Indiana 2022 Regular Session

Indiana House Bill HB1046 Compare Versions

Only one version of the bill is available at this time.

Old	New	Differences
1	1
2	2	Introduced Version
3	3	HOUSE BILL No. 1046
4	4	_____
5	5	DIGEST OF INTRODUCED BILL
6	6	Citations Affected: IC 25-1-9.8-20; IC 27-1; IC 27-8; IC 27-13-15.
7	7	Synopsis: Health insurance matters. Requires the commissioner of the
8	8	department of insurance to provide an order directing the
9	9	discontinuance of an illegal, unauthorized, or unsafe practice of an
10	10	insurance company. Provides that a health plan may not require a
11	11	participating provider to seek prior authorization for a particular health
12	12	service if the health plan approved at least 90% of the prior
13	13	authorization requests for the particular health service in the previous
14	14	six month period. Requires a health plan to post notice of a technical
15	15	issue with its claims submission system on the health plan's Internet
16	16	web site. Requires a health plan to post on its Internet web site not later
17	17	than February 1 of each year: (1) the 30 most frequently submitted CPT
18	18	codes in the previous calendar year; and (2) the percentage of the 30
19	19	most frequently submitted CPT codes that were approved in the
20	20	previous calendar year. Requires a health plan to provide annual and
21	21	quarterly financial statements to the department of insurance.
22	22	Establishes an approval process for a health plan's proposed premium
23	23	rate increase of 5% or greater as compared to the previous calendar
24	24	year. Requires an insurer and a health maintenance organization to
25	25	provide a contracted provider with a current reimbursement rate
26	26	schedule: (1) every two years; and (2) when three or more CPT code
27	27	rates change in a 12 month period. Requires an insurer and a health
28	28	maintenance organization to provide a contracted provider with notice
29	29	of a proposed material change to the agreement between the insurer or
30	30	health maintenance organization and the contracted provider at least 90
31	31	days prior to the proposed effective date. Establishes requirements for
32	32	the contents of a notice of a proposed material change. Requires an
33	33	(Continued next page)
34	34	Effective: July 1, 2022.
35	35	Heine
36	36	January 4, 2022, read first time and referred to Committee on Financial Institutions and
37	37	Insurance.
38	38	2022 IN 1046—LS 6517/DI 137 Digest Continued
39	39	insurer or health maintenance organization to provide a contracted
40	40	provider with notice at least 15 days prior to a change to an existing
41	41	prior authorization, precertification, notification, referral program, edit
42	42	program, or specific edits.
43	43	2022 IN 1046—LS 6517/DI 1372022 IN 1046—LS 6517/DI 137 Introduced
44	44	Second Regular Session of the 122nd General Assembly (2022)
45	45	PRINTING CODE. Amendments: Whenever an existing statute (or a section of the Indiana
46	46	Constitution) is being amended, the text of the existing provision will appear in this style type,
47	47	additions will appear in this style type, and deletions will appear in this style type.
48	48	Additions: Whenever a new statutory provision is being enacted (or a new constitutional
49	49	provision adopted), the text of the new provision will appear in this style type. Also, the
50	50	word NEW will appear in that style type in the introductory clause of each SECTION that adds
51	51	a new provision to the Indiana Code or the Indiana Constitution.
52	52	Conflict reconciliation: Text in a statute in this style type or this style type reconciles conflicts
53	53	between statutes enacted by the 2021 Regular Session of the General Assembly.
54	54	HOUSE BILL No. 1046
55	55	A BILL FOR AN ACT to amend the Indiana Code concerning
56	56	insurance.
57	57	Be it enacted by the General Assembly of the State of Indiana:
58	58	1 SECTION 1. IC 25-1-9.8-20 IS ADDED TO THE INDIANA CODE
59	59	2 AS A NEW SECTION TO READ AS FOLLOWS [EFFECTIVE JULY
60	60	3 1, 2022]: Sec. 20. A practitioner may satisfy the requirements of
61	61	4 this chapter by complying with the requirements set forth in
62	62	5 Section 2799B-6 of the federal Public Health Service Act, as added
63	63	6 by Public Law 116-260.
64	64	7 SECTION 2. IC 27-1-3-19 IS AMENDED TO READ AS
65	65	8 FOLLOWS [EFFECTIVE JULY 1, 2022]: Sec. 19. (a) Whenever the
66	66	9 commissioner determines that any insurance company to which this
67	67	10 article is applicable:
68	68	11 (1) is conducting its business contrary to law or in an unsafe or
69	69	12 unauthorized manner;
70	70	13 (2) has had its capital or surplus fund impaired or reduced below
71	71	14 the amount required by law; or
72	72	15 (3) has failed, neglected, or refused to observe and comply with
73	73	2022 IN 1046—LS 6517/DI 137 2
74	74	1 any law, order, or rule of the department or commissioner;
75	75	2 then the commissioner may, shall, by an order in writing addressed to
76	76	3 the board of directors, board of trustees, attorney in fact, partners, or
77	77	4 owners of or in any such insurance company, to direct the
78	78	5 discontinuance of any such illegal, unauthorized, or unsafe practice, the
79	79	6 restoration of an impairment to the capital or the surplus fund, or the
80	80	7 compliance with any such law, order, or rule of the department or
81	81	8 commissioner. The order shall be mailed to the last known principal
82	82	9 office of the insurance company by certified or registered mail or
83	83	10 delivered to an officer of the company and shall be considered to be
84	84	11 received by the insurance company three (3) days after mailing or on
85	85	12 the date of delivery.
