill for ambulance services under the health system.

As added by P.L.163-2024, SEC.4.

IC 27-1-2.3-1"Ambulance" Sec. 1. As used in this chapter, "ambulance" refers only to a vehicle that is used to provide ambulance service on land.

As added by P.L.170-2022, SEC.36.

IC 27-1-2.3-2"Ambulance service provider" Sec. 2. As used in this chapter, "ambulance service provider" means a person that:

(1) provides ambulance service; and

(2) holds a valid certificate issued by the commission under IC 16-31-3 authorizing the person to provide ambulance service.

As added by P.L.170-2022, SEC.36.

IC 27-1-2.3-2.8"Clean claim" Sec. 2.8. As used in this chapter, "clean claim" means a claim for payment for ambulance service:

(1) that is submitted to a health plan by an ambulance service provider; and

(2) about which there is no defect, impropriety, or particular circumstance requiring special treatment that may prevent or delay payment.

As added by P.L.163-2024, SEC.5.

IC 27-1-2.3-3"Covered individual" Sec. 3. As used in this chapter, "covered individual" means an individual who is entitled to coverage under a health plan.

As added by P.L.170-2022, SEC.36.

IC 27-1-2.3-4"Health plan" Sec. 4. (a) As used in this chapter, "health plan" means either of the following:

(1) A policy of accident and sickness insurance as defined in IC 27-8-5-1, but not including any insurance, plan, or policy set forth in IC 27-8-5-2.5(a).

(2) An individual contract (as defined in IC 27-13-1-21) or a group contract (as defined in IC 27-13-1-16) with a health maintenance organization that provides coverage for basic health care services (as defined in IC 27-13-1-4).

(b) The term does not include the state employee health plan.

As added by P.L.170-2022, SEC.36. Amended by P.L.163-2024, SEC.6.

IC 27-1-2.3-5"Health plan operator" Sec. 5. As used in this chapter, "health plan operator" means the following:

(1) In the case of a health plan described in section 4(a)(1) of this chapter, the insurer that issued the policy.

(2) In the case of a health plan described in section 4(a)(2) of this chapter, the health maintenance organization that entered into the contract.

As added by P.L.170-2022, SEC.36. Amended by P.L.163-2024, SEC.7.

IC 27-1-2.3-6"Nonparticipating" or "participating" Sec. 6. For purposes of this chapter:

(1) an ambulance service provider that provides ambulance service to an individual covered by a health plan is "nonparticipating" with respect to the health plan if the ambulance service provider has not, by contract, affiliation, agreement, or any other means, agreed to be compensated by the health plan at no more than a certain amount or rate for the ambulance service; and

(2) an ambulance service provider that provides ambulance service to an individual covered by a health plan is "participating" with respect to the health plan if the ambulance service provider has agreed to be compensated by the health plan at no more than a certain amount or rate for the ambulance service.

As added by P.L.170-2022, SEC.36.

IC 27-1-2.3-7"Person" Sec. 7. As used in this chapter, "person" means an individual, a corporation, a limited liability company, a partnership, or another legal entity.

As added by P.L.170-2022, SEC.36.

IC 27-1-2.3-7.5"State employee health plan" Sec. 7.5. As used in this chapter, "state employee health plan" means either of the following:

(1) A self-insurance program established under IC 5-10-8-7(b) to provide group coverage.

(2) A prepaid health care delivery plan through which health services are provided under IC 5-10-8-7(c).

As added by P.L.163-2024, SEC.8.

IC 27-1-2.3-8Fair negotiation of rates and terms for ambulance service; rate negotiations; considerations Sec. 8. (a) The state shall fairly negotiate rates and terms with any ambulance service provider willing to become a participating provider with respect to the state employee health plan.

(b) In negotiations under subsection (a), the state employee health plan must consider all of the following:

(1) The ambulance service provider's usual and customary rates.

(2) The ambulance service provider's resources, and whether the ambulance service provider's staff is available twenty-four (24) hours per day every day.

(3) The average wages and fuel costs in the geographical area in which the ambulance service provider operates.

(4) The number of times in which individuals covered by the state employee health plan have sought ambulance service from the ambulance service provider but the ambulance service provider's response was canceled or did not result in a transport.

(5) The local ordinances and state rules concerning staffing, response times, and equipment under which the ambulance service provider must operate.

(6) The types of requests for ambulance service for individuals covered by the state employee health plan that the ambulance service provider generally receives, and the requesting party or agency by which those requests are generally made.

(7) The average reimbursement rate per level of service that the ambulance service provider generally receives as a nonparticipating provider.

(8) The specific:

(A) clinical and staff capabilities; and

(B) equipment resources;

that an ambulance service provider must have to adequately meet the needs of individuals covered by the state employee health plan, such as for the transportation of individuals covered by the state employee health plan from one (1) hospital to another after traumatic injury.

(9) The average transport cost data reported to the office of the secretary of family and social services by governmental ambulance service providers located within the counties, and contiguous counties, that the nonparticipating ambulance service provider serves.

As added by P.L.170-2022, SEC.36. Amended by P.L.92-2023, SEC.1; P.L.163-2024, SEC.9.

