Introduced Version
HOUSE BILL No. 1191
_____
DIGEST OF INTRODUCED BILL
Citations Affected: IC 12-7-2-1.6; IC 12-15.
Synopsis: Medicaid matters. Allows a provider that has entered into
a contract with a managed care organization, after exhausting any
internal procedures of the managed care organization for provider
grievances and appeals, to request an independent review of the
managed care organization's action with an independent third party
provider selected by the office of Medicaid policy and planning.
Establishes a procedure for an independent third party provider to
review an action of a managed care organization. Prohibits a provision
in a contract between a provider and a managed care organization that
would negate or restrict the right of a provider to an independent
review and provides that such a contract provision is void and
unenforceable. Provides that if the office of the secretary of family and
social services (office) or a contractor of the office fails to pay or
denies a clean claim for any eligible Medicaid service within certain
time limits due to the office or contractor incorrectly processing the
clean claim because of errors attributable to the internal system of an
insurer or managed care organization, the office or contractor may not
assert that the provider failed to meet the timely filing requirements for
the claim. Changes the membership of the Medicaid advisory
committee (committee). Allows a member of the committee whose
position was eliminated to continue to serve until the member's term
expires. Establishes co-chairs for the committee and provides that the
elected co-chair of the committee serves for a two year term. Requires
the office to prepare a report that describes every type of report that
must be prepared by a Medicaid contractor or managed care entity and
submitted to the office or the office of Medicaid policy and planning.
(Continued next page)
Effective: July 1, 2024.
Clere
January 9, 2024, read first time and referred to Committee on Public Health.
2024 IN 1191—LS 6959/DI 147 Digest Continued
Specifies the information that must be contained in the report. Requires
the office to submit the report to the committee and the general
assembly. Requires the committee to hold public hearings on the
report. Makes technical changes.
2024 IN 1191—LS 6959/DI 1472024 IN 1191—LS 6959/DI 147 Introduced
Second Regular Session of the 123rd General Assembly (2024)
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 2023 Regular Session of the General Assembly.
HOUSE BILL No. 1191
A BILL FOR AN ACT to amend the Indiana Code concerning
human services.
Be it enacted by the General Assembly of the State of Indiana:
1 SECTION 1. IC 12-7-2-1.6 IS ADDED TO THE INDIANA CODE
2 AS A NEW SECTION TO READ AS FOLLOWS [EFFECTIVE JULY
3 1, 2024]: Sec. 1.6. "Administrator of the office" refers to the
4 administrator of the office of Medicaid policy and planning
5 appointed under IC 12-8-6.5-2.
6 SECTION 2. IC 12-15-11-11 IS ADDED TO THE INDIANA
7 CODE AS A NEW SECTION TO READ AS FOLLOWS
8 [EFFECTIVE JULY 1, 2024]: Sec. 11. (a) As used in this section,
9 "action" means:
10 (1) a denial of reimbursement for claims submitted for
11 covered services to an applicant, a pending applicant, a
12 conditionally eligible individual, or a member; or
13 (2) a reduction in reimbursement for claims submitted for
14 covered services to an applicant, a pending applicant, a
15 conditionally eligible individual, or a member.
2024 IN 1191—LS 6959/DI 147 2
1 (b) As used in this section, "contracted provider" means a
2 provider that has entered into a contract with a managed care
3 organization or a contractor of the office.
4 (c) As used in this section, "office" refers to the office of
5 Medicaid policy and planning established by IC 12-8-6.5-1.
6 (d) Except as provided in this section, the right of a provider
7 contracting with a managed care organization to dispute an action
8 by the managed care organization is governed by the provider's
9 contract with the managed care organization.
10 (e) A contracted provider that is directly affected by an action
11 of a managed care organization, after exhausting any internal
12 procedures of the managed care organization for provider
13 grievances and appeals, may file a request for an independent
14 review of the managed care organization's action with an
15 independent third party provider selected by the office.
