Introduced Version
HOUSE BILL No. 1046
_____
DIGEST OF INTRODUCED BILL
Citations Affected: IC 25-1-9.8-20; IC 27-1; IC 27-8; IC 27-13-15.
Synopsis: Health insurance matters. Requires the commissioner of the
department of insurance to provide an order directing the
discontinuance of an illegal, unauthorized, or unsafe practice of an
insurance company. Provides that a health plan may not require a
participating provider to seek prior authorization for a particular health
service if the health plan approved at least 90% of the prior
authorization requests for the particular health service in the previous
six month period. Requires a health plan to post notice of a technical
issue with its claims submission system on the health plan's Internet
web site. Requires a health plan to post on its Internet web site not later
than February 1 of each year: (1) the 30 most frequently submitted CPT
codes in the previous calendar year; and (2) the percentage of the 30
most frequently submitted CPT codes that were approved in the
previous calendar year. Requires a health plan to provide annual and
quarterly financial statements to the department of insurance.
Establishes an approval process for a health plan's proposed premium
rate increase of 5% or greater as compared to the previous calendar
year. Requires an insurer and a health maintenance organization to
provide a contracted provider with a current reimbursement rate
schedule: (1) every two years; and (2) when three or more CPT code
rates change in a 12 month period. Requires an insurer and a health
maintenance organization to provide a contracted provider with notice
of a proposed material change to the agreement between the insurer or
health maintenance organization and the contracted provider at least 90
days prior to the proposed effective date. Establishes requirements for
the contents of a notice of a proposed material change. Requires an
(Continued next page)
Effective: July 1, 2022.
Heine
January 4, 2022, read first time and referred to Committee on Financial Institutions and
Insurance.
2022 IN 1046—LS 6517/DI 137 Digest Continued
insurer or health maintenance organization to provide a contracted
provider with notice at least 15 days prior to a change to an existing
prior authorization, precertification, notification, referral program, edit
program, or specific edits.
2022 IN 1046—LS 6517/DI 1372022 IN 1046—LS 6517/DI 137 Introduced
Second Regular Session of the 122nd General Assembly (2022)
PRINTING CODE. Amendments: Whenever an existing statute (or a section of the Indiana
Constitution) is being amended, the text of the existing provision will appear in this style type,
additions will appear in this style type, and deletions will appear in this style type.
Additions: Whenever a new statutory provision is being enacted (or a new constitutional
provision adopted), the text of the new provision will appear in this style type. Also, the
word NEW will appear in that style type in the introductory clause of each SECTION that adds
a new provision to the Indiana Code or the Indiana Constitution.
Conflict reconciliation: Text in a statute in this style type or this style type reconciles conflicts
between statutes enacted by the 2021 Regular Session of the General Assembly.
HOUSE BILL No. 1046
A BILL FOR AN ACT to amend the Indiana Code concerning
insurance.
Be it enacted by the General Assembly of the State of Indiana:
1 SECTION 1. IC 25-1-9.8-20 IS ADDED TO THE INDIANA CODE
2 AS A NEW SECTION TO READ AS FOLLOWS [EFFECTIVE JULY
3 1, 2022]: Sec. 20. A practitioner may satisfy the requirements of
4 this chapter by complying with the requirements set forth in
5 Section 2799B-6 of the federal Public Health Service Act, as added
6 by Public Law 116-260.
7 SECTION 2. IC 27-1-3-19 IS AMENDED TO READ AS
8 FOLLOWS [EFFECTIVE JULY 1, 2022]: Sec. 19. (a) Whenever the
9 commissioner determines that any insurance company to which this
10 article is applicable:
11 (1) is conducting its business contrary to law or in an unsafe or
12 unauthorized manner;
13 (2) has had its capital or surplus fund impaired or reduced below
14 the amount required by law; or
15 (3) has failed, neglected, or refused to observe and comply with
2022 IN 1046—LS 6517/DI 137 2
1 any law, order, or rule of the department or commissioner;
2 then the commissioner may, shall, by an order in writing addressed to
3 the board of directors, board of trustees, attorney in fact, partners, or
4 owners of or in any such insurance company, to direct the
5 discontinuance of any such illegal, unauthorized, or unsafe practice, the
6 restoration of an impairment to the capital or the surplus fund, or the
7 compliance with any such law, order, or rule of the department or
8 commissioner. The order shall be mailed to the last known principal
9 office of the insurance company by certified or registered mail or
10 delivered to an officer of the company and shall be considered to be
11 received by the insurance company three (3) days after mailing or on
12 the date of delivery.
