Introduced Version
HOUSE BILL No. 1200
_____
DIGEST OF INTRODUCED BILL
Citations Affected: IC 5-10-8-6.9.
Synopsis: State employee health plan payment limits. Limits the
amount that a state employee health plan may pay for a medical facility
service provided to a covered individual to: (1) 200% of the amount
paid by the Medicare program for that type of medical facility service
or for a medical facility service of a similar type, if the medical facility
service is provided by an in network provider; and (2) 185% of the
amount paid by the Medicare program for that type of medical facility
service or for a medical facility service of a similar type, if the medical
facility service is provided by an out of network provider. Provides that
a determination of the state personnel department, a state employee
health plan, or a firm providing administrative services to a state
employee health plan that a medical facility service provided to a
covered individual is of a type similar to a particular type of medical
facility service covered by the Medicare program is conclusive.
Requires a medical facility that provides drugs to a covered individual,
in billing a state employee health plan for the cost of the drugs, to
include in the billing the same "TB" or "JG" modifier that the medical
facility would include in the billing if the medical facility were billing
the Medicare program for the drugs.
Effective: July 1, 2024.
McGuire, Carbaugh, Lehman,
Schaibley
January 9, 2024, read first time and referred to Committee on Insurance.
2024 IN 1200—LS 6739/DI 55 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. 1200
A BILL FOR AN ACT to amend the Indiana Code concerning state
and local administration.
Be it enacted by the General Assembly of the State of Indiana:
1 SECTION 1. IC 5-10-8-6.9 IS ADDED TO THE INDIANA CODE
2 AS A NEW SECTION TO READ AS FOLLOWS [EFFECTIVE JULY
3 1, 2024]: Sec. 6.9. (a) As used in this section, "cost sharing" means
4 one (1) or more of the following paid by or on behalf of a covered
5 individual for medical facility services:
6 (1) Coinsurance.
7 (2) A copayment.
8 (3) A deductible.
9 (4) Any other payment of part of the cost of covered medical
10 facility services that is made by the covered individual or by
11 another individual on behalf of the covered individual.
12 (b) As used in this section, "covered individual" means an
13 individual who is:
14 (1) entitled to coverage by a self-insurance program
15 established under section 7(b) of this chapter for the cost of
16 medical facility services provided to the individual; or
17 (2) entitled to be provided medical facility services through a
2024 IN 1200—LS 6739/DI 55 2
1 prepaid health care delivery plan entered into under section
2 7(c) of this chapter.
3 (c) As used in this section, "in network provider" means a
4 medical facility that is required under a network plan to provide
5 health care services to certain covered individuals at not more than
6 a preestablished rate or amount of compensation.
7 (d) As used in this section, "medical facility" means an
8 institution in which health care services are provided to
9 individuals. The term:
10 (1) includes:
11 (A) hospitals and other licensed ambulatory surgical
12 centers; and
13 (B) ambulatory outpatient surgical centers; but
14 (2) does not include:
15 (A) a private mental health institution licensed under
16 IC 12-25; or
17 (B) a Medicare certified, freestanding rehabilitation
18 hospital.
19 (e) As used in this section, "medical facility service" means any
20 of the following:
21 (1) An inpatient service provided by a medical facility.
22 (2) An outpatient service provided by a medical facility.
23 (3) Medical supplies provided to a covered individual in
24 connection with:
25 (A) an inpatient service; or
26 (B) an outpatient service;
27 that is provided by a medical facility.
28 (f) As used in this section, "Medicare program" means the
29 program established and operated under 42 U.S.C. 1395 et seq.
30 (g) As used in this section, "network plan" means a plan under
31 which providers are required by contract to provide health care
32 services to covered individuals at not more than a preestablished
33 rate or amount of compensation.
34 (h) As used in this section, "out of network provider" means a
35 medical facility that is not an in network provider.
36 (i) As used in this section, "payment" means the total
37 compensation for a medical facility service provided to a covered
38 individual that is paid:
39 (1) partly by a state employee health plan; and
40 (2) partly through cost sharing paid by or on behalf of the
41 covered individual.
42 (j) As used in this section, "state employee health plan" means:
2024 IN 1200—LS 6739/DI 55 3
1 (1) a self-insurance program established under section 7(b) of
2 this chapter; or
3 (2) a contract with a prepaid health care delivery plan entered
4 into under section 7(c) of this chapter.
5 (k) The payment for a medical facility service provided to a
6 covered individual may not exceed the following:
7 (1) For a medical facility service provided by an in network
8 provider, two hundred percent (200%) of the amount paid by
9 the Medicare program:
10 (A) for that type of medical facility service; or
11 (B) for a medical facility service of a similar type.
12 (2) For a medical facility service provided by an out of
13 network provider, one hundred eighty-five percent (185%) of
14 the amount paid by the Medicare program:
15 (A) for that type of medical facility service; or
16 (B) for a medical facility service of a similar type.
17 (l) For purposes of subsection (k)(1)(B) and (k)(2)(B), a
18 determination of:
19 (1) the state personnel department;
20 (2) a state employee health plan; or
21 (3) a firm providing administrative services to a state
22 employee health plan under section 7(b) of this chapter;
23 that a medical facility service provided to a covered individual is
24 of a type similar to a particular type of medical facility service
25 covered by the Medicare program is conclusive upon the medical
26 facility that provided the medical facility service, the covered
27 individual to whom the medical facility service was provided, and
28 the state employee health plan that provides coverage to the
29 covered individual.
30 (m) This subsection applies if:
31 (1) a medical facility provides drugs to a covered individual;
32 (2) the medical facility bills a state employee health plan for
33 the cost of the drugs; and
34 (3) the medical facility, based on the particular type of drugs
35 provided to the covered individual, would include a "TB"
36 modifier or "JG" modifier in the billing if the medical facility
37 were billing the Medicare program for the drugs instead of
38 billing the state employee health plan.
39 A medical facility described in subdivisions (1) through (3), in
40 billing the state employee health plan, shall include in the billing
41 the same "TB" modifier or "JG" modifier that the medical facility
42 would include in the billing if the medical facility were billing the
2024 IN 1200—LS 6739/DI 55 4
1 Medicare program for the drugs.
2024 IN 1200—LS 6739/DI 55