16 (f) The office shall establish the procedures and protocols for an
17 independent review under this section, which must include the
18 following:
19 (1) The review must be initiated by the filing of a request for
20 an independent review by the contracted provider.
21 (2) The independent review shall be conducted by an
22 independent third party provider that:
23 (A) is not related to or affiliated with the contracted
24 provider or the managed care organization;
25 (B) has the medical knowledge necessary to review the
26 medical issues presented in the review; and
27 (C) shall write a final decision concerning the action of the
28 managed care organization.
29 (3) The primary focus of the independent review must be the
30 medical necessity and other medically appropriate issues
31 concerning the action of the managed care organization.
32 (4) The final decision of the independent third party provider
33 is binding on the parties and may not be appealed. However,
34 if the contracted provider or managed care organization
35 proves to the office's satisfaction that the independent third
36 party provider did not materially follow the office's policies
37 and procedures, the office, in its sole discretion, may allow a
38 new review by a different independent third party provider.
39 (g) The office shall establish a fee schedule, based on the level of
40 review that is required, for the independent review under this
41 section. The fee must be paid to the independent third party
42 provider upon completion of the provider's responsibilities under
2024 IN 1191—LS 6959/DI 147 3
1 this section.
2 (h) The procedure, time limits, and other provisions set forth in
3 405 IAC 1.1-1 for appeals concerning applicants and recipients of
4 Medicaid apply to reviews under this section.
5 (i) Notwithstanding subsection (e), a contracted provider may
6 not file for an independent review under this section until after
7 December 31, 2025. This subsection expires January 1, 2026.
8 SECTION 3. IC 12-15-11-12 IS ADDED TO THE INDIANA
9 CODE AS A NEW SECTION TO READ AS FOLLOWS
10 [EFFECTIVE JULY 1, 2024]: Sec. 12. (a) A contract between a
11 provider and a managed care organization shall not negate or
12 restrict the right of a provider to an independent review under
13 section 11 this chapter.
14 (b) A contract provision that violates subsection (a) is void and
15 unenforceable.
16 SECTION 4. IC 12-15-13-1.7 IS AMENDED TO READ AS
17 FOLLOWS [EFFECTIVE JULY 1, 2024]: Sec. 1.7. (a) This section
18 does not apply to claims submitted for payment by nursing facilities.
19 (b) The office shall pay or deny each clean claim as follows:
20 (1) If the claim is filed electronically, within twenty-one (21) days
21 after the date the claim is received by:
22 (A) the office; or
23 (B) a contractor of the office under IC 12-15-30, if
24 IC 12-15-30 applies.
25 (2) If the claim is filed on paper, within thirty (30) days after the
26 date the claim is received by:
27 (A) the office; or
28 (B) a contractor of the office under IC 12-15-30, if
29 IC 12-15-30 applies.
30 (c) If:
31 (1) the office fails to pay or deny a clean claim in the time
32 required under subsection (b); and
33 (2) the office or a contractor of the office under IC 12-15-30
34 subsequently pays the claim;
35 the office shall pay the provider that submitted the claim interest on the
36 Medicaid allowable amount of the claim paid under this section.
37 (d) Interest paid under subsection (c) shall:
38 (1) begin accruing:
39 (A) twenty-two (22) days after the date the claim is filed under
40 subsection (b)(1); or
41 (B) thirty-one (31) days after the date the claim is filed under
42 subsection (b)(2); and
2024 IN 1191—LS 6959/DI 147 4
1 (2) stop accruing on the date the claim is paid.
2 (e) In paying interest under subsection (c), the office shall use the
3 same interest rate as provided in IC 12-15-21-3(7)(A).
4 (f) If the office or a contractor of the office denies or fails to pay
5 a clean claim for any eligible Medicaid service within the time
6 allowed by subsection (b) due to the office or contractor incorrectly
7 processing the clean claim because of errors attributable to the
8 internal system of an insurer or a managed care organization, the
9 office or contractor may not assert that the provider failed to meet
10 the timely filing requirements for the claim.
