IN
Indiana House Bill HB1200

Indiana 2024 Regular Session

Indiana House Bill HB1200 Compare Versions

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1-*HB1200.2*
2-Reprinted
3-February 1, 2024
1+*HB1200.1*
2+January 25, 2024
43 HOUSE BILL No. 1200
54 _____
6-DIGEST OF HB 1200 (Updated January 31, 2024 11:47 am - DI 141)
5+DIGEST OF HB 1200 (Updated January 24, 2024 11:50 am - DI 141)
76 Citations Affected: IC 5-10.
87 Synopsis: State employee health plan payment limits. Limits the
98 amount that a state employee health plan may pay for a medical facility
109 service provided to a covered individual to: (1) the lesser of the
1110 amount of compensation established by the network plan or 200% of
1211 the amount paid by the Medicare program for that type of medical
1312 facility service or for a medical facility service of a similar type, if the
1413 medical facility service is provided by an in network provider; and (2)
1514 185% of the amount paid by the Medicare program for that type of
1615 medical facility service or for a medical facility service of a similar
1716 type, if the medical facility service is provided by an out of network
1817 provider. Provides that a provider, after receiving payment from a state
1918 employee health plan for a medical facility service provided to a
2019 covered individual, is prohibited from charging the covered individual
2120 an additional amount, other than cost sharing amounts authorized by
22-(Continued next page)
23-Effective: July 1, 2024.
24-McGuire, Carbaugh, Lehman,
25-Schaibley
26-January 9, 2024, read first time and referred to Committee on Insurance.
27-January 25, 2024, amended, reported — Do Pass.
28-January 31, 2024, read second time, amended, ordered engrossed.
29-HB 1200—LS 6739/DI 55 Digest Continued
3021 the terms of the state employee health plan. Provides that a
3122 determination of the state personnel department, a state employee
3223 health plan, or a firm providing administrative services to a state
3324 employee health plan that a medical facility service provided to a
3425 covered individual is of a type similar to a particular type of medical
3526 facility service covered by the Medicare program is conclusive.
3627 Requires a medical facility that provides drugs to a covered individual,
3728 in billing a state employee health plan for the cost of the drugs, to
3829 include in the billing the same "TB" or "JG" modifier that the medical
3930 facility would include in the billing if the medical facility were billing
4031 the Medicare program for the drugs.
41-HB 1200—LS 6739/DI 55HB 1200—LS 6739/DI 55 Reprinted
42-February 1, 2024
32+Effective: July 1, 2024.
33+McGuire, Carbaugh, Lehman,
34+Schaibley
35+January 9, 2024, read first time and referred to Committee on Insurance.
36+January 25, 2024, amended, reported — Do Pass.
37+HB 1200—LS 6739/DI 55 January 25, 2024
4338 Second Regular Session of the 123rd General Assembly (2024)
4439 PRINTING CODE. Amendments: Whenever an existing statute (or a section of the Indiana
4540 Constitution) is being amended, the text of the existing provision will appear in this style type,
4641 additions will appear in this style type, and deletions will appear in this style type.
4742 Additions: Whenever a new statutory provision is being enacted (or a new constitutional
4843 provision adopted), the text of the new provision will appear in this style type. Also, the
4944 word NEW will appear in that style type in the introductory clause of each SECTION that adds
5045 a new provision to the Indiana Code or the Indiana Constitution.
5146 Conflict reconciliation: Text in a statute in this style type or this style type reconciles conflicts
5247 between statutes enacted by the 2023 Regular Session of the General Assembly.
5348 HOUSE BILL No. 1200
5449 A BILL FOR AN ACT to amend the Indiana Code concerning state
5550 and local administration.
5651 Be it enacted by the General Assembly of the State of Indiana:
5752 1 SECTION 1. IC 5-10-8-6.9 IS ADDED TO THE INDIANA CODE
5853 2 AS A NEW SECTION TO READ AS FOLLOWS [EFFECTIVE JULY
59-3 1, 2024]: Sec. 6.9. (a) This section applies after June 30, 2025.
60-4 (b) As used in this section, "cost sharing" means one (1) or more
61-5 of the following paid by or on behalf of a covered individual for
62-6 medical facility services:
63-7 (1) Coinsurance.
64-8 (2) A copayment.
65-9 (3) A deductible.
66-10 (4) Any other payment of part of the cost of covered medical
67-11 facility services that is made by the covered individual or by
68-12 another individual on behalf of the covered individual.
