§ 27-8-5-1.5 — Filing, review, approval, and disapproval process

Indiana § 27-8-5-1.5

• Jurisdiction: Indiana
• Title 27: INSURANCE
• Art. 8: LIFE, ACCIDENT, AND HEALTH
• Ch. 5: Accident and Sickness Insurance─Policy Provisions

Text

5. (a) This section applies to a policy of
accident and sickness insurance issued on an individual, a group, a
franchise, or a blanket basis, including a policy issued by an
assessment company or a fraternal benefit society.
(b) As used in this section, "commissioner" refers to the insurance
commissioner appointed under IC 27-1-1-2.
(c) As used in this section, "grossly inadequate filing" means a
policy form filing:
(1) that fails to provide key information, including state specific
information, regarding a product, policy, or rate; or
(2) that demonstrates an insufficient understanding of applicable
legal requirements.
(d) As used in this section, "policy form" means a policy, a contract,
a certificate, a rider, an endorsement, an evidence of coverage, or any
amendment that is required by law to be filed with the commissioner
for approval before use in Indiana.
(e) As used in this section, "type of insurance" refers to a type of
coverage listed on the National Association of Insurance
Commissioners Uniform Life, Accident and Health, Annuity and Credit
Product Coding Matrix under the heading "Continuing Care Retirement
Communities", "Health", "Long Term Care", or "Medicare
Supplement".
(f) Each person having a role in the filing process described in
subsection (i) shall act in good faith and with due diligence in the
performance of the person's duties.
(g) A policy form, including a policy form of a policy, contract,
certificate, rider, endorsement, evidence of coverage, or amendment
that is issued through a health benefit exchange (as defined in IC 27-19-2-8), may not be issued or delivered in Indiana unless the policy
form has been filed with and approved by the commissioner.
(h) The commissioner shall do the following:
(1) Create a document containing a list of all product filing
requirements for each type of insurance, with appropriate
citations to the law, administrative rule, or bulletin that specifies
the requirement, including the citation for the type of insurance
to which the requirement applies.
(2) Make the document described in subdivision (1) available on
the department of insurance Internet site.
(3) Update the document described in subdivision (1) at least
annually and not more than thirty (30) days following any change
in a filing requirement.
(i) The filing process is as follows:
(1) A filer shall submit a policy form filing that:
(A) includes a copy of the document described in subsection
(h);
(B) indicates the location within the policy form or supplement
that relates to each requirement contained in the document
described in subsection (h); and
(C) certifies that the policy form meets all requirements of state
law.
(2) The commissioner shall review a policy form filing and, not
more than thirty (30) days after the commissioner receives the
filing under subdivision (1):
(A) approve the filing; or
(B) provide written notice of a determination:
(i) that deficiencies exist in the filing; or
(ii) that the commissioner disapproves the filing.
A written notice provided by the commissioner under clause (B)
must be based only on the requirements set forth in the document
described in subsection (h) and must cite the specific
requirements not met by the filing. A written notice provided by
the commissioner under clause (B)(i) must state the reasons for
the commissioner's determination in sufficient detail to enable the
filer to bring the policy form into compliance with the
requirements not met by the filing.
(3) A filer may resubmit a policy form that:
(A) was determined deficient under subdivision (2) and has
been amended to correct the deficiencies; or
(B) was disapproved under subdivision (2) and has been
revised.
A policy form resubmitted under this subdivision must meet the
requirements set forth as described in subdivision (1) and must be
resubmitted not more than thirty (30) days after the filer receives
the commissioner's written notice of deficiency or disapproval. If
a policy form is not resubmitted within thirty (30) days after
receipt of the written notice, the commissioner's determination
regarding the policy form is final.
(4) The commissioner shall review a policy form filing
resubmitted under subdivision (3) and, not more than thirty (30)
days after the commissioner receives the resubmission:
(A) approve the resubmitted policy form; or
(B) provide written notice that the commissioner disapproves
the resubmitted policy form.
A written notice of disapproval provided by the commissioner
under clause (B) must be based only on the requirements set forth
in the document described in subsection (h), must cite the specific
requirements not met by the filing, and must state the reasons for
the commissioner's determination in detail. The commissioner's
approval or disapproval of a resubmitted policy form under this
subdivision is final, except that the commissioner may allow the
filer to resubmit a further revised policy form if the filer, in the
filer's resubmission under subdivision (3), introduced new
provisions or materially modified a substantive provision of the
policy form. If the commissioner allows a filer to resubmit a
further revised policy form under this subdivision, the filer must
resubmit the further revised policy form not more than thirty (30)