13 (b) If the insurance company fails, neglects, or refuses to comply
14 with the terms of that order within thirty (30) days after its receipt by
15 the insurance company, or within a shorter period set out in the order
16 if the commissioner determines that an emergency exists, the
17 commissioner may, in addition to any other remedy conferred upon the
18 department or the commissioner by law, bring an action against any
19 such insurance company, its officers, and agents to compel that
20 compliance.
21 (c) The action shall be brought by the commissioner in the Marion
22 County circuit court. The action shall be commenced and prosecuted
23 in accordance with the Indiana Rules of Trial Procedure, and relief for
24 noncompliance of the order includes any remedy appropriate under the
25 facts, including injunction, preliminary injunction, and temporary
26 restraining order. In that action, a change of venue from the judge, but
27 no change of venue from the county, is permitted.
28 SECTION 3. IC 27-1-37.5-10, AS ADDED BY P.L.208-2018,
29 SECTION 8, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE
30 JULY 1, 2022]: Sec. 10. (a) This section applies to a request for prior
31 authorization delivered to a health plan after December 31, 2019.
32 (b) A health plan shall accept a request for prior authorization
33 delivered to the health plan by a covered individual's health care
34 provider through a secure electronic transmission. A health care
35 provider shall submit a request for prior authorization through a secure
36 electronic transmission. A health plan shall provide for:
37 (1) a secure electronic transmission; and
38 (2) acknowledgment of receipt, by use of a transaction number or
39 another reference code;
40 of a request for prior authorization and any supporting information.
41 (c) Subsection (b) does not apply and a health plan that requires
42 prior authorization shall accept a request for prior authorization that is
2022 IN 1046—LS 6517/DI 137 3
1 not submitted through a secure electronic transmission if a covered
2 individual's health care provider and the health plan have entered into
3 an agreement under which the health plan agrees to process prior
4 authorization requests that are not submitted through a secure
5 electronic transmission because:
6 (1) secure electronic transmission of prior authorization requests
7 would cause financial hardship for the health care provider;
8 (2) the area in which the health care provider is located lacks
9 sufficient Internet access; or
10 (3) the health care provider has an insufficient number of covered
11 individuals as patients or customers, as determined by the
12 commissioner, to warrant the financial expense that compliance
13 with subsection (b) would require.
14 (d) If a covered individual's health care provider is described in
15 subsection (c), the health plan shall accept from the health care
16 provider a request for prior authorization as follows:
17 (1) The prior authorization request must be made on the
18 standardized prior authorization form established by the
19 department under section 16 of this chapter.
20 (2) The health plan shall provide for secure electronic
21 transmission and acknowledgement acknowledgment of receipt
22 of the standardized prior authorization form and any supporting
23 information for the prior authorization by use of a transaction
24 number or another reference code.
25 (e) A health plan that utilizes a third party to review requests
26 for prior authorization:
27 (1) may not require a covered individual's health care
28 provider to submit a request for prior authorization to the
29 third party; and
30 (2) must transmit a request for prior authorization provided
31 by a covered individual's health care provider through secure
32 electronic transmission to the third party.
33 SECTION 4. IC 27-1-37.5-13.5 IS ADDED TO THE INDIANA
34 CODE AS A NEW SECTION TO READ AS FOLLOWS
35 [EFFECTIVE JULY 1, 2022]: Sec. 13.5. (a) A health plan may not
36 require a participating provider to obtain prior authorization for
37 a particular health care service if, in the most recent six (6) month
38 period, the health plan has approved at least ninety percent (90%)
39 of the prior authorization requests submitted by the participating
40 provider for the particular health care service.
41 (b) A health plan must update a participating provider not later
42 than January 1 and July 1 of each calendar year of the particular
2022 IN 1046—LS 6517/DI 137 4
1 health care services that do not require prior authorization for the
2 following six (6) month period under subsection (a).