69-13 (c) As used in this section, "covered individual" means an
70-14 individual who is:
71-15 (1) entitled to coverage by a self-insurance program
72-16 established under section 7(b) of this chapter for the cost of
73-17 medical facility services provided to the individual; or
54+3 1, 2024]: Sec. 6.9. (a) As used in this section, "cost sharing" means
55+4 one (1) or more of the following paid by or on behalf of a covered
56+5 individual for medical facility services:
57+6 (1) Coinsurance.
58+7 (2) A copayment.
59+8 (3) A deductible.
60+9 (4) Any other payment of part of the cost of covered medical
61+10 facility services that is made by the covered individual or by
62+11 another individual on behalf of the covered individual.
63+12 (b) As used in this section, "covered individual" means an
64+13 individual who is:
65+14 (1) entitled to coverage by a self-insurance program
66+15 established under section 7(b) of this chapter for the cost of
67+16 medical facility services provided to the individual; or
68+17 (2) entitled to be provided medical facility services through a
7469 HB 1200—LS 6739/DI 55 2
75-1 (2) entitled to be provided medical facility services through a
76-2 prepaid health care delivery plan entered into under section
77-3 7(c) of this chapter.
78-4 (d) As used in this section, "in network provider" means a
79-5 medical facility that is required under a network plan to provide
80-6 health care services to certain covered individuals at not more than
81-7 a preestablished rate or amount of compensation.
82-8 (e) As used in this section, "medical facility" means an
83-9 institution in which health care services are provided to
84-10 individuals. The term:
85-11 (1) includes:
86-12 (A) hospitals and other licensed ambulatory surgical
87-13 centers; and
88-14 (B) ambulatory outpatient surgical centers; but
89-15 (2) does not include:
90-16 (A) a private mental health institution licensed under
91-17 IC 12-25;
92-18 (B) a Medicare certified, freestanding rehabilitation
93-19 hospital;
94-20 (C) a federal Centers for Medicare and Medicaid Services
95-21 (CMS) certified critical access hospital; or
96-22 (D) a federal Centers for Medicare and Medicaid Services
97-23 (CMS) certified rural emergency hospital.
98-24 (f) As used in this section, "medical facility service" means any
99-25 of the following:
100-26 (1) An inpatient service provided by a medical facility.
101-27 (2) An outpatient service provided by a medical facility.
102-28 (3) Medical supplies provided to a covered individual in
103-29 connection with:
104-30 (A) an inpatient service; or
105-31 (B) an outpatient service;
106-32 that is provided by a medical facility.
107-33 (4) Any service for which a claim is submitted using a:
108-34 (A) HIPAA X12 837I institutional form or its successor
109-35 form;
110-36 (B) CMS-1450 form or its successor form; or
111-37 (C) UB-04 form or its successor form.
112-38 The term does not include any service for which a claim is
113-39 submitted using a HIPAA X12 837P electronic claims transaction
114-40 for professional services or its successor transaction, a CMS-1500
115-41 form or its successor form, or a HCFA-1500 form or its successor
116-42 form.
70+1 prepaid health care delivery plan entered into under section
71+2 7(c) of this chapter.
72+3 (c) As used in this section, "in network provider" means a
73+4 medical facility that is required under a network plan to provide
74+5 health care services to certain covered individuals at not more than
75+6 a preestablished rate or amount of compensation.
76+7 (d) As used in this section, "medical facility" means an
77+8 institution in which health care services are provided to
78+9 individuals. The term:
79+10 (1) includes:
80+11 (A) hospitals and other licensed ambulatory surgical
81+12 centers; and
82+13 (B) ambulatory outpatient surgical centers; but
83+14 (2) does not include:
84+15 (A) a private mental health institution licensed under
85+16 IC 12-25; or
86+17 (B) a Medicare certified, freestanding rehabilitation
87+18 hospital.
88+19 (e) As used in this section, "medical facility service" means any
89+20 of the following:
90+21 (1) An inpatient service provided by a medical facility.
91+22 (2) An outpatient service provided by a medical facility.
92+23 (3) Medical supplies provided to a covered individual in
93+24 connection with:
94+25 (A) an inpatient service; or
95+26 (B) an outpatient service;
96+27 that is provided by a medical facility.
97+28 (4) Any service for which a claim is submitted using a:
98+29 (A) HIPAA X12 837I institutional form or its successor
99+30 form;
100+31 (B) CMS-1450 form or its successor form; or
101+32 (C) UB-04 form or its successor form.
102+33 The term does not include any service for which a claim is
103+34 submitted using a HIPAA X12 837P electronic claims transaction
104+35 for professional services or its successor transaction, a CMS-1500
105+36 form or its successor form, or a HCFA-1500 form or its successor
106+37 form.
107+38 (f) As used in this section, "Medicare program" means the
108+39 program established and operated under 42 U.S.C. 1395 et seq.
