Indiana 2024 Regular Session

Indiana House Bill HB1091 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. 1091
4	4	_____
5	5	DIGEST OF INTRODUCED BILL
6	6	Citations Affected: IC 27-1-37.7.
7	7	Synopsis: Prior authorization. Requires, on or after January 1, 2026,
8	8	health plans (plan) to allow health professionals who have at least an
9	9	85% approval rate of prior authorization requests through a plan to
10	10	receive a one year exemption from the plan's prior authorization
11	11	requirements. Provides that health professionals have a right to an
12	12	appeal of a prior authorization denial or rescission. Provides that the
13	13	appeal is to be conducted by a health professional of the same or
14	14	similar specialty as the health professional who has or is being
15	15	considered for an exemption.
16	16	Effective: July 1, 2024.
17	17	Pressel
18	18	January 8, 2024, read first time and referred to Committee on Insurance.
19	19	2024 IN 1091—LS 6636/DI 154 Introduced
20	20	Second Regular Session of the 123rd General Assembly (2024)
21	21	PRINTING CODE. Amendments: Whenever an existing statute (or a section of the Indiana
22	22	Constitution) is being amended, the text of the existing provision will appear in this style type,
23	23	additions will appear in this style type, and deletions will appear in this style type.
24	24	Additions: Whenever a new statutory provision is being enacted (or a new constitutional
25	25	provision adopted), the text of the new provision will appear in this style type. Also, the
26	26	word NEW will appear in that style type in the introductory clause of each SECTION that adds
27	27	a new provision to the Indiana Code or the Indiana Constitution.
28	28	Conflict reconciliation: Text in a statute in this style type or this style type reconciles conflicts
29	29	between statutes enacted by the 2023 Regular Session of the General Assembly.
30	30	HOUSE BILL No. 1091
31	31	A BILL FOR AN ACT to amend the Indiana Code concerning
32	32	insurance.
33	33	Be it enacted by the General Assembly of the State of Indiana:
34	34	1 SECTION 1. IC 27-1-37.7 IS ADDED TO THE INDIANA CODE
35	35	2 AS A NEW CHAPTER TO READ AS FOLLOWS [EFFECTIVE
36	36	3 JULY 1, 2024]:
37	37	4 Chapter 37.7. Prior Authorization Exemption
38	38	5 Sec. 1. (a) This chapter does not:
39	39	6 (1) apply to prior authorization that is delegated by a health
40	40	7 plan to a risk-bearing organization;
41	41	8 (2) require a health plan to perform prior authorization that
42	42	9 has otherwise been delegated to a risk-bearing organization;
43	43	10 or
44	44	11 (3) apply to vision only and dental only health plans and
45	45	12 coverage.
46	46	13 (b) This chapter applies to the following:
47	47	14 (1) A pharmacy benefit manager under contract with a health
48	48	15 plan to administer prior authorization for prescription drugs.
49	49	16 (2) All product types offered by the health plan that are
50	50	17 regulated by the department, but including Medicaid
51	51	2024 IN 1091—LS 6636/DI 154 2
52	52	1 managed care plans only to the extent permissible under
53	53	2 federal law.
54	54	3 Sec. 2. As used in this chapter, "health care entity" means a:
55	55	4 (1) hospital under IC 16-21;
56	56	5 (2) health facility under IC 16-28; and
57	57	6 (3) psychiatric facility under IC 12-25.
58	58	7 Sec. 3. (a) As used in this chapter, "health care service" means
59	59	8 a health care procedure, treatment, or service that is either:
60	60	9 (1) provided at a health care entity licensed in Indiana; or
61	61	10 (2) provided or ordered by a health professional.
62	62	11 (b) The term includes the provision of pharmaceutical products
63	63	12 or services, or durable medical equipment.
64	64	13 (c) The term does not include:
65	65	14 (1) specialty drugs;
66	66	15 (2) experimental, investigational, or unproven drugs or
67	67	16 products under the applicable enrollee's coverage; or
68	68	17 (3) prescription drugs not approved by the federal Food and
69	69	18 Drug Administration.