11 SECTION 5. IC 12-15-33-3, AS AMENDED BY P.L.140-2019,
12 SECTION 1, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE
13 JULY 1, 2024]: Sec. 3. (a) The committee shall be appointed as
14 follows:
15 (1) One (1) member shall be appointed by the administrator of the
16 office to represent each of the following organizations:
17 (A) Indiana Council of Community Mental Health Centers.
18 (B) Indiana State Medical Association.
19 (C) Indiana State Chapter of the American Academy of
20 Pediatrics.
21 (D) Indiana Hospital Association.
22 (E) Indiana Dental Association.
23 (F) Indiana State Psychiatric Association.
24 (G) Indiana State Osteopathic Association.
25 (H) Indiana State Nurses Association.
26 (I) Indiana State Licensed Practical Nurses Association.
27 (J) Indiana State Podiatry Association.
28 (K) Indiana Health Care Association.
29 (L) Indiana Optometric Association.
30 (M) Indiana Pharmaceutical Association.
31 (N) Indiana Psychological Association.
32 (O) Indiana State Chiropractic Association.
33 (P) Indiana Ambulance Emergency Medical Services
34 Association.
35 (Q) Indiana Association for Home and Hospice Care.
36 (R) Indiana Academy of Ophthalmology.
37 (S) Indiana Speech and Hearing Speech-Language-Hearing
38 Association.
39 (T) Indiana Academy of Physician Assistants.
40 (U) Indiana Association of Rehabilitation Facilities.
41 (V) Indiana Association of Health Plans.
42 (W) Indiana Primary Health Care Association.
2024 IN 1191—LS 6959/DI 147 5
1 (2) Ten (10) members shall be appointed by the governor as
2 follows:
3 (A) One (1) member who represents agricultural interests.
4 (B) (A) One (1) member who represents business and
5 industrial interests.
6 (C) (B) One (1) member who represents labor interests.
7 (D) (C) One (1) member who represents insurance interests.
8 (E) One (1) member who represents a statewide taxpayer
9 association.
10 (F) Two (2) members who are parent advocates.
11 (G) Three (3) members who represent Indiana citizens.
12 (D) A representative nominated by AARP Indiana.
13 (E) A representative nominated by The Arc of Indiana.
14 (F) A representative nominated by the Indiana Minority
15 Health Coalition.
16 (G) A representative nominated by the Indiana Rural
17 Health Association.
18 (H) A representative nominated by Mental Health America
19 of Indiana.
20 (I) A representative nominated by an Alzheimer's
21 Association chapter that provides services in at least one
22 (1) county in Indiana.
23 (J) A representative nominated by a United Way that
24 provides services in at least one (1) county in Indiana.
25 (3) Six (6) members shall be appointed by the president pro
26 tempore of the senate acting in the capacity as president pro
27 tempore of the senate to represent the senate. Three (3) of the
28 members appointed under this subdivision shall serve on the
29 standing fiscal subcommittee created under section 8(b) of this
30 chapter.
31 (4) Six (6) members shall be appointed by the speaker of the
32 house of representatives to represent the house of representatives.
33 Three (3) of the members appointed under this subdivision shall
34 serve on the standing fiscal subcommittee created under section
35 8(b) of this chapter.
36 (5) The governor shall rotate the appointment of:
37 (A) a member of a chapter described in subdivision (2)(I)
38 among the chapters described in subdivision (2)(I); and
39 (B) a member of a United Way described in subdivision
40 (2)(J) among the United Ways described in subdivision
41 (2)(J).
42 (b) Notwithstanding subsection (a)(3), after consultation with the
2024 IN 1191—LS 6959/DI 147 6
1 minority leader of the senate, the president pro tempore of the senate
2 shall appoint three (3) of the members from the minority party of the
3 senate.