109+40 (g) As used in this section, "network plan" means a plan under
110+41 which providers are required by contract to provide health care
111+42 services to covered individuals at not more than a preestablished
117112 HB 1200—LS 6739/DI 55 3
118-1 (g) As used in this section, "Medicare program" means the
119-2 program established and operated under 42 U.S.C. 1395 et seq.
120-3 (h) As used in this section, "network plan" means a plan under
121-4 which providers are required by contract to provide health care
122-5 services to covered individuals at not more than a preestablished
123-6 rate or amount of compensation.
124-7 (i) As used in this section, "out of network provider" means a
125-8 medical facility that is not an in network provider.
126-9 (j) As used in this section, "payment" means the total
127-10 compensation for a medical facility service provided to a covered
128-11 individual that is paid:
129-12 (1) partly by a state employee health plan; and
130-13 (2) partly through cost sharing paid by or on behalf of the
131-14 covered individual.
132-15 (k) As used in this section, "state employee health plan" means:
133-16 (1) a self-insurance program established under section 7(b) of
134-17 this chapter; or
135-18 (2) a contract with a prepaid health care delivery plan entered
136-19 into under section 7(c) of this chapter.
137-20 (l) The payment for a medical facility service provided to a
138-21 covered individual may not exceed the following:
139-22 (1) For a medical facility service provided by an in network
140-23 provider, the lesser of:
141-24 (A) the rate or amount of compensation established by the
142-25 network plan for in network providers; or
143-26 (B) two hundred percent (200%) of the amount paid by the
144-27 Medicare program:
145-28 (i) for that type of medical facility service; or
146-29 (ii) for a medical facility service of a similar type.
147-30 (2) For a medical facility service provided by an out of
148-31 network provider, one hundred eighty-five percent (185%) of
149-32 the amount paid by the Medicare program:
150-33 (A) for that type of medical facility service; or
151-34 (B) for a medical facility service of a similar type.
152-35 The limit on the amount of payment for a medical facility service
153-36 shall be determined under subdivision (1) or (2) based on the date
154-37 of service and date of adjudication of the service. The limit
155-38 applying to the amount of payment for a medical facility service is
156-39 not subject to an increase after the date of adjudication based on
157-40 any adjustment that the federal Centers for Medicare and
158-41 Medicaid Services (CMS) may make in the amount paid by the
159-42 Medicare program for a type of medical facility service.
113+1 rate or amount of compensation.
114+2 (h) As used in this section, "out of network provider" means a
115+3 medical facility that is not an in network provider.
116+4 (i) As used in this section, "payment" means the total
117+5 compensation for a medical facility service provided to a covered
118+6 individual that is paid:
119+7 (1) partly by a state employee health plan; and
120+8 (2) partly through cost sharing paid by or on behalf of the
121+9 covered individual.
122+10 (j) As used in this section, "state employee health plan" means:
123+11 (1) a self-insurance program established under section 7(b) of
124+12 this chapter; or
125+13 (2) a contract with a prepaid health care delivery plan entered
126+14 into under section 7(c) of this chapter.
127+15 (k) The payment for a medical facility service provided to a
128+16 covered individual may not exceed the following:
129+17 (1) For a medical facility service provided by an in network
130+18 provider, the lesser of:
131+19 (A) the rate or amount of compensation established by the
132+20 network plan for in network providers; or
133+21 (B) two hundred percent (200%) of the amount paid by the
134+22 Medicare program:
135+23 (i) for that type of medical facility service; or
136+24 (ii) for a medical facility service of a similar type.
137+25 (2) For a medical facility service provided by an out of
138+26 network provider, one hundred eighty-five percent (185%) of
139+27 the amount paid by the Medicare program:
140+28 (A) for that type of medical facility service; or
141+29 (B) for a medical facility service of a similar type.
142+30 The limit on the amount of payment for a medical facility service
143+31 shall be determined under subdivision (1) or (2) based on the date
144+32 of service and date of adjudication of the service. The limit
145+33 applying to the amount of payment for a medical facility service is
146+34 not subject to an increase after the date of adjudication based on
147+35 any adjustment that the federal Centers for Medicare and
148+36 Medicaid Services (CMS) may make in the amount paid by the
149+37 Medicare program for a type of medical facility service.
150+38 (l) A provider that receives payment for a medical facility
151+39 service in accordance with subsection (k)(1) or (k)(2) may not
152+40 charge to or collect from:
153+41 (1) the covered individual; or
154+42 (2) a person financially responsible for the covered individual;
160155 HB 1200—LS 6739/DI 55 4
161-1 (m) A provider that receives payment for a medical facility
162-2 service in accordance with subsection (l)(1) or (l)(2) may not
163-3 charge to or collect from:
164-4 (1) the covered individual; or
165-5 (2) a person financially responsible for the covered individual;
166-6 an amount in addition to the amount paid under subsection (l)(1)
167-7 or (l)(2), other than cost sharing amounts authorized by the terms
168-8 of the state employee health plan.