3 (c) A health plan may rescind a participating provider's
4 exemption from obtaining prior authorization for a particular
5 health care service under subsection (a) if the health plan makes a
6 determination, on the basis of a retrospective review of a random
7 sample of not less than five (5) and no more than twenty (20) claims
8 submitted by the participating provider during the most recent six
9 (6) month period, that less than ninety percent (90%) of the claims
10 for the particular health care service met the medical necessity
11 criteria that would have been used by the health plan when
12 conducting prior authorization review for the particular health
13 care service during the relevant six (6) month period. Nothing in
14 this subsection prohibits a participating provider from qualifying
15 for an exemption from obtaining prior authorization for a
16 particular health care service in a future six (6) month period as
17 provided for in subsection (a), even if an exemption was previously
18 rescinded.
19 (d) A rescission by a health plan under subsection (c) must:
20 (1) be provided to the participating provider in writing not
21 less than thirty (30) calendar days prior to the effective date
22 of the rescission;
23 (2) include documentation of the random sample of claims;
24 and
25 (3) include information on how the participating provider
26 may appeal the rescission.
27 (e) If an exemption from obtaining prior authorization for a
28 particular health care service granted under subsection (a) is
29 rescinded by a health plan following review under subsection (c),
30 a participating provider may appeal the rescission. After reviewing
31 any supporting documentation submitted by the participating
32 provider with the appeal, a health plan must make a decision on
33 the appeal and provide the decision to the participating provider
34 in writing not later than fourteen (14) calendar days after the
35 health plan receives notice of the appeal.
36 SECTION 5. IC 27-1-46-18 IS ADDED TO THE INDIANA CODE
37 AS A NEW SECTION TO READ AS FOLLOWS [EFFECTIVE JULY
38 1, 2022]: Sec. 18. A provider facility may satisfy the requirements
39 of this chapter by complying with the requirements set forth in
40 Section 2799B-6 of the federal Public Health Service Act, as added
41 by Public Law 116-260.
42 SECTION 6. IC 27-1-48 IS ADDED TO THE INDIANA CODE AS
2022 IN 1046—LS 6517/DI 137 5
1 A NEW CHAPTER TO READ AS FOLLOWS [EFFECTIVE JULY
2 1, 2022]:
3 Chapter 48. Health Plan Transparency
4 Sec. 1. As used in this chapter, "covered individual" means an
5 individual who is entitled to coverage under a health plan.
6 Sec. 2. As used in this chapter, "CPT code" refers to the medical
7 billing code that applies to a specific health care service, as
8 published in the Current Procedural Terminology code set
9 maintained by the American Medical Association.
10 Sec. 3. (a) As used in this chapter, "health care service" means
11 a health care related service or product rendered or sold by a
12 health care provider within the scope of the health care provider's
13 license or legal authorization, including hospital, medical, surgical,
14 mental health, and substance abuse services or products.
15 (b) The term does not include the following:
16 (1) Dental services.
17 (2) Vision services.
18 (3) Long term rehabilitation treatment.
19 (4) Pharmaceutical services or products.
20 Sec. 4. (a) As used in this chapter, "health plan" means any of
21 the following that provides coverage for health care services:
22 (1) A policy of accident and sickness insurance (as defined in
23 IC 27-8-5-1). However, the term does not include the
24 coverages described in IC 27-8-5-2.5(a).
25 (2) A contract with a health maintenance organization (as
26 defined in IC 27-13-1-19) that provides coverage for basic
27 health care services (as defined in IC 27-13-1-4).
28 (3) The Medicaid risk based managed care program under
29 IC 12-15.
30 (b) The term includes a person that administers any of the
31 following:
32 (1) A policy described in subsection (a)(1).
33 (2) A contract described in subsection (a)(2).
34 (3) Medicaid risk based managed care.
35 Sec. 5. As used in this chapter, "participating provider" refers
36 to the following:
37 (1) A health care provider that has entered into an agreement
38 with an insurer under IC 27-8-11-3.
39 (2) A participating provider (as defined in IC 27-13-1-24).
40 Sec. 6. As used in this chapter, "prior authorization" means a
41 practice implemented by a health plan through which coverage of
42 a health care service is dependent on the covered individual or
2022 IN 1046—LS 6517/DI 137 6
1 health care provider obtaining approval from the health plan
2 before the health care service is rendered. The term includes
3 prospective or utilization review procedures conducted before a
4 health care service is rendered.
5 Sec. 7. (a) Within twenty-four (24) hours of the identification of
6 a technical issue with a health plan's claims submission system that
7 would require a participating provider to submit a second claim
8 for the same health care service, the health plan must post notice
9 of the technical issue on the health plan's Internet web site.