days after the filer receives notice under clause (B), and the
commissioner shall issue a final determination on the further
revised policy form not more than thirty (30) days after the
commissioner receives the further revised policy form.
(5) If the commissioner disapproves a policy form filing under
this subsection, the commissioner shall notify the filer, in writing,
of the filer's right to a hearing as described in subsection (r). A
disapproved policy form filing may not be used for a policy of
accident and sickness insurance unless the disapproval is
overturned in a hearing conducted under this subsection.
(6) If the commissioner does not take any action on a policy form
that is filed or resubmitted under this subsection in accordance
with any applicable period specified in subdivision (2), (3), or (4),
the policy form filing is considered to be approved.
(j) Except as provided in this subsection, the commissioner may not
disapprove a policy form resubmitted under subsection (i)(3) or (i)(4)
for a reason other than a reason specified in the original notice of
determination under subsection (i)(2)(B). The commissioner may
disapprove a resubmitted policy form for a reason other than a reason
specified in the original notice of determination under subsection (i)(2)
if:
(1) the filer has introduced a new provision in the resubmission;
(2) the filer has materially modified a substantive provision of the
policy form in the resubmission;
(3) there has been a change in requirements applying to the policy
form; or
(4) there has been reviewer error and the written disapproval fails
to state a specific requirement with which the policy form does
not comply.
(k) The commissioner may return a grossly inadequate filing to the
filer without triggering a deadline set forth in this section.
(l) The commissioner may disapprove a policy form if:
(1) the benefits provided under the policy form are not reasonable
in relation to the premium charged; or
(2) the policy form contains provisions that are unjust, unfair,
inequitable, misleading, or deceptive, or that encourage
misrepresentation of the policy.
(m) Before approving or disapproving a premium rate increase or
decrease, the commissioner shall consider the following:
(1) The products affected, by line of business.
(2) The number of covered lives affected.
(3) Whether the product is open or closed to new members in the
product block.
(4) Applicable median cost sharing for the product, as allowed by
state or federal law.
(5) The benefits provided and the underlying costs of the health
services rendered.
(6) The implementation date of the increase or decrease.
(7) The overall percent premium rate increase or decrease that is
requested.
(8) The actual percent premium rate increase or decrease to be
approved.
(9) Incurred claims paid each year for the past three (3) years, if
applicable.
(10) Earned premiums for each of the past three (3) years, if
applicable.
(11) Projected medical cost trends in the geographic service
region, if the product for which a rate increase or decrease is
requested is not a product offered statewide.
(12) If applicable, historical rebates paid to the policyholder from
the most recent health plan year under the federal Patient
Protection and Affordable Care Act (P.L. 111-148), as amended
by the federal Health Care and Education Reconciliation Act of
2010 (P.L. 111-152).
(13) The median cost sharing amount for an individual covered by
the product, or the actuarial value information as required under
the Patient Protection and Affordable Care Act, if applicable.
(n) The commissioner shall not approve a new product unless the
commissioner has, at a minimum, considered the matters set forth in
subsection (m)(1) through (m)(13).
(o) The information compiled, prepared, and considered by the
commissioner under subsection (m)(1) through (m)(13) is subject to the
requirements of IC 5-14-3. However, the commissioner's approval of
a new product or a rate increase or decrease may take effect before the
information compiled, prepared, and considered by the commissioner
under subsection (m)(1) through (m)(13) is made accessible to the
public under IC 5-14-3.
(p) When considering whether to approve a premium rate increase,
the commissioner shall consider whether the current rate is appropriate
for achieving the insurer's target loss ratio.
(q) To the extent authorized by the Patient Protection and
Affordable Care Act and other federal law, the commissioner, under
this section, may:
(1) consider network adequacy;
(2) conduct form review to ensure:
(A) minimum essential health benefits; and
(B) nondiscriminatory benefit design;
(3) perform accreditation confirmation; and
(4) confirm quality measures.
(r) Upon disapproval of a filing under this section, the commissioner
shall provide written notice to the filer or insurer of the right to a
hearing within twenty (20) days of a request for a hearing.
(s) Unless a policy form approved under this chapter contains a
material error or omission, the commissioner may not:
(1) retroactively disapprove the policy form; or
(2) examine the filer of the policy form during a routine or
targeted market conduct examination for compliance with a policy
form filing requirement that was not in existence at the time the
policy form was filed.

Legislative History

As added by P.L.173-2007, SEC.22. Amended by P.L.111-2008, SEC.3; P.L.278-2013, SEC.24; P.L.124-2018, SEC.76; P.L.190-2023, SEC.25.