§ 27-8-10-1 — Definitions

Indiana § 27-8-10-1

• Jurisdiction: Indiana
• Title 27: INSURANCE
• Art. 8: LIFE, ACCIDENT, AND HEALTH
• Ch. 10: Comprehensive Health Insurance

Text

(a) The definitions in this section apply
throughout this chapter.
(b) "Association" means the Indiana comprehensive health
insurance association established under section 2.1 of this chapter.
(c) "Association policy" means a policy issued by the association
that provides coverage specified in section 3 of this chapter. The term
does not include a Medicare supplement policy that is issued under
section 9 of this chapter.
(d) "Carrier" means an insurer providing medical, hospital, or
surgical expense incurred health insurance policies.
(e) "Church plan" means a plan defined in the federal Employee
Retirement Income Security Act of 1974 under 26 U.S.C. 414(e).
(f) "Commissioner" refers to the insurance commissioner.
(g) "Creditable coverage" has the meaning set forth in the federal
Health Insurance Portability and Accountability Act of 1996 (26 U.S.C.
9801(c)(1)).
(h) "Eligible expenses" means those charges for health care services
and articles provided for in section 3 of this chapter.
(i) "Federal income poverty level" has the meaning set forth in IC 12-15-2-1.
(j) "Federally eligible individual" means an individual:
(1) for whom, as of the date on which the individual seeks
coverage under this chapter, the aggregate period of creditable
coverage is at least eighteen (18) months and whose most recent
prior creditable coverage was under a:
(A) group health plan;
(B) governmental plan; or
(C) church plan;
or health insurance coverage in connection with any of these
plans;
(2) who is not eligible for coverage under:
(A) a group health plan;
(B) Part A or Part B of Title XVIII of the federal Social Security
Act (42 U.S.C. 1395 et seq.); or
(C) a state plan under Title XIX of the federal Social Security
Act (42 U.S.C. 1396 et seq.);
and does not have other health insurance coverage;
(3) with respect to whom the individual's most recent coverage
was not terminated for factors relating to nonpayment of
premiums or fraud;
(4) who, if after being offered the option of continuation coverage
under the Consolidated Omnibus Budget Reconciliation Act of
1985 (COBRA) (29 U.S.C. 1191b(d)(1)), or under a similar state
program, elected such coverage; and
(5) who, if after electing continuation coverage described in
subdivision (4), has exhausted continuation coverage under the
provision or program.
(k) "Governmental plan" means a plan as defined under the federal
Employee Retirement Income Security Act of 1974 (26 U.S.C. 414(d))
and any plan established or maintained for its employees by the United
States government or by any agency or instrumentality of the United
States government.
(l) "Group health plan" means an employee welfare benefit plan (as
defined in 29 U.S.C. 1167(1)) to the extent that the plan provides
medical care payments to, or on behalf of, employees or their
dependents, as defined under the terms of the plan, directly or through
insurance, reimbursement, or otherwise.
(m) "Health care facility" means any institution providing health
care services that is licensed in this state, including institutions
engaged principally in providing services for health maintenance
organizations or for the diagnosis or treatment of human disease, pain,
injury, deformity, or physical condition, including a general hospital,
special hospital, mental hospital, public health center, diagnostic
center, treatment center, rehabilitation center, extended care facility,
skilled nursing home, nursing home, intermediate care facility,
tuberculosis hospital, chronic disease hospital, maternity hospital,
outpatient clinic, home health care agency, bioanalytical laboratory, or
central services facility servicing one (1) or more such institutions.
(n) "Health care institutions" means skilled nursing facilities, home
health agencies, and hospitals.
(o) "Health care provider" means any physician, hospital,
pharmacist, or other person who is licensed in Indiana to furnish health
care services.
(p) "Health care services" means any services or products included
in the furnishing to any individual of medical care, dental care, or
hospitalization, or incident to the furnishing of such care or
hospitalization, as well as the furnishing to any person of any other
services or products for the purpose of preventing, alleviating, curing,
or healing human illness or injury.
(q) "Health insurance" means hospital, surgical, and medical
expense incurred policies, nonprofit service plan contracts, health
maintenance organizations, limited service health maintenance
organizations, and self-insured plans. However, the term "health
insurance" does not include short term travel accident policies,
accident only policies, fixed indemnity policies, automobile medical
payment, or incidental coverage issued with or as a supplement to
liability insurance.
(r) "Insured" means all individuals who are provided qualified
comprehensive health insurance coverage under an individual policy,
including all dependents and other insured persons, if any.
(s) "Medicaid" means medical assistance provided by the state
under the Medicaid program under IC 12-15.
(t) "Medical care payment" means amounts paid for:
(1) the diagnosis, care, mitigation, treatment, or prevention of
disease or amounts paid for the purpose of affecting any structure
or function of the body;
(2) transportation primarily for and essential to Medicare services
referred to in subdivision (1); and
(3) insurance covering medical care referred to in subdivisions (1)
and (2).
(u) "Medically necessary" means health care services that the
association has determined:
(1) are recommended by a legally qualified physician;
(2) are commonly and customarily recognized throughout the
physician's profession as appropriate in the treatment of the
patient's diagnosed illness; and
(3) are not primarily for the scholastic education or career and
technical training of the provider or patient.
(v) "Medicare" means Title XVIII of the federal Social Security Act
(42 U.S.C. 1395 et seq.).
(w) "Policy" means a contract, policy, or plan of health insurance.
(x) "Policy year" means a twelve (12) month period during which a
policy provides coverage or obligates the carrier to provide health care
services.
(y) "Health maintenance organization" has the meaning set out in IC 27-13-1-19.
(z) "Resident" means an individual who is:
(1) legally domiciled in Indiana for at least twelve (12) months
before applying for an association policy; or
(2) a federally eligible individual and legally domiciled in
Indiana.
(aa) "Self-insurer" means an employer who provides services,
payment for, or reimbursement of any part of the cost of health care
services other than payment of insurance premiums or subscriber
charges to a carrier. However, the term "self-insurer" does not include
an employer who is exempt from state insurance regulation by federal
law, or an employer who is a political subdivision of the state of
Indiana.
(bb) "Services of a skilled nursing facility" means services that must
commence within fourteen (14) days following a confinement of at
least three (3) consecutive days in a hospital for the same condition.
(cc) "Skilled nursing facility", "home health agency", "hospital", and
"home health services" have the meanings assigned to them in 42
U.S.C. 1395x.
(dd) "Medicare supplement policy" means an individual policy of
accident and sickness insurance that is designed primarily as a
supplement to reimbursements under Medicare for the hospital,
medical, and surgical expenses of individuals who are eligible for
Medicare benefits.
(ee) "Limited service health maintenance organization" has the
meaning set forth in IC 27-13-34-4.
As added by Acts 1981, P.L.249, SEC.1. Amended by
P.L.253-1989, SEC.1; P.L.1-1990, SEC.260; P.L.2-1992, SEC.785;
P.L.26-1994, SEC.13; P.L.116-1994, SEC.64; P.L.2-1995, SEC.107;
P.L.188-1995, SEC.8; P.L.91-1998, SEC.12; P.L.1-2001, SEC.33;
P.L.193-2003, SEC.3; P.L.234-2007, SEC.165; P.L.124-2018,
SEC.77.