10 (b) When a technical issue that was posted under subsection (a)
11 is resolved, the health plan must post an update on the resolution
12 of the technical issue on the health plan's Internet web site for not
13 less than seventy-two (72) hours.
14 Sec. 8. (a) Not later than February 1 of each calendar year, a
15 health plan must post on the health plan's Internet web site:
16 (1) the thirty (30) most frequently submitted CPT codes that
17 were submitted by participating providers for prior
18 authorization during the previous calendar year; and
19 (2) the percentage of the thirty (30) most frequently submitted
20 CPT codes that were approved in the previous calendar year,
21 disaggregated by CPT code.
22 (b) A health plan must maintain the information required under
23 subsection (a) on the health plan's Internet web site, organized by
24 year and on a single and easily accessible web page.
25 Sec. 9. (a) A health plan must file with the department:
26 (1) not later than February 1 of each calendar year, the
27 amount of administrative fees charged by the health plan for
28 each administrative service only contract for self-insured
29 health plans, disaggregated by each contract, from the
30 previous calendar year;
31 (2) not later than March 1 of each calendar year, the health
32 plan's annual financial statement from the previous calendar
33 year;
34 (3) not later than May 15 of each calendar year, the health
35 plan's first quarter financial statement from the current
36 calendar year;
37 (4) not later than August 15 of each calendar year, the health
38 plan's second quarter financial statement from the current
39 calendar year; and
40 (5) not later than November 15 of each calendar year, the
41 health plan's third quarter financial statement from the
42 current calendar year.
2022 IN 1046—LS 6517/DI 137 7
1 (b) The department must post the information filed under
2 subsection (a) not later than ten (10) business days after receiving
3 the information on the department's Internet web site on a single
4 and easily accessible web page.
5 SECTION 7. IC 27-8-4-8 IS AMENDED TO READ AS FOLLOWS
6 [EFFECTIVE JULY 1, 2022]: Sec. 8. A. (a) Except as provided in
7 section 8.5 of this chapter, any insurer may revise its schedules of
8 premium rates from time to time, and shall file such revised schedules
9 with the commissioner. No insurer shall issue any credit life insurance
10 policy or credit accident and health insurance policy for which the
11 premium rate exceeds that determined by the schedules of such insurer
12 as then on file with the commissioner.
13 B. (b) Each individual policy, or group certificate shall provide that
14 in the event of termination of the insurance prior to the scheduled
15 maturity date of the indebtedness, any refund of an amount paid by the
16 debtor for insurance shall be paid or credited promptly to the person
17 entitled thereto; Provided, however, That the commissioner shall
18 prescribe a minimum refund and no refund which would be less than
19 such minimum need be made. The formula to be used in computing
20 such refund shall be filed with and approved by the commissioner.
21 C. (c) If a creditor requires a debtor to make any payment for credit
22 life insurance or credit accident and health insurance and an individual
23 policy or group certificate of insurance is not issued, the creditor shall
24 immediately give written notice to such debtor and shall promptly
25 make an appropriate credit to the account.
26 D. (d) The amount charged to a debtor for any credit life or credit
27 health and accident insurance shall not exceed the premiums charged
28 by the insurer, as computed at the time the charge to the debtor is
29 determined.
30 SECTION 8. IC 27-8-4-8.5 IS ADDED TO THE INDIANA CODE
31 AS A NEW SECTION TO READ AS FOLLOWS [EFFECTIVE JULY
32 1, 2022]: Sec. 8.5. (a) If the premium rate for a health insurance
33 policy will increase five percent (5%) or greater as compared to
34 the previous calendar year:
35 (1) the insurer must submit:
36 (A) the planned premium rate increase; and
37 (B) written justification for the planned premium rate
38 increase;
39 to the commissioner or the commissioner's designee for
40 review and approval prior to the planned premium rate
41 increase going into effect. The department must post the
42 written justification for the planned premium rate increase on
2022 IN 1046—LS 6517/DI 137 8
1 the department's Internet web site not later than ten (10)
2 calendar days after receiving the written justification for the
3 planned premium rate increase;
4 (2) after reviewing the insurer's written justification for the
5 planned premium rate increase, the commissioner or the
6 commissioner's designee must approve or deny the insurer's
7 planned premium rate increase in writing within twenty (20)
8 calendar days;
9 (3) if the insurer's planned premium rate increase is denied by
10 the commissioner or the commissioner's designee under
11 subdivision (2), the insurer may submit:
12 (A) a lower planned premium rate increase; and
13 (B) written justification for the lower planned premium
14 rate increase;
15 to the commissioner or the commissioner's designee for
16 review and approval prior to the lower planned premium rate
17 increase going into effect. The department must post the
18 written justification for the lower planned premium rate
19 increase on the department's Internet web site not later than
20 ten (10) calendar days after receiving the written justification
21 for the planned premium rate increase;
22 (4) after reviewing the insurer's written justification for the
23 lower planned premium rate increase, the commissioner or
24 the commissioner's designee must approve or deny the
25 insurer's lower planned premium rate increase in writing
26 within twenty (20) calendar days; and
27 (5) if the commissioner or the commissioner's designee denies
28 an insurer's lower planned premium rate increase submitted
29 under subdivision (3), the insurer may not increase the
30 premium rate five percent (5%) or more for that calendar
31 year.
