Indiana § 27-13-24-1 - Grounds for suspension or revocation

§ 27-13-24-1. Grounds for suspension or revocation

Sec. 1. (a) The commissioner may suspend or revoke a certificate of authority issued under this article or deny an application submitted under this article if the commissioner finds that any of the following conditions exists:

(1) The health maintenance organization is operating:

(A) significantly in contravention of its basic organizational document; or

(B) in a manner contrary to that described in any other information submitted under IC 27-13-2;

unless amendments to the basic organizational document or other submissions that are consistent with the operations of the organization have been filed with and approved by the commissioner.

(2) The health maintenance organization:

(A) issues an evidence of coverage;

(B) enters into a contract with a participating provider; or

(C) uses a schedule of charges for health care services;

that does not comply with the requirements of IC 27-13-7, IC 27-13-15, and IC 27-13-20.

(3) The health maintenance organization does not provide or arrange for basic health care services.

(4) The commissioner determines that the health maintenance organization is unable to fulfill its obligations to furnish health care coverage.

(5) The health maintenance organization is no longer financially responsible and may reasonably be expected to be unable to meet its obligations to enrollees or prospective enrollees.

(6) The health maintenance organization has failed to correct, within the time prescribed by section 2 of this chapter, any deficiency occurring due to the impairment of the prescribed minimum net worth of the health maintenance organization.

(7) The health maintenance organization has failed to implement the grievance procedures required by IC 27-13-10 in a reasonable manner to resolve valid complaints.

(8) The health maintenance organization or any person acting on behalf of the organization has intentionally advertised or merchandised the services of the organization in an untrue, a misrepresentative, a misleading, a deceptive, or an unfair manner.

(9) The continued operation of the health maintenance organization would be hazardous to the enrollees of the organization.

(10) The health maintenance organization fails to comply with the requirements provided under IC 27-13-36 through IC 27-13-40.

(11) The health maintenance organization has otherwise failed substantially to comply with this article.

(b) The commissioner, in a proceeding under IC 4-21.5-3-8, may impose a civil penalty of not more than twenty-five thousand dollars ($25,000) against a health maintenance organization for each cause listed in subsection (a). The civil penalties may not exceed one hundred thousand dollars ($100,000) for any one (1) health maintenance organization in one (1) calendar year. The penalty may be imposed in addition to or instead of a suspension or revocation of the certificate of authority of the health maintenance organization.

As added by P.L.26-1994, SEC.25. Amended by P.L.69-1998, SEC.10.