86	86	13 (b) If the insurance company fails, neglects, or refuses to comply
87	87	14 with the terms of that order within thirty (30) days after its receipt by
88	88	15 the insurance company, or within a shorter period set out in the order
89	89	16 if the commissioner determines that an emergency exists, the
90	90	17 commissioner may, in addition to any other remedy conferred upon the
91	91	18 department or the commissioner by law, bring an action against any
92	92	19 such insurance company, its officers, and agents to compel that
93	93	20 compliance.
94	94	21 (c) The action shall be brought by the commissioner in the Marion
95	95	22 County circuit court. The action shall be commenced and prosecuted
96	96	23 in accordance with the Indiana Rules of Trial Procedure, and relief for
97	97	24 noncompliance of the order includes any remedy appropriate under the
98	98	25 facts, including injunction, preliminary injunction, and temporary
99	99	26 restraining order. In that action, a change of venue from the judge, but
100	100	27 no change of venue from the county, is permitted.
101	101	28 SECTION 3. IC 27-1-37.5-10, AS ADDED BY P.L.208-2018,
102	102	29 SECTION 8, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE
103	103	30 JULY 1, 2022]: Sec. 10. (a) This section applies to a request for prior
104	104	31 authorization delivered to a health plan after December 31, 2019.
105	105	32 (b) A health plan shall accept a request for prior authorization
106	106	33 delivered to the health plan by a covered individual's health care
107	107	34 provider through a secure electronic transmission. A health care
108	108	35 provider shall submit a request for prior authorization through a secure
109	109	36 electronic transmission. A health plan shall provide for:
110	110	37 (1) a secure electronic transmission; and
111	111	38 (2) acknowledgment of receipt, by use of a transaction number or
112	112	39 another reference code;
113	113	40 of a request for prior authorization and any supporting information.
114	114	41 (c) Subsection (b) does not apply and a health plan that requires
115	115	42 prior authorization shall accept a request for prior authorization that is
116	116	2022 IN 1046—LS 6517/DI 137 3
117	117	1 not submitted through a secure electronic transmission if a covered
118	118	2 individual's health care provider and the health plan have entered into
119	119	3 an agreement under which the health plan agrees to process prior
120	120	4 authorization requests that are not submitted through a secure
121	121	5 electronic transmission because:
122	122	6 (1) secure electronic transmission of prior authorization requests
123	123	7 would cause financial hardship for the health care provider;
124	124	8 (2) the area in which the health care provider is located lacks
125	125	9 sufficient Internet access; or
126	126	10 (3) the health care provider has an insufficient number of covered
127	127	11 individuals as patients or customers, as determined by the
128	128	12 commissioner, to warrant the financial expense that compliance
129	129	13 with subsection (b) would require.
130	130	14 (d) If a covered individual's health care provider is described in
131	131	15 subsection (c), the health plan shall accept from the health care
132	132	16 provider a request for prior authorization as follows:
133	133	17 (1) The prior authorization request must be made on the
134	134	18 standardized prior authorization form established by the
135	135	19 department under section 16 of this chapter.
136	136	20 (2) The health plan shall provide for secure electronic
137	137	21 transmission and acknowledgement acknowledgment of receipt
138	138	22 of the standardized prior authorization form and any supporting
139	139	23 information for the prior authorization by use of a transaction
140	140	24 number or another reference code.
141	141	25 (e) A health plan that utilizes a third party to review requests
142	142	26 for prior authorization:
143	143	27 (1) may not require a covered individual's health care
144	144	28 provider to submit a request for prior authorization to the
145	145	29 third party; and
146	146	30 (2) must transmit a request for prior authorization provided
147	147	31 by a covered individual's health care provider through secure
148	148	32 electronic transmission to the third party.
149	149	33 SECTION 4. IC 27-1-37.5-13.5 IS ADDED TO THE INDIANA
150	150	34 CODE AS A NEW SECTION TO READ AS FOLLOWS
151	151	35 [EFFECTIVE JULY 1, 2022]: Sec. 13.5. (a) A health plan may not
152	152	36 require a participating provider to obtain prior authorization for
153	153	37 a particular health care service if, in the most recent six (6) month
154	154	38 period, the health plan has approved at least ninety percent (90%)
155	155	39 of the prior authorization requests submitted by the participating
156	156	40 provider for the particular health care service.
157	157	41 (b) A health plan must update a participating provider not later
158	158	42 than January 1 and July 1 of each calendar year of the particular
159	159	2022 IN 1046—LS 6517/DI 137 4
160	160	1 health care services that do not require prior authorization for the
161	161	2 following six (6) month period under subsection (a).