IC 27-1-2.3-8.1Health plan operator payment to a nonparticipating ambulance service Sec. 8.1. A health plan operator shall provide payment to a nonparticipating ambulance service provider for ambulance service provided to a covered individual:

(1) at a rate set or approved, by contract or ordinance, by the county or municipality in which the ambulance service originated;

(2) at the rate of four hundred percent (400%) of the current published rate for ambulance service as established by the Centers for Medicare and Medicaid Services under Title XVIII of the federal Social Security Act (42 U.S.C. 1395 et seq.) for the same ambulance service provided in the same geographic area; or

(3) according to the nonparticipating ambulance service provider's billed charges;

whichever is less.

As added by P.L.163-2024, SEC.10.

IC 27-1-2.3-8.2Health plan operator payment in full to a nonparticipating ambulance service provider; limits on cost sharing amounts that a covered individual pays Sec. 8.2. (a) If a health plan operator makes payment to a nonparticipating ambulance service provider according to section 8.1 of this chapter for ambulance service provided to a covered individual:

(1) the payment shall be considered payment in full for the ambulance service provided, except for any copayment, coinsurance, deductible, and other cost sharing amounts that the health plan requires the covered individual to pay; and

(2) the nonparticipating ambulance service provider is prohibited from billing the covered individual for any additional amount for the ambulance service provided.

(b) The copayment, coinsurance, deductible, and other cost sharing amounts that a health plan requires a covered individual to pay in connection with ambulance service provided to the covered individual by a nonparticipating ambulance service provider shall not exceed the copayment, coinsurance, deductible, and other cost sharing amounts that the covered individual would be required to pay if the ambulance service had been provided to the covered individual by a participating ambulance service provider.

As added by P.L.163-2024, SEC.11.

IC 27-1-2.3-8.3Procedures for remitting payment to a nonparticipating ambulance provider for claims Sec. 8.3. (a) A health plan operator that receives a clean claim for ambulance service provided to a covered individual by a nonparticipating ambulance service provider:

(1) shall remit payment for the ambulance service directly to the nonparticipating ambulance service provider not more than thirty (30) days after receiving the clean claim; and

(2) shall not send payment to the covered individual.

(b) If a claim that a health plan operator receives for ambulance service provided to a covered individual by a nonparticipating ambulance service provider is not a clean claim, the health plan operator, not more than thirty (30) days after receiving the claim, shall:

(1) remit payment for the ambulance service directly to the nonparticipating ambulance service provider; or

(2) send to the nonparticipating ambulance service provider a written notice that:

(A) acknowledges the date of the receipt of the claim; and

(B) either:

(i) states that the health plan operator is declining to pay all or part of the claim and sets forth the specific reason or reasons for declining to pay the claim in full; or

(ii) states that additional information is needed to determine whether all or part of the claim is payable and specifically describes the additional information that is needed.

As added by P.L.163-2024, SEC.12.

IC 27-1-2.3-9ExpiredAs added by P.L.92-2023, SEC.2. Expired 1-1-2025 by P.L.92-2023, SEC.2.

IC 27-1-3Chapter 3. General Powers and Duties of the Department

27-1-3-1Exemption from individual liability 27-1-3-2Conflicts of interest 27-1-3-3Seal of department 27-1-3-4Business practices of insurance companies 27-1-3-5Certified copies of documents and commissioner's certification of facts as prima facie evidence 27-1-3-6Repealed 27-1-3-7Rules and regulations 27-1-3-8Repealed 27-1-3-9Repealed 27-1-3-10Power to revoke or suspend certificate of authority 27-1-3-10.5Disclosure of information 27-1-3-11Confidential information 27-1-3-12Acceptance of examination made by another state 27-1-3-13Blanks for annual statement; separate exhibit 27-1-3-14Notice of insolvency, failure, or suspension of operations; failure to give notice 27-1-3-15Filing fees; collection 27-1-3-16Disposition of taxes and fees accrued 27-1-3-17Repealed 27-1-3-18Solicitation for political assessments or contributions; violations 27-1-3-19Order to correct improper practices or remedy deficiencies; actions to compel compliance 27-1-3-20Certificate of authority; issuance; necessity; removal of unqualified officers or directors; violations; civil penalties 27-1-3-21Execution of instruments or documents 27-1-3-22Fraudulent insurance act; definition; liability 27-1-3-23Civil actions; substantial justification 27-1-3-24Declaration of dividend other than from earned surplus; approval 27-1-3-25Review of ordinary shareholder dividends to determine reasonableness 27-1-3-26Order to limit ordinary shareholder dividends 27-1-3-27Order to limit or disallow payment of ordinary shareholder dividends 27-1-3-28Department of insurance fund; establishment; deposits 27-1-3-29Enforceability of policies exceeding authority of insurer or violating statute or rule 27-1-3-30Expired 27-1-3-31Expired 27-1-3-32Posting of life insurance and other financial information 27-1-3-33Publication of grievance related information on Internet 27-1-3-34Proof of mailing 27-1-3-35State innovation waiver application 27-1-3-36Partnerships and joint ventures; prior authorization