4 (c) Notwithstanding subsection (a)(4), after consultation with the
5 minority leader of the house of representatives, the speaker of the
6 house shall appoint three (3) of the members from the minority party
7 of the house.
8 SECTION 6. IC 12-15-33-5 IS AMENDED TO READ AS
9 FOLLOWS [EFFECTIVE JULY 1, 2024]: Sec. 5. (a) An appointment
10 to the committee is for a four (4) year term, except the representatives
11 of the senate and house of representatives, whose terms coincide with
12 the representative's or senator's respective legislative terms.
13 (b) Notwithstanding any other law, an individual:
14 (1) who was a member of the committee and was appointed
15 under section 3 of this chapter before July 1, 2024;
16 (2) who on June 30, 2024, had at least one (1) year remaining
17 on the member's term; and
18 (3) whose position to be appointed on the committee was
19 eliminated on July 1, 2024;
20 may continue to serve as a member of the committee until the
21 member's original term expires. This subsection expires July 1,
22 2027.
23 SECTION 7. IC 12-15-33-7 IS AMENDED TO READ AS
24 FOLLOWS [EFFECTIVE JULY 1, 2024]: Sec. 7. (a) The administrator
25 of the office and a member of the committee who is elected at the
26 last meeting of the committee during an odd-numbered year shall
27 serve as secretary co-chairs of the committee.
28 (b) The member of the committee who is elected co-chair under
29 this section shall serve as co-chair for a term of two (2) years.
30 SECTION 8. IC 12-15-33-9 IS AMENDED TO READ AS
31 FOLLOWS [EFFECTIVE JULY 1, 2024]: Sec. 9. The committee shall
32 do the following:
33 (1) Meet at least four (4) times each year, one (1) time in each
34 calendar quarter.
35 (2) Hold special meetings that the committee or the secretary a
36 co-chair requests.
37 SECTION 9. IC 12-15-33-11 IS ADDED TO THE INDIANA
38 CODE AS A NEW SECTION TO READ AS FOLLOWS
39 [EFFECTIVE JULY 1, 2024]: Sec. 11. (a) The office of the secretary
40 shall prepare a report that describes every type of report that must
41 be prepared by a Medicaid contractor or managed care entity and
42 submitted to the office of the secretary or the office. The report
2024 IN 1191—LS 6959/DI 147 7
1 must contain the following information:
2 (1) The name or type of each report that contains only
3 information that is required by federal law or a federal
4 agency.
5 (2) The name or type of each report that contains information
6 that is required by state law or a state agency.
7 (b) For the reports that are identified under subsection (a)(2),
8 the report must contain the following information for each type of
9 report:
10 (1) The purpose of the report.
11 (2) Entities that use the reported information.
12 (3) The manner in which the information is being used.
13 (4) Whether there is information that is required in the report
14 that is not being actively used.
15 (5) Whether there is information in the report that is
16 duplicated in another report.
17 (6) Any data from the report or aggregate data that is
18 available to the public.
19 (c) The report required under this section must contain the
20 following information:
21 (1) Any process that is used to evaluate the purpose and use of
22 the reports, including consolidating or eliminating reports.
23 (2) Recommendations on how to make information from the
24 reports and data held by the office of the secretary that is
25 compliant with the federal Health Insurance Portability and
26 Accountability Act (HIPAA) available to the general
27 assembly, Medicaid contractors, managed care entities, and
28 the public to be used for accountability, policymaking, and
29 innovation purposes.
30 (d) The report required under this section must be submitted
31 before October 1, 2024, to the:
32 (1) committee; and
33 (2) general assembly in an electronic format under IC 5-14-6.
34 (e) The committee:
35 (1) shall hold public hearings on the report; and
36 (2) may make recommendations to the office of the secretary
37 and the general assembly.
38 (f) This section expires July 1, 2025.
2024 IN 1191—LS 6959/DI 147