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 to
the commissioner for a certificate of authority to establish and
operate 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 health
maintenance organization without obtaining a certificate of authority
under this article.
(b) If a participating provider contracts with another provider
under a contract that complies with IC 27-13-15 to provide health
services on a prepaid basis to enrollees of a health maintenance
organization 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 corporation
defined under IC 27-1-2-3, may obtain a certificate of authority if the
foreign corporation:
(1) is authorized to do business in Indiana under IC 23-1-49 or
IC 23-17-26; and
(2) complies with this article.
(b) A foreign corporation (as defined in IC 27-1-2-3) may obtain
a certificate of authority if the foreign corporation complies with this
article.
(c) A foreign or alien health maintenance organization granted a
certificate of authority under this section has the same but no greater
rights and privileges than a domestic health maintenance
organization.
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 a
health maintenance organization must be:
(1) verified by an officer or authorized representative of the
applicant; 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 a
health maintenance organization must set forth or be accompanied by
the 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 applicable
documents, and all amendments to those documents.
(2) A copy of the bylaws, rules and regulations, or similar
document regulating the conduct of the internal affairs of the
applicant.
(3) A list, on a form acceptable to the commissioner, of the
names, addresses, official positions, and biographical
information of the persons who are to be responsible for the
conduct 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 committee
of the applicant.
(B) The principal officers, if the applicant is a corporation.
(C) The partners or members, if the applicant is a partnership
or an association.
(D) The manager or, if there is no manager, all members of
a limited liability company.
(4) A copy of any contract form that has been made or is to be
made between any class of providers and the health
maintenance organization.
(5) A copy of any contract that has been made or is to be made
between:
(A) third party administrators, agents, or persons identified
under subdivision (3); and
(B) the health maintenance organization.
(6) A copy of the form of evidence of coverage that is to be
issued by the health maintenance organization to an enrollee.
(7) A copy of the form of a group contract, if any, that is to be
issued by the health maintenance organization to an employer,
a union, a trustee, or another entity.
(8) Financial statements showing the assets, liabilities, and
sources of financial support of the applicant, including:
(A) a copy of the most recent certified financial statement of
the 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 be
charged 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 capital
expenditures, purchase and sale of investments, and
deposits with the state; and
(iii) income and expense statements;
anticipated from the start of operations until the organization
has had net income for at least one (1) year.
(D) A statement of the sources of working capital as well as
any other sources of funding.
(10) If the applicant is not domiciled in Indiana, an executed
power of attorney appointing the commissioner, the
commissioner's successors in office, and authorized deputies of
the commissioner as the true and lawful attorney of the
applicant in and for Indiana upon whom all lawful process in
any legal action or proceeding against the health maintenance
organization on a cause of action arising in Indiana may be
served.
(11) A statement or map reasonably indicating, on a
county-by-county basis, the service area to be served by the
health maintenance organization.
(12) A description of the internal procedures to be used by the
health maintenance organization for the investigation and
resolution of the complaints and grievances of enrollees.
(13) A description of the proposed quality management
program of the applicant, including the following:
(A) The formal organizational structure.
(B) Methods for developing criteria.
(C) Procedures for comprehensive evaluation of the quality
of care rendered to enrollees.
(D) Processes to initiate corrective action and reevaluation
when deficiencies in provider performance or organizational
performance are identified.
(14) A description of the procedures to be implemented to meet
the requirements set forth in IC 27-13-12 through IC 27-13-17.
(15) A list of the names, addresses, and license numbers of any
providers with whom the health maintenance organization has
agreements.
(16) Any other information required by the commissioner to
make 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 any
modifications or amendments to the items of information required in
an application under section 5 of this chapter.
(b) The commissioner may adopt rules under this section that
provide that any modifications or amendments to the items of
information in the application required of a health maintenance
organization:
(1) must be submitted to the commissioner before the
modification 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 to
the commissioner at the time of the next succeeding site visit or
examination of the organization by the department of insurance.
(c) A health maintenance organization shall file any assumed
corporate name with the department at least thirty (30) days before
assuming 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 or
amendments
Sec. 7. Any modification or amendment requiring the approval of
the commissioner under rules adopted under section 6 of this chapter
is considered approved unless the commissioner disapproves the
modification or amendment not more than thirty (30) days after the
modification or amendment is submitted. However, the
commissioner may postpone the action, if necessary for proper
consideration, and if the commissioner gives written notice of the
postponement 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 authority
to operate a health maintenance organization unless the applicant has
submitted to the commissioner a written waiver of the health
maintenance 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 under
this article may not:
(1) use as a part of its corporate name the words "United
States", "Federal", "government", "official", or any word that
would imply that the company is an administrative agency of
the state of Indiana or of the United States, or that it is subject
to supervision of any department other than the department of
insurance; or
(2) take or assume a corporate name the same as, or confusingly
similar to, an existing name of any other insurance company or
other entity licensed or regulated under IC 27, unless at the
same time:
(A) the other company changes its corporate name or
withdraws from transacting business in Indiana; and
(B) the written consent of the other company, signed and
verified under oath by its secretary, is filed with the
department.
(b) This section does not affect the right of any health
maintenance 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, and
thereafter 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.