162	162	3 (c) A health plan may rescind a participating provider's
163	163	4 exemption from obtaining prior authorization for a particular
164	164	5 health care service under subsection (a) if the health plan makes a
165	165	6 determination, on the basis of a retrospective review of a random
166	166	7 sample of not less than five (5) and no more than twenty (20) claims
167	167	8 submitted by the participating provider during the most recent six
168	168	9 (6) month period, that less than ninety percent (90%) of the claims
169	169	10 for the particular health care service met the medical necessity
170	170	11 criteria that would have been used by the health plan when
171	171	12 conducting prior authorization review for the particular health
172	172	13 care service during the relevant six (6) month period. Nothing in
173	173	14 this subsection prohibits a participating provider from qualifying
174	174	15 for an exemption from obtaining prior authorization for a
175	175	16 particular health care service in a future six (6) month period as
176	176	17 provided for in subsection (a), even if an exemption was previously
177	177	18 rescinded.
178	178	19 (d) A rescission by a health plan under subsection (c) must:
179	179	20 (1) be provided to the participating provider in writing not
180	180	21 less than thirty (30) calendar days prior to the effective date
181	181	22 of the rescission;
182	182	23 (2) include documentation of the random sample of claims;
183	183	24 and
184	184	25 (3) include information on how the participating provider
185	185	26 may appeal the rescission.
186	186	27 (e) If an exemption from obtaining prior authorization for a
187	187	28 particular health care service granted under subsection (a) is
188	188	29 rescinded by a health plan following review under subsection (c),
189	189	30 a participating provider may appeal the rescission. After reviewing
190	190	31 any supporting documentation submitted by the participating
191	191	32 provider with the appeal, a health plan must make a decision on
192	192	33 the appeal and provide the decision to the participating provider
193	193	34 in writing not later than fourteen (14) calendar days after the
194	194	35 health plan receives notice of the appeal.
195	195	36 SECTION 5. IC 27-1-46-18 IS ADDED TO THE INDIANA CODE
196	196	37 AS A NEW SECTION TO READ AS FOLLOWS [EFFECTIVE JULY
197	197	38 1, 2022]: Sec. 18. A provider facility may satisfy the requirements
198	198	39 of this chapter by complying with the requirements set forth in
199	199	40 Section 2799B-6 of the federal Public Health Service Act, as added
200	200	41 by Public Law 116-260.
201	201	42 SECTION 6. IC 27-1-48 IS ADDED TO THE INDIANA CODE AS
202	202	2022 IN 1046—LS 6517/DI 137 5
203	203	1 A NEW CHAPTER TO READ AS FOLLOWS [EFFECTIVE JULY
204	204	2 1, 2022]:
205	205	3 Chapter 48. Health Plan Transparency
206	206	4 Sec. 1. As used in this chapter, "covered individual" means an
207	207	5 individual who is entitled to coverage under a health plan.
208	208	6 Sec. 2. As used in this chapter, "CPT code" refers to the medical
209	209	7 billing code that applies to a specific health care service, as
210	210	8 published in the Current Procedural Terminology code set
211	211	9 maintained by the American Medical Association.
212	212	10 Sec. 3. (a) As used in this chapter, "health care service" means
213	213	11 a health care related service or product rendered or sold by a
214	214	12 health care provider within the scope of the health care provider's
215	215	13 license or legal authorization, including hospital, medical, surgical,
216	216	14 mental health, and substance abuse services or products.
217	217	15 (b) The term does not include the following:
218	218	16 (1) Dental services.
219	219	17 (2) Vision services.
220	220	18 (3) Long term rehabilitation treatment.
221	221	19 (4) Pharmaceutical services or products.
222	222	20 Sec. 4. (a) As used in this chapter, "health plan" means any of
223	223	21 the following that provides coverage for health care services:
224	224	22 (1) A policy of accident and sickness insurance (as defined in
225	225	23 IC 27-8-5-1). However, the term does not include the
226	226	24 coverages described in IC 27-8-5-2.5(a).
227	227	25 (2) A contract with a health maintenance organization (as
228	228	26 defined in IC 27-13-1-19) that provides coverage for basic
229	229	27 health care services (as defined in IC 27-13-1-4).
230	230	28 (3) The Medicaid risk based managed care program under
231	231	29 IC 12-15.
232	232	30 (b) The term includes a person that administers any of the
233	233	31 following:
234	234	32 (1) A policy described in subsection (a)(1).
235	235	33 (2) A contract described in subsection (a)(2).
236	236	34 (3) Medicaid risk based managed care.
237	237	35 Sec. 5. As used in this chapter, "participating provider" refers
238	238	36 to the following:
239	239	37 (1) A health care provider that has entered into an agreement
240	240	38 with an insurer under IC 27-8-11-3.
241	241	39 (2) A participating provider (as defined in IC 27-13-1-24).
242	242	40 Sec. 6. As used in this chapter, "prior authorization" means a
243	243	41 practice implemented by a health plan through which coverage of
244	244	42 a health care service is dependent on the covered individual or
245	245	2022 IN 1046—LS 6517/DI 137 6
246	246	1 health care provider obtaining approval from the health plan
247	247	2 before the health care service is rendered. The term includes
248	248	3 prospective or utilization review procedures conducted before a
249	249	4 health care service is rendered.
250	250	5 Sec. 7. (a) Within twenty-four (24) hours of the identification of
251	251	6 a technical issue with a health plan's claims submission system that
252	252	7 would require a participating provider to submit a second claim
253	253	8 for the same health care service, the health plan must post notice
254	254	9 of the technical issue on the health plan's Internet web site.
