3.1 Indiana Health Insurance Policy Requirements

The IDOI as Sole Health Regulator

Unlike states that split oversight between an insurance department and a managed-care agency, Indiana concentrates authority in one body: the Indiana Department of Insurance (IDOI). The IDOI licenses insurers and producers, reviews and approves policy forms and rates, investigates complaints, and enforces both Indiana statute (Title 27 of the Indiana Code) and the federal Affordable Care Act (ACA) standards that Indiana has incorporated.

The exam likes the distractor "Department of Managed Health Care" — that is a California body, not Indiana. The correct answer is always the IDOI.

HMO Licensing Standards

A Health Maintenance Organization (HMO) is a prepaid plan that delivers care through a contracted provider network, usually requiring a primary care physician (PCP) referral to see specialists. To operate in Indiana an HMO must obtain a certificate of authority from the IDOI and maintain solvency safeguards:

• A quality assurance / utilization review program to monitor care
• A grievance and appeals process members can use to contest denials
• Adequate provider network access and emergency-care coverage
• Solvency reserves and deposits set by the IDOI under Indiana Code Article 27-13

Worked scenario

A Hoosier enrolled in an HMO is billed out-of-network for an emergency-room visit while traveling. Under ACA emergency-care rules adopted in Indiana, the plan must cover emergency services without prior authorization and apply in-network cost-sharing, even if the hospital is outside the network. A producer who tells the member "the HMO never covers out-of-area ERs" has given incorrect advice — a common exam trap testing the prudent-layperson emergency standard.

The 10-Day Free Look

Indiana gives buyers of individual health policies a 10-day free look beginning the day the policy is delivered. Within those 10 days the policyowner may return the policy for any reason and receive a full premium refund, as though the policy never took effect. This mirrors Indiana's life-insurance free look, which also runs 10 days — a parallel the test rewards you for knowing.

Exam tip: Free look = 10 days for individual life AND individual health in Indiana, but 30 days for individual long-term care (covered in 3.3). Mixing these up is one of the most-missed Indiana state-law items.

The Ten Essential Health Benefits

Every ACA-compliant individual and small-group plan sold in Indiana must cover the ten Essential Health Benefits (EHBs). Memorize them as a checklist — the exam often asks which item is NOT an EHB:

1. Ambulatory (outpatient) patient services
2. Emergency services
3. Hospitalization
4. Maternity and newborn care
5. Mental health and substance use disorder services
6. Prescription drugs
7. Rehabilitative and habilitative services and devices
8. Laboratory services
9. Preventive and wellness services and chronic disease management
10. Pediatric services, including oral and vision care

Note that adult dental and adult vision are NOT EHBs — only pediatric dental/vision is mandated. Cosmetic surgery, long-term custodial care, and routine adult eyeglasses are also excluded.

Guaranteed Issue, Guaranteed Renewal, and Pre-Existing Conditions

For ACA-compliant plans, Indiana follows three linked protections:

A carrier may not cancel an individual's policy because that person developed cancer or filed large claims. The only valid non-renewal grounds are nonpayment, material misrepresentation/fraud, or an across-the-board plan withdrawal with advance notice to all enrollees.

Mental Health and Substance Use Parity

Federal and Indiana parity rules require that financial requirements (copays, coinsurance, deductibles) and treatment limits (visit caps, day limits) for mental health and substance use disorder benefits be no more restrictive than those applied to comparable medical/surgical benefits. A plan that allows unlimited physical-therapy visits but caps psychotherapy at 20 visits violates parity.

The Healthcare.gov Marketplace

Indiana never built a state exchange; residents enroll through the federal Healthcare.gov platform. Key features:

• Plans are sold in metal tiers — Bronze (~60% actuarial value), Silver (~70%), Gold (~80%), Platinum (~90%)
• Advance premium tax credits (APTCs) lower premiums based on household income
• Cost-sharing reductions (CSRs) lower deductibles/copays but only on Silver plans for eligible lower-income buyers
• Open enrollment runs annually; special enrollment periods (SEPs) open for qualifying life events such as marriage, birth, or loss of other coverage

Exam trap: Subsidies are available ONLY through Healthcare.gov, not from off-exchange ("direct") plans. "Covered Indiana" and "Hoosier Health" are invented names used as distractors.

Open enrollment vs. special enrollment

Outside the annual open-enrollment window, a Hoosier generally cannot buy an individual ACA plan unless a qualifying life event (QLE) opens a special enrollment period. Common QLEs and their typical 60-day SEP windows include marriage, the birth or adoption of a child, a permanent move to a new coverage area, and involuntary loss of minimum essential coverage (such as losing a job or aging off a parent's plan at 26). Voluntarily dropping coverage or failing to pay premiums does NOT trigger an SEP — a frequently tested distinction. A producer who promises a client "you can enroll anytime you want" is misstating marketplace rules.