70	70	19 Sec. 4. As used in this chapter, "health plan" has the meaning
71	71	20 set forth in IC 27-1-37.3-5.
72	72	21 Sec. 5. As used in this chapter, "health professional" means a
73	73	22 physician licensed under IC 25-22.5.
74	74	23 Sec. 6. (a) As used in this chapter, "prior authorization" means
75	75	24 the process by which utilization review determines the medical
76	76	25 necessity or medical appropriateness of otherwise covered health
77	77	26 care services before or concurrent with the rendering of those
78	78	27 health care services.
79	79	28 (b) The term includes a health plan requirement that an enrollee
80	80	29 or health professional notify the health plan before providing a
81	81	30 health care service, including preauthorization, precertification,
82	82	31 and prior approval of the health care service.
83	83	32 (c) The term does not include utilization review that is used and
84	84	33 submitted by health care entities to track the ongoing
85	85	34 appropriateness of care and confirm payment to the facilities from
86	86	35 health plans.
87	87	36 Sec. 7. (a) As used in this chapter, "risk-bearing organization"
88	88	37 means an entity that:
89	89	38 (1) is:
90	90	39 (A) a professional medical corporation, or other form of
91	91	40 corporation controlled by health professionals;
92	92	41 (B) a medical partnership;
93	93	42 (C) a medical foundation exempt from licensure; or
94	94	2024 IN 1091—LS 6636/DI 154 3
95	95	1 (D) another lawfully organized group of health
96	96	2 professionals that delivers, furnishes, or otherwise
97	97	3 arranges for or provides health care services; and
98	98	4 (2) does all of the following:
99	99	5 (A) Contracts directly with a health plan or arranges for
100	100	6 health care services for the health plan's enrollees.
101	101	7 (B) Receives compensation for those health care services
102	102	8 on any capitated or fixed periodic payment basis.
103	103	9 (C) Is responsible for the processing and payment of claims
104	104	10 made by health professionals for health care services
105	105	11 rendered by those health professionals on behalf of a
106	106	12 health plan that are covered under the capitation or fixed
107	107	13 periodic payment made by the health plan to the
108	108	14 risk-bearing organization.
109	109	15 (b) The term does not include:
110	110	16 (1) an individual or a health plan; or
111	111	17 (2) a provider organization that provides a health plan that
112	112	18 files with the department consolidated financial statements
113	113	19 that include the provider organization.
114	114	20 Sec. 8. (a) On or after January 1, 2026, a health plan shall not
115	115	21 require a contracted health professional to complete or obtain a
116	116	22 prior authorization for any covered health care services or
117	117	23 treatments if, in the most recent completed one (1) year contracted
118	118	24 period, the health plan approved not less than eighty-five percent
119	119	25 (85%) of the prior authorization requests submitted by the health
120	120	26 professional for the class of health care services or treatments
121	121	27 subject to prior authorization for enrollees of the health plan.
122	122	28 (b) A health professional shall have a total contracting history
123	123	29 of at least thirty-six (36) months with the health plan to be
124	124	30 considered eligible for an exemption under subsection (a). The
125	125	31 thirty-six (36) months do not need to be continuous.
126	126	32 (c) A health professional's exemption under subsection (a) shall
127	127	33 apply to all health care services, items, and supplies, including
128	128	34 drugs, that are covered by the health plan contract and are within
129	129	35 the contracted health professional's medical licensure, board
130	130	36 certification, specialty, or scope of practice.
131	131	37 (d) A health plan shall provide an electronic prior authorization
132	132	38 process that a health professional shall agree to use in order to be
133	133	39 considered for an exemption under subsection (a). However, a
134	134	40 health plan may waive this requirement based on the health
135	135	41 professional's access to requisite technologies and infrastructure,
136	136	42 including broadband Internet.