255	255	10 (b) When a technical issue that was posted under subsection (a)
256	256	11 is resolved, the health plan must post an update on the resolution
257	257	12 of the technical issue on the health plan's Internet web site for not
258	258	13 less than seventy-two (72) hours.
259	259	14 Sec. 8. (a) Not later than February 1 of each calendar year, a
260	260	15 health plan must post on the health plan's Internet web site:
261	261	16 (1) the thirty (30) most frequently submitted CPT codes that
262	262	17 were submitted by participating providers for prior
263	263	18 authorization during the previous calendar year; and
264	264	19 (2) the percentage of the thirty (30) most frequently submitted
265	265	20 CPT codes that were approved in the previous calendar year,
266	266	21 disaggregated by CPT code.
267	267	22 (b) A health plan must maintain the information required under
268	268	23 subsection (a) on the health plan's Internet web site, organized by
269	269	24 year and on a single and easily accessible web page.
270	270	25 Sec. 9. (a) A health plan must file with the department:
271	271	26 (1) not later than February 1 of each calendar year, the
272	272	27 amount of administrative fees charged by the health plan for
273	273	28 each administrative service only contract for self-insured
274	274	29 health plans, disaggregated by each contract, from the
275	275	30 previous calendar year;
276	276	31 (2) not later than March 1 of each calendar year, the health
277	277	32 plan's annual financial statement from the previous calendar
278	278	33 year;
279	279	34 (3) not later than May 15 of each calendar year, the health
280	280	35 plan's first quarter financial statement from the current
281	281	36 calendar year;
282	282	37 (4) not later than August 15 of each calendar year, the health
283	283	38 plan's second quarter financial statement from the current
284	284	39 calendar year; and
285	285	40 (5) not later than November 15 of each calendar year, the
286	286	41 health plan's third quarter financial statement from the
287	287	42 current calendar year.
288	288	2022 IN 1046—LS 6517/DI 137 7
289	289	1 (b) The department must post the information filed under
290	290	2 subsection (a) not later than ten (10) business days after receiving
291	291	3 the information on the department's Internet web site on a single
292	292	4 and easily accessible web page.
293	293	5 SECTION 7. IC 27-8-4-8 IS AMENDED TO READ AS FOLLOWS
294	294	6 [EFFECTIVE JULY 1, 2022]: Sec. 8. A. (a) Except as provided in
295	295	7 section 8.5 of this chapter, any insurer may revise its schedules of
296	296	8 premium rates from time to time, and shall file such revised schedules
297	297	9 with the commissioner. No insurer shall issue any credit life insurance
298	298	10 policy or credit accident and health insurance policy for which the
299	299	11 premium rate exceeds that determined by the schedules of such insurer
300	300	12 as then on file with the commissioner.
301	301	13 B. (b) Each individual policy, or group certificate shall provide that
302	302	14 in the event of termination of the insurance prior to the scheduled
303	303	15 maturity date of the indebtedness, any refund of an amount paid by the
304	304	16 debtor for insurance shall be paid or credited promptly to the person
305	305	17 entitled thereto; Provided, however, That the commissioner shall
306	306	18 prescribe a minimum refund and no refund which would be less than
307	307	19 such minimum need be made. The formula to be used in computing
308	308	20 such refund shall be filed with and approved by the commissioner.
309	309	21 C. (c) If a creditor requires a debtor to make any payment for credit
310	310	22 life insurance or credit accident and health insurance and an individual
311	311	23 policy or group certificate of insurance is not issued, the creditor shall
312	312	24 immediately give written notice to such debtor and shall promptly
313	313	25 make an appropriate credit to the account.
314	314	26 D. (d) The amount charged to a debtor for any credit life or credit
315	315	27 health and accident insurance shall not exceed the premiums charged
316	316	28 by the insurer, as computed at the time the charge to the debtor is
317	317	29 determined.
318	318	30 SECTION 8. IC 27-8-4-8.5 IS ADDED TO THE INDIANA CODE
319	319	31 AS A NEW SECTION TO READ AS FOLLOWS [EFFECTIVE JULY
320	320	32 1, 2022]: Sec. 8.5. (a) If the premium rate for a health insurance
321	321	33 policy will increase five percent (5%) or greater as compared to
322	322	34 the previous calendar year:
323	323	35 (1) the insurer must submit:
324	324	36 (A) the planned premium rate increase; and
325	325	37 (B) written justification for the planned premium rate
326	326	38 increase;
327	327	39 to the commissioner or the commissioner's designee for
328	328	40 review and approval prior to the planned premium rate
329	329	41 increase going into effect. The department must post the
330	330	42 written justification for the planned premium rate increase on
331	331	2022 IN 1046—LS 6517/DI 137 8
332	332	1 the department's Internet web site not later than ten (10)
333	333	2 calendar days after receiving the written justification for the
334	334	3 planned premium rate increase;
335	335	4 (2) after reviewing the insurer's written justification for the
336	336	5 planned premium rate increase, the commissioner or the
337	337	6 commissioner's designee must approve or deny the insurer's
338	338	7 planned premium rate increase in writing within twenty (20)
339	339	8 calendar days;
340	340	9 (3) if the insurer's planned premium rate increase is denied by
341	341	10 the commissioner or the commissioner's designee under
342	342	11 subdivision (2), the insurer may submit:
343	343	12 (A) a lower planned premium rate increase; and
344	344	13 (B) written justification for the lower planned premium
345	345	14 rate increase;
346	346	15 to the commissioner or the commissioner's designee for
347	347	16 review and approval prior to the lower planned premium rate
348	348	17 increase going into effect. The department must post the
349	349	18 written justification for the lower planned premium rate
350	350	19 increase on the department's Internet web site not later than
351	351	20 ten (10) calendar days after receiving the written justification
352	352	21 for the planned premium rate increase;
353	353	22 (4) after reviewing the insurer's written justification for the
354	354	23 lower planned premium rate increase, the commissioner or
355	355	24 the commissioner's designee must approve or deny the
356	356	25 insurer's lower planned premium rate increase in writing
357	357	26 within twenty (20) calendar days; and
358	358	27 (5) if the commissioner or the commissioner's designee denies
359	359	28 an insurer's lower planned premium rate increase submitted
360	360	29 under subdivision (3), the insurer may not increase the
361	361	30 premium rate five percent (5%) or more for that calendar
362	362	31 year.
