§ 27-13-34-15 — Required contract terms and conditions; exemptions

Indiana § 27-13-34-15

• Jurisdiction: Indiana
• Title 27: INSURANCE
• Art. 13: HEALTH MAINTENANCE ORGANIZATIONS
• Ch. 34: Limited Service Health Maintenance Organizations

Text

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.

Legislative History

As added by P.L.26-1994, SEC.25. Amended by P.L.69-1998, SEC.13.