32 (b) If an insurer's planned premium rate increase of five percent
33 (5%) or more is approved under subsection (a)(2) or (a)(4), the
34 insurer must provide written justification of the premium rate
35 increase to an individual or entity covered by the health insurance
36 policy not less than thirty (30) days prior to the premium rate
37 increase going into effect.
38 SECTION 9. IC 27-8-5.7-2.5 IS ADDED TO THE INDIANA
39 CODE AS A NEW SECTION TO READ AS FOLLOWS
40 [EFFECTIVE JULY 1, 2022]: Sec. 2.5. As used in this chapter, "CPT
41 code" refers to the medical billing code that applies to a specific
42 health care service, as published in the Current Procedural
2022 IN 1046—LS 6517/DI 137 9
1 Terminology code set maintained by the American Medical
2 Association.
3 SECTION 10. IC 27-8-5.7-5 IS AMENDED TO READ AS
4 FOLLOWS [EFFECTIVE JULY 1, 2022]: Sec. 5. (a) An insurer shall
5 pay or deny each clean claim in accordance with section sections 6 and
6 6.5 of this chapter.
7 (b) An insurer shall notify a provider of any deficiencies in a
8 submitted claim not more than:
9 (1) thirty (30) days for a claim that is filed electronically; or
10 (2) forty-five (45) days for a claim that is filed on paper;
11 and describe any remedy necessary to establish a clean claim.
12 (c) Failure of an insurer to notify a provider as required under
13 subsection (b) establishes the submitted claim as a clean claim.
14 SECTION 11. IC 27-8-5.7-6.5 IS ADDED TO THE INDIANA
15 CODE AS A NEW SECTION TO READ AS FOLLOWS
16 [EFFECTIVE JULY 1, 2022]: Sec. 6.5. (a) An insurer may not:
17 (1) alter the CPT code submitted for a clean claim; and
18 (2) pay for a CPT code of lesser monetary value;
19 unless the medical record of the clean claim has been reviewed by
20 an employee of the insurer who is licensed under IC 25-22.5. An
21 employee of an insurer who is licensed under IC 25-22.5 and
22 reviews medical records under this subsection is subject to review
23 by the medical licensing board created by IC 25-22.5-2-1 for
24 violations of the standards for the competent practice of medicine.
25 (b) An insurer may not deny payment for a clean claim based
26 solely on the location of the service, if the location of the service is
27 in the contracted network of the insurer.
28 (c) An insurer may not alter a clean claim to only pay for the
29 CPT codes necessary for an individual's final diagnosis, if the CPT
30 codes billed were deemed medically necessary to reach the final
31 diagnosis.
32 SECTION 12. IC 27-8-11-3 IS AMENDED TO READ AS
33 FOLLOWS [EFFECTIVE JULY 1, 2022]: Sec. 3. (a) An insurer may:
34 (1) enter into agreements with providers relating to terms and
35 conditions of reimbursement for health care services that may be
36 rendered to insureds of the insurer, including agreements relating
37 to the amounts to be charged the insured for services rendered or
38 the terms and conditions for activities intended to reduce
39 inappropriate care;
40 (2) issue or administer policies in this state that include incentives
41 for the insured to utilize the services of a provider that has entered
42 into an agreement with the insurer under subdivision (1); and
2022 IN 1046—LS 6517/DI 137 10
1 (3) issue or administer policies in this state that provide for
2 reimbursement for expenses of health care services only if the
3 services have been rendered by a provider that has entered into an
4 agreement with the insurer under subdivision (1).