363	363	32 (b) If an insurer's planned premium rate increase of five percent
364	364	33 (5%) or more is approved under subsection (a)(2) or (a)(4), the
365	365	34 insurer must provide written justification of the premium rate
366	366	35 increase to an individual or entity covered by the health insurance
367	367	36 policy not less than thirty (30) days prior to the premium rate
368	368	37 increase going into effect.
369	369	38 SECTION 9. IC 27-8-5.7-2.5 IS ADDED TO THE INDIANA
370	370	39 CODE AS A NEW SECTION TO READ AS FOLLOWS
371	371	40 [EFFECTIVE JULY 1, 2022]: Sec. 2.5. As used in this chapter, "CPT
372	372	41 code" refers to the medical billing code that applies to a specific
373	373	42 health care service, as published in the Current Procedural
374	374	2022 IN 1046—LS 6517/DI 137 9
375	375	1 Terminology code set maintained by the American Medical
376	376	2 Association.
377	377	3 SECTION 10. IC 27-8-5.7-5 IS AMENDED TO READ AS
378	378	4 FOLLOWS [EFFECTIVE JULY 1, 2022]: Sec. 5. (a) An insurer shall
379	379	5 pay or deny each clean claim in accordance with section sections 6 and
380	380	6 6.5 of this chapter.
381	381	7 (b) An insurer shall notify a provider of any deficiencies in a
382	382	8 submitted claim not more than:
383	383	9 (1) thirty (30) days for a claim that is filed electronically; or
384	384	10 (2) forty-five (45) days for a claim that is filed on paper;
385	385	11 and describe any remedy necessary to establish a clean claim.
386	386	12 (c) Failure of an insurer to notify a provider as required under
387	387	13 subsection (b) establishes the submitted claim as a clean claim.
388	388	14 SECTION 11. IC 27-8-5.7-6.5 IS ADDED TO THE INDIANA
389	389	15 CODE AS A NEW SECTION TO READ AS FOLLOWS
390	390	16 [EFFECTIVE JULY 1, 2022]: Sec. 6.5. (a) An insurer may not:
391	391	17 (1) alter the CPT code submitted for a clean claim; and
392	392	18 (2) pay for a CPT code of lesser monetary value;
393	393	19 unless the medical record of the clean claim has been reviewed by
394	394	20 an employee of the insurer who is licensed under IC 25-22.5. An
395	395	21 employee of an insurer who is licensed under IC 25-22.5 and
396	396	22 reviews medical records under this subsection is subject to review
397	397	23 by the medical licensing board created by IC 25-22.5-2-1 for
398	398	24 violations of the standards for the competent practice of medicine.
399	399	25 (b) An insurer may not deny payment for a clean claim based
400	400	26 solely on the location of the service, if the location of the service is
401	401	27 in the contracted network of the insurer.
402	402	28 (c) An insurer may not alter a clean claim to only pay for the
403	403	29 CPT codes necessary for an individual's final diagnosis, if the CPT
404	404	30 codes billed were deemed medically necessary to reach the final
405	405	31 diagnosis.
406	406	32 SECTION 12. IC 27-8-11-3 IS AMENDED TO READ AS
407	407	33 FOLLOWS [EFFECTIVE JULY 1, 2022]: Sec. 3. (a) An insurer may:
408	408	34 (1) enter into agreements with providers relating to terms and
409	409	35 conditions of reimbursement for health care services that may be
410	410	36 rendered to insureds of the insurer, including agreements relating
411	411	37 to the amounts to be charged the insured for services rendered or
412	412	38 the terms and conditions for activities intended to reduce
413	413	39 inappropriate care;
414	414	40 (2) issue or administer policies in this state that include incentives
415	415	41 for the insured to utilize the services of a provider that has entered
416	416	42 into an agreement with the insurer under subdivision (1); and
417	417	2022 IN 1046—LS 6517/DI 137 10
418	418	1 (3) issue or administer policies in this state that provide for
419	419	2 reimbursement for expenses of health care services only if the
420	420	3 services have been rendered by a provider that has entered into an
421	421	4 agreement with the insurer under subdivision (1).
