*HB1200.1*
January 25, 2024
HOUSE BILL No. 1200
_____
DIGEST OF HB 1200 (Updated January 24, 2024 11:50 am - DI 141)
Citations Affected: IC 5-10.
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) the lesser of the
amount of compensation established by the network plan or 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 provider, after receiving payment from a state
employee health plan for a medical facility service provided to a
covered individual, is prohibited from charging the covered individual
an additional amount, other than cost sharing amounts authorized by
the terms of the state employee health plan. 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.
January 25, 2024, amended, reported — Do Pass.
HB 1200—LS 6739/DI 55 January 25, 2024
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
HB 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 (4) Any service for which a claim is submitted using a:
29 (A) HIPAA X12 837I institutional form or its successor
30 form;
31 (B) CMS-1450 form or its successor form; or
32 (C) UB-04 form or its successor form.
33 The term does not include any service for which a claim is
34 submitted using a HIPAA X12 837P electronic claims transaction
35 for professional services or its successor transaction, a CMS-1500
36 form or its successor form, or a HCFA-1500 form or its successor
37 form.
38 (f) As used in this section, "Medicare program" means the
39 program established and operated under 42 U.S.C. 1395 et seq.
40 (g) As used in this section, "network plan" means a plan under
41 which providers are required by contract to provide health care
42 services to covered individuals at not more than a preestablished
HB 1200—LS 6739/DI 55 3
1 rate or amount of compensation.
2 (h) As used in this section, "out of network provider" means a
3 medical facility that is not an in network provider.
4 (i) As used in this section, "payment" means the total
5 compensation for a medical facility service provided to a covered
6 individual that is paid:
7 (1) partly by a state employee health plan; and
8 (2) partly through cost sharing paid by or on behalf of the
9 covered individual.
10 (j) As used in this section, "state employee health plan" means:
11 (1) a self-insurance program established under section 7(b) of
12 this chapter; or
13 (2) a contract with a prepaid health care delivery plan entered
14 into under section 7(c) of this chapter.
15 (k) The payment for a medical facility service provided to a
16 covered individual may not exceed the following:
17 (1) For a medical facility service provided by an in network
18 provider, the lesser of:
19 (A) the rate or amount of compensation established by the
20 network plan for in network providers; or
21 (B) two hundred percent (200%) of the amount paid by the
22 Medicare program:
23 (i) for that type of medical facility service; or
24 (ii) for a medical facility service of a similar type.
25 (2) For a medical facility service provided by an out of
26 network provider, one hundred eighty-five percent (185%) of
27 the amount paid by the Medicare program:
28 (A) for that type of medical facility service; or
29 (B) for a medical facility service of a similar type.
30 The limit on the amount of payment for a medical facility service
31 shall be determined under subdivision (1) or (2) based on the date
32 of service and date of adjudication of the service. The limit
33 applying to the amount of payment for a medical facility service is
34 not subject to an increase after the date of adjudication based on
35 any adjustment that the federal Centers for Medicare and
36 Medicaid Services (CMS) may make in the amount paid by the
37 Medicare program for a type of medical facility service.
38 (l) A provider that receives payment for a medical facility
39 service in accordance with subsection (k)(1) or (k)(2) may not
40 charge to or collect from:
41 (1) the covered individual; or
42 (2) a person financially responsible for the covered individual;
HB 1200—LS 6739/DI 55 4
1 an amount in addition to the amount paid under subsection (k)(1)
2 or (k)(2), other than cost sharing amounts authorized by the terms
3 of the state employee health plan.
4 (m) If a third party administrator making payments for medical
5 facility services for a state employee health plan does not provide
6 payment on a fee-for-service basis, the payment method that the
7 third party administrator uses must take into account the limits
8 specified in subsection (k)(1) and (k)(2). The payment methods used
9 by a third party administrator may include:
10 (1) value based payments;
11 (2) capitation payments; and
12 (3) bundled payments.