137	137	2024 IN 1091—LS 6636/DI 154 4
138	138	1 Sec. 9. (a) A health plan shall evaluate whether a contracted
139	139	2 health professional without an exemption from prior authorization
140	140	3 requirements qualifies for an exemption under section 8 of this
141	141	4 chapter once every twelve (12) months or upon the request of the
142	142	5 health professional, but not more than once every twelve (12)
143	143	6 months.
144	144	7 (b) A health plan may evaluate whether a contracted health
145	145	8 professional continues to qualify for an exemption from prior
146	146	9 authorization requirements under subsection (a) not more than
147	147	10 once every twelve (12) months.
148	148	11 (c) This section does not require a health plan to evaluate an
149	149	12 existing exemption period or prevent the establishment of a longer
150	150	13 exemption period.
151	151	14 (d) A contracted health professional is not required to request
152	152	15 an exemption from prior authorization requirements to qualify for
153	153	16 the exemption.
154	154	17 (e) A health plan shall provide a health professional who
155	155	18 receives an exemption with a notice that includes a statement that
156	156	19 the health professional qualifies for the exemption and a statement
157	157	20 of the duration of the exemption.
158	158	21 Sec. 10. (a) Upon a health professional's request, the health plan
159	159	22 shall provide a health professional who is denied an exemption
160	160	23 from the preauthorization requirements with:
161	161	24 (1) the facts and information that support the denial,
162	162	25 including statistics and data for the relevant prior
163	163	26 authorization request evaluation period; and
164	164	27 (2) detailed information sufficient to demonstrate that the
165	165	28 health professional does not meet the criteria for an
166	166	29 exemption under section 8 of this chapter.
167	167	30 (b) A health professional's exemption from prior authorization
168	168	31 requirements shall remain in effect until the:
169	169	32 (1) thirtieth calendar day after the date the health plan
170	170	33 notifies the health professional of the health plan's
171	171	34 determination to rescind the exemption; or
172	172	35 (2) fifth business day after the date the independent review
173	173	36 affirms the health plan's determination to rescind the
174	174	37 exemption, if the health professional appeals the rescission
175	175	38 determination.
176	176	39 Sec. 11. (a) A health plan shall only rescind a prior
177	177	40 authorization exemption at the end of the twelve (12) month period
178	178	41 and if the health plan meets all of the following requirements:
179	179	42 (1) For exemptions under section 8 of this chapter, makes a
180	180	2024 IN 1091—LS 6636/DI 154 5
181	181	1 determination that the health professional would not have met
182	182	2 the eighty-five percent (85%) approval criteria based on a
183	183	3 retrospective review of a sample of a minimum of thirty (30),
184	184	4 but not more than fifty (50), claims for covered health care
185	185	5 services for which the exemption applies for the previous
186	186	6 twelve (12) months. However, if the health plan makes a
187	187	7 determination that the health professional would have met the
188	188	8 eighty-five percent (85%) approval criteria based on a
189	189	9 retrospective review of a sample of thirty (30) claims for
190	190	10 covered health care services for which the exemption applies
191	191	11 for the previous twelve (12) months, the health plan need not
192	192	12 review more than thirty (30) claims.
193	193	13 (2) Complies with other applicable requirements specified in
194	194	14 this section, including:
195	195	15 (A) notifies the health professional at least thirty (30)
196	196	16 calendar days before the proposed rescission of the
197	197	17 exemption is to take effect; and
198	198	18 (B) provides the notice required under clause (A) with both
199	199	19 of the following included:
200	200	20 (i) The information and data relied on to make the
201	201	21 determination.
202	202	22 (ii) A plain language explanation of how the health
203	203	23 professional may appeal and seek an independent review
204	204	24 of the determination under this section.
205	205	25 (b) A determination to rescind or deny a prior authorization
206	206	26 exemption shall be made by a health professional licensed in
207	207	27 Indiana, who has the same or similar specialty as the health
208	208	28 professional who has or is being considered for an exemption, and
209	209	29 who has experience in providing the type of health care services for
210	210	30 which the exemption applies.
211	211	31 (c) If a health plan does not finalize a rescission determination
212	212	32 as specified in this section, the health professional is considered to
213	213	33 have met the criteria under section 8 of this chapter to continue to
214	214	34 qualify for the exemption.