422	422	5 (b) Before entering into any agreement under subsection (a)(1), an
423	423	6 insurer shall establish terms and conditions that must be met by
424	424	7 providers wishing to enter into an agreement with the insurer under
425	425	8 subsection (a)(1). These terms and conditions may not discriminate
426	426	9 unreasonably against or among providers. For the purposes of this
427	427	10 subsection, neither differences in prices among hospitals or other
428	428	11 institutional providers produced by a process of individual negotiation
429	429	12 nor price differences among other providers in different geographical
430	430	13 areas or different specialties constitutes unreasonable discrimination.
431	431	14 Upon request by a provider seeking to enter into an agreement with an
432	432	15 insurer under subsection (a)(1), the insurer shall make available to the
433	433	16 provider a written statement of the terms and conditions that must be
434	434	17 met by providers wishing to enter into an agreement with the insurer
435	435	18 under subsection (a)(1).
436	436	19 (c) No hospital, physician, pharmacist, or other provider designated
437	437	20 in IC 27-8-6-1 willing to meet the terms and conditions of agreements
438	438	21 described in this section may be denied the right to enter into an
439	439	22 agreement under subsection (a)(1). When an insurer denies a provider
440	440	23 the right to enter into an agreement with the insurer under subsection
441	441	24 (a)(1) on the grounds that the provider does not satisfy the terms and
442	442	25 conditions established by the insurer for providers entering into
443	443	26 agreements with the insurer, the insurer shall provide the provider with
444	444	27 a written notice that:
445	445	28 (1) explains the basis of the insurer's denial; and
446	446	29 (2) states the specific terms and conditions that the provider, in
447	447	30 the opinion of the insurer, does not satisfy.
448	448	31 (d) In no event may an insurer deny or limit reimbursement to an
449	449	32 insured under this chapter on the grounds that the insured was not
450	450	33 referred to the provider by a person acting on behalf of or under an
451	451	34 agreement with the insurer.
452	452	35 (e) No cause of action shall arise against any person or insurer for:
453	453	36 (1) disclosing information as required by this section; or
454	454	37 (2) the subsequent use of the information by unauthorized
455	455	38 individuals.
456	456	39 Nor shall such a cause of action arise against any person or provider for
457	457	40 furnishing personal or privileged information to an insurer. However,
458	458	41 this subsection provides no immunity for disclosing or furnishing false
459	459	42 information with malice or willful intent to injure any person, provider,
460	460	2022 IN 1046—LS 6517/DI 137 11
461	461	1 or insurer.
462	462	2 (f) Nothing in this chapter abrogates the privileges and immunities
463	463	3 established in IC 34-30-15 (or IC 34-4-12.6 before its repeal).
464	464	4 (g) An insurer that enters into an agreement with a provider
465	465	5 under subsection (a)(1) must provide the provider a current
466	466	6 reimbursement rate schedule:
467	467	7 (1) every two (2) years; and
468	468	8 (2) when three (3) or more CPT code (as defined in
469	469	9 IC 27-1-37.5-3) rates under the agreement are changed in a
470	470	10 twelve (12) month period.
471	471	11 SECTION 13. IC 27-8-11-14 IS ADDED TO THE INDIANA
472	472	12 CODE AS A NEW SECTION TO READ AS FOLLOWS
473	473	13 [EFFECTIVE JULY 1, 2022]: Sec. 14. (a) As used in this section,
474	474	14 "contracted provider" means a provider that has entered into an
475	475	15 agreement with an insurer under section 3 of this chapter.
476	476	16 (b) As used in this section, "material change" means a change
477	477	17 to an agreement between a contracted provider and an insurer
478	478	18 under section 3 of this chapter, the occurrence and timing of which
479	479	19 are not otherwise clearly identified in the agreement, that:
480	480	20 (1) decreases the contracted provider's payment or
481	481	21 compensation; or
482	482	22 (2) changes the administrative procedures in a way that may
483	483	23 reasonably be expected to significantly increase the
484	484	24 contracted provider's administrative expense.
485	485	25 The term includes changes to network requirements and inclusion
486	486	26 in any new or modified insurance products.
487	487	27 (c) Each insurer offering a preferred provider plan must
488	488	28 establish procedures for modifying an existing agreement with a
489	489	29 contracted provider that meet the requirements of this section.
490	490	30 (d) If an insurer offering a preferred provider plan intends to
491	491	31 make a material change to an agreement it has entered into with a
492	492	32 contracted provider under section 3 of this chapter, the insurer
493	493	33 must provide the contracted provider with notice at least ninety
494	494	34 (90) days prior to the proposed effective date of the material
495	495	35 change. The notice must include:
496	496	36 (1) the proposed effective date of the material change;
497	497	37 (2) a description of the material change;
498	498	38 (3) a statement that the contracted provider has the option to
499	499	39 either accept or reject the material change under this section;
500	500	40 (4) the name, business address, telephone number, and
501	501	41 electronic mail address of a representative of the insurer who
502	502	42 may discuss the material change, if requested by the
503	503	2022 IN 1046—LS 6517/DI 137 12
504	504	1 contracted provider;
505	505	2 (5) notice of the opportunity to request a meeting using real
506	506	3 time communication or to communicate via electronic mail to
507	507	4 discuss the material change, if requested by the contracted
508	508	5 provider; and
509	509	6 (6) notice that upon three (3) material changes in a twelve (12)
510	510	7 month period, the contracted provider may request a copy of
511	511	8 the agreement with the material changes incorporated into it.