5 (b) Before entering into any agreement under subsection (a)(1), an
6 insurer shall establish terms and conditions that must be met by
7 providers wishing to enter into an agreement with the insurer under
8 subsection (a)(1). These terms and conditions may not discriminate
9 unreasonably against or among providers. For the purposes of this
10 subsection, neither differences in prices among hospitals or other
11 institutional providers produced by a process of individual negotiation
12 nor price differences among other providers in different geographical
13 areas or different specialties constitutes unreasonable discrimination.
14 Upon request by a provider seeking to enter into an agreement with an
15 insurer under subsection (a)(1), the insurer shall make available to the
16 provider a written statement of the terms and conditions that must be
17 met by providers wishing to enter into an agreement with the insurer
18 under subsection (a)(1).
19 (c) No hospital, physician, pharmacist, or other provider designated
20 in IC 27-8-6-1 willing to meet the terms and conditions of agreements
21 described in this section may be denied the right to enter into an
22 agreement under subsection (a)(1). When an insurer denies a provider
23 the right to enter into an agreement with the insurer under subsection
24 (a)(1) on the grounds that the provider does not satisfy the terms and
25 conditions established by the insurer for providers entering into
26 agreements with the insurer, the insurer shall provide the provider with
27 a written notice that:
28 (1) explains the basis of the insurer's denial; and
29 (2) states the specific terms and conditions that the provider, in
30 the opinion of the insurer, does not satisfy.
31 (d) In no event may an insurer deny or limit reimbursement to an
32 insured under this chapter on the grounds that the insured was not
33 referred to the provider by a person acting on behalf of or under an
34 agreement with the insurer.
35 (e) No cause of action shall arise against any person or insurer for:
36 (1) disclosing information as required by this section; or
37 (2) the subsequent use of the information by unauthorized
38 individuals.
39 Nor shall such a cause of action arise against any person or provider for
40 furnishing personal or privileged information to an insurer. However,
41 this subsection provides no immunity for disclosing or furnishing false
42 information with malice or willful intent to injure any person, provider,
2022 IN 1046—LS 6517/DI 137 11
1 or insurer.
2 (f) Nothing in this chapter abrogates the privileges and immunities
3 established in IC 34-30-15 (or IC 34-4-12.6 before its repeal).
4 (g) An insurer that enters into an agreement with a provider
5 under subsection (a)(1) must provide the provider a current
6 reimbursement rate schedule:
7 (1) every two (2) years; and
8 (2) when three (3) or more CPT code (as defined in
9 IC 27-1-37.5-3) rates under the agreement are changed in a
10 twelve (12) month period.
11 SECTION 13. IC 27-8-11-14 IS ADDED TO THE INDIANA
12 CODE AS A NEW SECTION TO READ AS FOLLOWS
13 [EFFECTIVE JULY 1, 2022]: Sec. 14. (a) As used in this section,
14 "contracted provider" means a provider that has entered into an
15 agreement with an insurer under section 3 of this chapter.
16 (b) As used in this section, "material change" means a change
17 to an agreement between a contracted provider and an insurer
18 under section 3 of this chapter, the occurrence and timing of which
19 are not otherwise clearly identified in the agreement, that:
20 (1) decreases the contracted provider's payment or
21 compensation; or
22 (2) changes the administrative procedures in a way that may
23 reasonably be expected to significantly increase the
24 contracted provider's administrative expense.
25 The term includes changes to network requirements and inclusion
26 in any new or modified insurance products.
27 (c) Each insurer offering a preferred provider plan must
28 establish procedures for modifying an existing agreement with a
29 contracted provider that meet the requirements of this section.
30 (d) If an insurer offering a preferred provider plan intends to
31 make a material change to an agreement it has entered into with a
32 contracted provider under section 3 of this chapter, the insurer
33 must provide the contracted provider with notice at least ninety
34 (90) days prior to the proposed effective date of the material
35 change. The notice must include:
36 (1) the proposed effective date of the material change;
37 (2) a description of the material change;
38 (3) a statement that the contracted provider has the option to
39 either accept or reject the material change under this section;
40 (4) the name, business address, telephone number, and
41 electronic mail address of a representative of the insurer who
42 may discuss the material change, if requested by the
2022 IN 1046—LS 6517/DI 137 12
1 contracted provider;
2 (5) notice of the opportunity to request a meeting using real
3 time communication or to communicate via electronic mail to
4 discuss the material change, if requested by the contracted
5 provider; and
6 (6) notice that upon three (3) material changes in a twelve (12)
7 month period, the contracted provider may request a copy of
8 the agreement with the material changes incorporated into it.