215	215	35 (d) A health professional:
216	216	36 (1) may appeal the decision to deny or rescind a prior
217	217	37 authorization exemption; and
218	218	38 (2) has a right to have the appeal conducted by a health
219	219	39 professional licensed in Indiana who has the same or similar
220	220	40 specialty as the health professional who has or is being
221	221	41 considered for an exemption, and who was not directly
222	222	42 involved in making the initial denial or rescission of the
223	223	2024 IN 1091—LS 6636/DI 154 6
224	224	1 exemption.
225	225	2 (e) The appeal described in subsection (d) may be conducted by
226	226	3 a health plan's contracted specialist reviewer, provided the
227	227	4 reviewer is a health professional of the same or similar specialty as
228	228	5 the health professional seeking appeal.
229	229	6 (f) A health professional may request that the reviewing health
230	230	7 professional conducting the appeal described in subsection (d)
231	231	8 consider a random sample of claims submitted to the health plan
232	232	9 by the health professional during the relevant evaluation period as
233	233	10 part of the review.
234	234	11 (g) Within thirty (30) days of receipt of the appeal described in
235	235	12 subsection (d), the health plan shall reconsider the denial or
236	236	13 rescission of the prior authorization exemption and provide a
237	237	14 written response to the health professional with the appeal
238	238	15 determination and the basis for the determination, including
239	239	16 pertinent facts and information relied upon in reaching the
240	240	17 determination.
241	241	18 (h) A health plan shall:
242	242	19 (1) be bound by the determination made under this section;
243	243	20 and
244	244	21 (2) not retroactively deny or modify a covered health care
245	245	22 service on the basis of a rescission of a prior authorization
246	246	23 exemption, even if the health plan's determination to rescind
247	247	24 the exemption is affirmed pursuant to this section.
248	248	25 (i) Following a final determination or review affirming the
249	249	26 rescission or denial of a prior authorization exemption, a health
250	250	27 professional is eligible for consideration of an exemption after a
251	251	28 twelve (12) month period.
252	252	29 Sec. 12. A health plan shall not deny or reduce payment for a
253	253	30 covered health care service exempted from a prior authorization
254	254	31 requirement under section 8 of this chapter, including a covered
255	255	32 health care service performed or supervised by another health
256	256	33 professional when the performing or supervising health
257	257	34 professional or other health professional who ordered the health
258	258	35 care service received a prior authorization exemption, unless the
259	259	36 performing or supervising health professional or other health
260	260	37 professional did either of the following:
261	261	38 (1) Knowingly and materially misrepresented the health care
262	262	39 service in a request for payment submitted to a health plan
263	263	40 with the specific intent to deceive and obtain an unlawful
264	264	41 payment from the health plan.
265	265	42 (2) Failed to substantially perform the health care service.
266	266	2024 IN 1091—LS 6636/DI 154 7
267	267	1 Sec. 13. Nothing in this chapter shall be interpreted to prevent
268	268	2 a health plan from taking action, including rescinding a prior
269	269	3 authorization exemption granted under section 8 of this chapter at
270	270	4 any time, against a contracted health professional who has been
271	271	5 found, through an investigation by the health plan, to have
272	272	6 committed fraud or to have a pattern of waste or abuse in violation
273	273	7 of the health plan's contract.
274	274	8 Sec. 14. A grievance or appeal submitted by or on behalf of an
275	275	9 enrollee regarding a delay, denial, or modification of health care
276	276	10 services shall be reviewed by a physician and surgeon of the same
277	277	11 or similar specialty as the physician and surgeon requesting prior
278	278	12 authorization for those health care services.
279	279	13 Sec. 15. A health plan's policies and procedures shall include a
280	280	14 process for annually monitoring prior authorization approval,
281	281	15 modification, appeal, and denial rates to identify health care
282	282	16 services, items, and supplies, including drugs, that are regularly
283	283	17 approved.
284	284	2024 IN 1091—LS 6636/DI 154