512	512	9 Provision of a copy of the agreement by the insurer is for
513	513	10 informational purposes only and does not affect the terms and
514	514	11 conditions of the agreement.
515	515	12 (e) If a proposed material change relates to the contracted
516	516	13 provider's inclusion in any new or modified insurance products or
517	517	14 proposes changes to the contracted provider's networks:
518	518	15 (1) the material change will only take effect upon the
519	519	16 acceptance of the contracted provider, evidenced by a written
520	520	17 signature; and
521	521	18 (2) the notice of the material change must be sent by certified
522	522	19 mail, return receipt requested.
523	523	20 (f) For any other proposed material change not addressed in
524	524	21 subsection (e), the following requirements apply:
525	525	22 (1) The material change must take effect on the date provided
526	526	23 in the notice, unless the contracted provider objects to the
527	527	24 change under subdivision (2).
528	528	25 (2) A contracted provider who wishes to object to a material
529	529	26 change under this subsection must do so in writing, and the
530	530	27 written protest must be delivered not later than thirty (30)
531	531	28 days after the date the contracted provider receives notice of
532	532	29 the material change.
533	533	30 (3) Not later than thirty (30) days after the insurer receives
534	534	31 the contracted provider's objection under subdivision (2), the
535	535	32 insurer and the contracted provider must confer in an effort
536	536	33 to reach an agreement on the material change or any counter
537	537	34 proposals offered by the contracted provider.
538	538	35 (4) If the insurer and the contracted provider fail to reach an
539	539	36 agreement during the thirty (30) day period as described in
540	540	37 subdivision (3), the insurer and the contracted provider are
541	541	38 allowed thirty (30) days to unwind their relationship, provide
542	542	39 notice to patients and other affected parties, and terminate
543	543	40 the agreement pursuant to its original terms.
544	544	41 (5) The notice of a material change under this subsection must
545	545	42 be sent in an orange envelope with the phrase "ATTENTION!
546	546	2022 IN 1046—LS 6517/DI 137 13
547	547	1 AGREEMENT AMENDMENT ENCLOSED!" in at least 14
548	548	2 point bold font printed on the front of the envelope. This color
549	549	3 of envelope must be used for the sole purpose of
550	550	4 communicating material changes and may not be used for
551	551	5 other types of communication from an insurer.
552	552	6 (g) If an insurer offering a preferred provider plan makes a
553	553	7 change to an agreement that changes an existing prior
554	554	8 authorization, precertification, notification, or referral program,
555	555	9 or changes an edit program or specific edits, the insurer must
556	556	10 provide notice of the change to a contracted provider not later than
557	557	11 fifteen (15) days prior to the change.
558	558	12 (h) Any notice required to be mailed under this section must be
559	559	13 sent to the contracted provider's point of contact, as set forth in the
560	560	14 agreement. If no point of contact is set forth in the agreement, the
561	561	15 insurer must send the notice to the contracted provider's place of
562	562	16 business, addressed to the contracted provider.
563	563	17 SECTION 14. IC 27-13-15-1 IS AMENDED TO READ AS
564	564	18 FOLLOWS [EFFECTIVE JULY 1, 2022]: Sec. 1. (a) A contract
565	565	19 between a health maintenance organization and a participating provider
566	566	20 of health care services:
567	567	21 (1) must be in writing;
568	568	22 (2) may not prohibit the participating provider from disclosing:
569	569	23 (A) the terms of the contract as it relates to financial or other
570	570	24 incentives to limit medical services by the participating
571	571	25 provider; or
572	572	26 (B) all treatment options available to an insured, including
573	573	27 those not covered by the insured's policy;
574	574	28 (3) may not provide for a financial or other penalty to a provider
575	575	29 for making a disclosure permitted under subdivision (2); and
576	576	30 (4) must provide that in the event the health maintenance
577	577	31 organization fails to pay for health care services as specified by
578	578	32 the contract, the subscriber or enrollee is not liable to the
579	579	33 participating provider for any sums owed by the health
580	580	34 maintenance organization.
581	581	35 (b) An enrollee is not entitled to coverage of a health care service
582	582	36 under a group or an individual contract unless that health care service
583	583	37 is included in the enrollee's contract.
584	584	38 (c) A provider is not entitled to payment under a contract for health
585	585	39 care services provided to an enrollee unless the provider has a contract
586	586	40 or an agreement with the carrier.
587	587	41 (d) A health maintenance organization that enters into a
588	588	42 contract with a participating provider must provide the
589	589	2022 IN 1046—LS 6517/DI 137 14
590	590	1 participating provider with a current reimbursement rate
591	591	2 schedule:
592	592	3 (1) every two (2) years; and
593	593	4 (2) when three (3) or more CPT code (as defined in
594	594	5 IC 27-1-37.5-3) rates under the contract change in a twelve
595	595	6 (12) month period.
596	596	7 (d) This section applies to a contract entered, renewed, or modified
597	597	8 after June 30, 1996.