9 Provision of a copy of the agreement by the insurer is for
10 informational purposes only and does not affect the terms and
11 conditions of the agreement.
12 (e) If a proposed material change relates to the contracted
13 provider's inclusion in any new or modified insurance products or
14 proposes changes to the contracted provider's networks:
15 (1) the material change will only take effect upon the
16 acceptance of the contracted provider, evidenced by a written
17 signature; and
18 (2) the notice of the material change must be sent by certified
19 mail, return receipt requested.
20 (f) For any other proposed material change not addressed in
21 subsection (e), the following requirements apply:
22 (1) The material change must take effect on the date provided
23 in the notice, unless the contracted provider objects to the
24 change under subdivision (2).
25 (2) A contracted provider who wishes to object to a material
26 change under this subsection must do so in writing, and the
27 written protest must be delivered not later than thirty (30)
28 days after the date the contracted provider receives notice of
29 the material change.
30 (3) Not later than thirty (30) days after the insurer receives
31 the contracted provider's objection under subdivision (2), the
32 insurer and the contracted provider must confer in an effort
33 to reach an agreement on the material change or any counter
34 proposals offered by the contracted provider.
35 (4) If the insurer and the contracted provider fail to reach an
36 agreement during the thirty (30) day period as described in
37 subdivision (3), the insurer and the contracted provider are
38 allowed thirty (30) days to unwind their relationship, provide
39 notice to patients and other affected parties, and terminate
40 the agreement pursuant to its original terms.
41 (5) The notice of a material change under this subsection must
42 be sent in an orange envelope with the phrase "ATTENTION!
2022 IN 1046—LS 6517/DI 137 13
1 AGREEMENT AMENDMENT ENCLOSED!" in at least 14
2 point bold font printed on the front of the envelope. This color
3 of envelope must be used for the sole purpose of
4 communicating material changes and may not be used for
5 other types of communication from an insurer.
6 (g) If an insurer offering a preferred provider plan makes a
7 change to an agreement that changes an existing prior
8 authorization, precertification, notification, or referral program,
9 or changes an edit program or specific edits, the insurer must
10 provide notice of the change to a contracted provider not later than
11 fifteen (15) days prior to the change.
12 (h) Any notice required to be mailed under this section must be
13 sent to the contracted provider's point of contact, as set forth in the
14 agreement. If no point of contact is set forth in the agreement, the
15 insurer must send the notice to the contracted provider's place of
16 business, addressed to the contracted provider.
17 SECTION 14. IC 27-13-15-1 IS AMENDED TO READ AS
18 FOLLOWS [EFFECTIVE JULY 1, 2022]: Sec. 1. (a) A contract
19 between a health maintenance organization and a participating provider
20 of health care services:
21 (1) must be in writing;
22 (2) may not prohibit the participating provider from disclosing:
23 (A) the terms of the contract as it relates to financial or other
24 incentives to limit medical services by the participating
25 provider; or
26 (B) all treatment options available to an insured, including
27 those not covered by the insured's policy;
28 (3) may not provide for a financial or other penalty to a provider
29 for making a disclosure permitted under subdivision (2); and
30 (4) must provide that in the event the health maintenance
31 organization fails to pay for health care services as specified by
32 the contract, the subscriber or enrollee is not liable to the
33 participating provider for any sums owed by the health
34 maintenance organization.
35 (b) An enrollee is not entitled to coverage of a health care service
36 under a group or an individual contract unless that health care service
37 is included in the enrollee's contract.
38 (c) A provider is not entitled to payment under a contract for health
39 care services provided to an enrollee unless the provider has a contract
40 or an agreement with the carrier.
41 (d) A health maintenance organization that enters into a
42 contract with a participating provider must provide the
2022 IN 1046—LS 6517/DI 137 14
1 participating provider with a current reimbursement rate
2 schedule:
3 (1) every two (2) years; and
4 (2) when three (3) or more CPT code (as defined in
5 IC 27-1-37.5-3) rates under the contract change in a twelve
6 (12) month period.
7 (d) This section applies to a contract entered, renewed, or modified
8 after June 30, 1996.