13 (n) For purposes of subsection (k)(1)(B)(ii) and (k)(2)(B), a
14 determination of:
15 (1) the state personnel department;
16 (2) a state employee health plan; or
17 (3) a firm providing administrative services to a state
18 employee health plan under section 7(b) of this chapter;
19 that a medical facility service provided to a covered individual is
20 of a type similar to a particular type of medical facility service
21 covered by the Medicare program is conclusive upon the medical
22 facility that provided the medical facility service, the covered
23 individual to whom the medical facility service was provided, and
24 the state employee health plan that provides coverage to the
25 covered individual.
26 (o) This subsection applies if:
27 (1) a medical facility provides drugs to a covered individual;
28 (2) the medical facility bills a state employee health plan for
29 the cost of the drugs; and
30 (3) the medical facility, based on the particular type of drugs
31 provided to the covered individual, would include a "TB"
32 modifier or "JG" modifier in the billing if the medical facility
33 were billing the Medicare program for the drugs instead of
34 billing the state employee health plan.
35 A medical facility described in subdivisions (1) through (3), in
36 billing the state employee health plan, shall include in the billing
37 the same "TB" modifier or "JG" modifier that the medical facility
38 would include in the billing if the medical facility were billing the
39 Medicare program for the drugs.
HB 1200—LS 6739/DI 55 5
COMMITTEE REPORT
Mr. Speaker: Your Committee on Insurance, to which was referred
House Bill 1200, has had the same under consideration and begs leave
to report the same back to the House with the recommendation that said
bill be amended as follows:
Page 2, between lines 27 and 28, begin a new line block indented
and insert:
"(4) Any service for which a claim is submitted using a:
(A) HIPAA X12 837I institutional form or its successor
form;
(B) CMS-1450 form or its successor form; or
(C) UB-04 form or its successor form.
The term does not include any service for which a claim is
submitted using a HIPAA X12 837P electronic claims transaction
for professional services or its successor transaction, a CMS-1500
form or its successor form, or a HCFA-1500 form or its successor
form. ".
Page 3, delete lines 7 through 11, begin a new line block indented
and insert:
"(1) For a medical facility service provided by an in network
provider, the lesser of:
(A) the rate or amount of compensation established by the
network plan for in network providers; or
(B) two hundred percent (200%) of the amount paid by the
Medicare program:
(i) for that type of medical facility service; or
(ii) for a medical facility service of a similar type.".
Page 3, between lines 16 and 17, begin a new line blocked left and
insert:
"The limit on the amount of payment for a medical facility service
shall be determined under subdivision (1) or (2) based on the date
of service and date of adjudication of the service. The limit
applying to the amount of payment for a medical facility service is
not subject to an increase after the date of adjudication based on
any adjustment that the federal Centers for Medicare and
Medicaid Services (CMS) may make in the amount paid by the
Medicare program for a type of medical facility service.
(l) A provider that receives payment for a medical facility
service in accordance with subsection (k)(1) or (k)(2) may not
charge to or collect from:
(1) the covered individual; or
(2) a person financially responsible for the covered individual;
HB 1200—LS 6739/DI 55 6
an amount in addition to the amount paid under subsection (k)(1)
or (k)(2), other than cost sharing amounts authorized by the terms
of the state employee health plan.
(m) If a third party administrator making payments for medical
facility services for a state employee health plan does not provide
payment on a fee-for-service basis, the payment method that the
third party administrator uses must take into account the limits
specified in subsection (k)(1) and (k)(2). The payment methods used
by a third party administrator may include:
(1) value based payments;
(2) capitation payments; and
(3) bundled payments.".
Page 3, line 17, delete "(l)" and insert "(n)".
Page 3, line 17, delete "(k)(1)(B)" and insert "(k)(1)(B)(ii)".
Page 3, line 30, delete "(m)" and insert "(o)".
and when so amended that said bill do pass.
(Reference is to HB 1200 as introduced.)
CARBAUGH
Committee Vote: yeas 9, nays 4.
HB 1200—LS 6739/DI 55