598	598	9 SECTION 15. IC 27-13-15-7 IS ADDED TO THE INDIANA
599	599	10 CODE AS A NEW SECTION TO READ AS FOLLOWS
600	600	11 [EFFECTIVE JULY 1, 2022]: Sec. 7. (a) As used in this section,
601	601	12 "material change" means a change to a contract between a
602	602	13 participating provider and a health maintenance organization, the
603	603	14 occurrence and timing of which are not otherwise clearly identified
604	604	15 in the contract, that:
605	605	16 (1) decreases the participating provider's payment or
606	606	17 compensation; or
607	607	18 (2) changes the administrative procedures in a way that may
608	608	19 reasonably be expected to significantly increase the
609	609	20 participating provider's administrative expense.
610	610	21 The term includes changes to network requirements and inclusion
611	611	22 in any new or modified insurance products.
612	612	23 (b) A health maintenance organization must establish
613	613	24 procedures for modifying an existing contract with a participating
614	614	25 provider that meet the requirements of this section.
615	615	26 (c) If a health maintenance organization intends to make a
616	616	27 material change to a contract it has entered into with a
617	617	28 participating provider under section 1 of this chapter, the health
618	618	29 maintenance organization must provide the participating provider
619	619	30 with notice at least ninety (90) days prior to the proposed effective
620	620	31 date of the material change. The notice must include:
621	621	32 (1) the proposed effective date of the material change;
622	622	33 (2) a description of the material change;
623	623	34 (3) a statement that the participating provider has the option
624	624	35 to either accept or reject the material change under this
625	625	36 section;
626	626	37 (4) the name, business address, telephone number, and
627	627	38 electronic mail address of a representative of the health
628	628	39 maintenance organization who may discuss the material
629	629	40 change, if requested by the participating provider;
630	630	41 (5) notice of the opportunity to request a meeting using real
631	631	42 time communication or to communicate via electronic mail to
632	632	2022 IN 1046—LS 6517/DI 137 15
633	633	1 discuss the material change, if requested by the participating
634	634	2 provider; and
635	635	3 (6) notice that upon three (3) material changes in a twelve (12)
636	636	4 month period, the participating provider may request a copy
637	637	5 of the contract with the material changes incorporated into it.
638	638	6 Provision of a copy of the contract by the health maintenance
639	639	7 organization is for informational purposes only and does not affect
640	640	8 the terms and conditions of the contract.
641	641	9 (d) If a proposed material change relates to a participating
642	642	10 provider's inclusion in any new or modified insurance products or
643	643	11 proposes changes to a participating provider's networks:
644	644	12 (1) the material change will only take effect upon the
645	645	13 acceptance of the participating provider, evidenced by a
646	646	14 written signature; and
647	647	15 (2) the notice of the material change must be sent by certified
648	648	16 mail, return receipt requested.
649	649	17 (e) For any other proposed material change not addressed in
650	650	18 subsection (d), the following requirements apply:
651	651	19 (1) The material change must take effect on the date provided
652	652	20 in the notice, unless the participating provider objects to the
653	653	21 change under subdivision (2).
654	654	22 (2) A participating provider who wishes to object to a
655	655	23 material change under this subsection must do so in writing,
656	656	24 and the written protest must be delivered not later than thirty
657	657	25 (30) days after the date the participating provider receives
658	658	26 notice of the material change.
659	659	27 (3) Not later than thirty (30) days after the health
660	660	28 maintenance organization receives the participating
661	661	29 provider's objection under subdivision (2), the health
662	662	30 maintenance organization and the participating provider
663	663	31 must confer in an effort to reach an agreement on the
664	664	32 material change or any counter proposals offered by the
665	665	33 participating provider.
666	666	34 (4) If the health maintenance organization and the
667	667	35 participating provider fail to reach an agreement during the
668	668	36 thirty (30) day period as described in subdivision (3), the
669	669	37 health maintenance organization and the participating
670	670	38 provider are allowed thirty (30) days to unwind their
671	671	39 relationship, provide notice to patients and other affected
672	672	40 parties, and terminate the contract pursuant to its original
673	673	41 terms.
674	674	42 (5) The notice of a material change under this subsection must
675	675	2022 IN 1046—LS 6517/DI 137 16
676	676	1 be sent in an orange envelope with the phrase "ATTENTION!
677	677	2 AGREEMENT AMENDMENT ENCLOSED!" in at least 14
678	678	3 point bold font printed on the front of the envelope. This color
679	679	4 of envelope must be used for the sole purpose of
680	680	5 communicating material changes and may not be used for
681	681	6 other types of communication from a health maintenance
682	682	7 organization.
683	683	8 (f) If a health maintenance organization makes a change to a
684	684	9 contract that changes an existing prior authorization,
685	685	10 precertification, notification, or referral program, or changes an
686	686	11 edit program or specific edits, the health maintenance organization
687	687	12 must provide notice of the change to a participating provider not
688	688	13 later than fifteen (15) days prior to the change.
689	689	14 (g) Any notice required to be mailed under this section must be
690	690	15 sent to the participating provider's point of contact, as set forth in
691	691	16 the contract. If no point of contact is set forth in the contract, the
692	692	17 health maintenance organization must send the notice to the
693	693	18 participating provider's place of business, addressed to the
694	694	19 participating provider.
695	695	2022 IN 1046—LS 6517/DI 137