9 SECTION 15. IC 27-13-15-7 IS ADDED TO THE INDIANA
10 CODE AS A NEW SECTION TO READ AS FOLLOWS
11 [EFFECTIVE JULY 1, 2022]: Sec. 7. (a) As used in this section,
12 "material change" means a change to a contract between a
13 participating provider and a health maintenance organization, the
14 occurrence and timing of which are not otherwise clearly identified
15 in the contract, that:
16 (1) decreases the participating provider's payment or
17 compensation; or
18 (2) changes the administrative procedures in a way that may
19 reasonably be expected to significantly increase the
20 participating provider's administrative expense.
21 The term includes changes to network requirements and inclusion
22 in any new or modified insurance products.
23 (b) A health maintenance organization must establish
24 procedures for modifying an existing contract with a participating
25 provider that meet the requirements of this section.
26 (c) If a health maintenance organization intends to make a
27 material change to a contract it has entered into with a
28 participating provider under section 1 of this chapter, the health
29 maintenance organization must provide the participating provider
30 with notice at least ninety (90) days prior to the proposed effective
31 date of the material change. The notice must include:
32 (1) the proposed effective date of the material change;
33 (2) a description of the material change;
34 (3) a statement that the participating provider has the option
35 to either accept or reject the material change under this
36 section;
37 (4) the name, business address, telephone number, and
38 electronic mail address of a representative of the health
39 maintenance organization who may discuss the material
40 change, if requested by the participating provider;
41 (5) notice of the opportunity to request a meeting using real
42 time communication or to communicate via electronic mail to
2022 IN 1046—LS 6517/DI 137 15
1 discuss the material change, if requested by the participating
2 provider; and
3 (6) notice that upon three (3) material changes in a twelve (12)
4 month period, the participating provider may request a copy
5 of the contract with the material changes incorporated into it.
6 Provision of a copy of the contract by the health maintenance
7 organization is for informational purposes only and does not affect
8 the terms and conditions of the contract.
9 (d) If a proposed material change relates to a participating
10 provider's inclusion in any new or modified insurance products or
11 proposes changes to a participating provider's networks:
12 (1) the material change will only take effect upon the
13 acceptance of the participating provider, evidenced by a
14 written signature; and
15 (2) the notice of the material change must be sent by certified
16 mail, return receipt requested.
17 (e) For any other proposed material change not addressed in
18 subsection (d), the following requirements apply:
19 (1) The material change must take effect on the date provided
20 in the notice, unless the participating provider objects to the
21 change under subdivision (2).
22 (2) A participating provider who wishes to object to a
23 material change under this subsection must do so in writing,
24 and the written protest must be delivered not later than thirty
25 (30) days after the date the participating provider receives
26 notice of the material change.
27 (3) Not later than thirty (30) days after the health
28 maintenance organization receives the participating
29 provider's objection under subdivision (2), the health
30 maintenance organization and the participating provider
31 must confer in an effort to reach an agreement on the
32 material change or any counter proposals offered by the
33 participating provider.
34 (4) If the health maintenance organization and the
35 participating provider fail to reach an agreement during the
36 thirty (30) day period as described in subdivision (3), the
37 health maintenance organization and the participating
38 provider are allowed thirty (30) days to unwind their
39 relationship, provide notice to patients and other affected
40 parties, and terminate the contract pursuant to its original
41 terms.
42 (5) The notice of a material change under this subsection must
2022 IN 1046—LS 6517/DI 137 16
1 be sent in an orange envelope with the phrase "ATTENTION!
2 AGREEMENT AMENDMENT ENCLOSED!" in at least 14
3 point bold font printed on the front of the envelope. This color
4 of envelope must be used for the sole purpose of
5 communicating material changes and may not be used for
6 other types of communication from a health maintenance
7 organization.
8 (f) If a health maintenance organization makes a change to a
9 contract that changes an existing prior authorization,
10 precertification, notification, or referral program, or changes an
11 edit program or specific edits, the health maintenance organization
12 must provide notice of the change to a participating provider not
13 later than fifteen (15) days prior to the change.
14 (g) Any notice required to be mailed under this section must be
15 sent to the participating provider's point of contact, as set forth in
16 the contract. If no point of contact is set forth in the contract, the
17 health maintenance organization must send the notice to the
18 participating provider's place of business, addressed to the
19 participating provider.
2022 IN 1046—LS 6517/DI 137