169-9 (n) If a third party administrator making payments for medical
170-10 facility services for a state employee health plan does not provide
171-11 payment on a fee-for-service basis, the payment method that the
172-12 third party administrator uses must take into account the limits
173-13 specified in subsection (l)(1) and (l)(2). The payment methods used
174-14 by a third party administrator may include:
175-15 (1) value based payments;
176-16 (2) capitation payments; and
177-17 (3) bundled payments.
178-18 (o) For purposes of subsection (l)(1)(B)(ii) and (l)(2)(B), a
179-19 determination of:
180-20 (1) the state personnel department;
181-21 (2) a state employee health plan; or
182-22 (3) a firm providing administrative services to a state
183-23 employee health plan under section 7(b) of this chapter;
184-24 that a medical facility service provided to a covered individual is
185-25 of a type similar to a particular type of medical facility service
186-26 covered by the Medicare program is conclusive upon the medical
187-27 facility that provided the medical facility service, the covered
188-28 individual to whom the medical facility service was provided, and
189-29 the state employee health plan that provides coverage to the
190-30 covered individual.
191-31 (p) This subsection applies if:
192-32 (1) a medical facility provides drugs to a covered individual;
193-33 (2) the medical facility bills a state employee health plan for
194-34 the cost of the drugs; and
195-35 (3) the medical facility, based on the particular type of drugs
196-36 provided to the covered individual, would include a "TB"
197-37 modifier or "JG" modifier in the billing if the medical facility
198-38 were billing the Medicare program for the drugs instead of
199-39 billing the state employee health plan.
200-40 A medical facility described in subdivisions (1) through (3), in
201-41 billing the state employee health plan, shall include in the billing
202-42 the same "TB" modifier or "JG" modifier that the medical facility
156+1 an amount in addition to the amount paid under subsection (k)(1)
157+2 or (k)(2), other than cost sharing amounts authorized by the terms
158+3 of the state employee health plan.
159+4 (m) If a third party administrator making payments for medical
160+5 facility services for a state employee health plan does not provide
161+6 payment on a fee-for-service basis, the payment method that the
162+7 third party administrator uses must take into account the limits
163+8 specified in subsection (k)(1) and (k)(2). The payment methods used
164+9 by a third party administrator may include:
165+10 (1) value based payments;
166+11 (2) capitation payments; and
167+12 (3) bundled payments.
168+13 (n) For purposes of subsection (k)(1)(B)(ii) and (k)(2)(B), a
169+14 determination of:
170+15 (1) the state personnel department;
171+16 (2) a state employee health plan; or
172+17 (3) a firm providing administrative services to a state
173+18 employee health plan under section 7(b) of this chapter;
174+19 that a medical facility service provided to a covered individual is
175+20 of a type similar to a particular type of medical facility service
176+21 covered by the Medicare program is conclusive upon the medical
177+22 facility that provided the medical facility service, the covered
178+23 individual to whom the medical facility service was provided, and
179+24 the state employee health plan that provides coverage to the
180+25 covered individual.
181+26 (o) This subsection applies if:
182+27 (1) a medical facility provides drugs to a covered individual;
183+28 (2) the medical facility bills a state employee health plan for
184+29 the cost of the drugs; and
185+30 (3) the medical facility, based on the particular type of drugs
186+31 provided to the covered individual, would include a "TB"
187+32 modifier or "JG" modifier in the billing if the medical facility
188+33 were billing the Medicare program for the drugs instead of
189+34 billing the state employee health plan.
190+35 A medical facility described in subdivisions (1) through (3), in
191+36 billing the state employee health plan, shall include in the billing
192+37 the same "TB" modifier or "JG" modifier that the medical facility
193+38 would include in the billing if the medical facility were billing the
194+39 Medicare program for the drugs.
203195 HB 1200—LS 6739/DI 55 5
204-1 would include in the billing if the medical facility were billing the
205-2 Medicare program for the drugs.
206-HB 1200—LS 6739/DI 55 6
207196 COMMITTEE REPORT
208197 Mr. Speaker: Your Committee on Insurance, to which was referred
209198 House Bill 1200, has had the same under consideration and begs leave
210199 to report the same back to the House with the recommendation that said
211200 bill be amended as follows:
212201 Page 2, between lines 27 and 28, begin a new line block indented
213202 and insert:
214203 "(4) Any service for which a claim is submitted using a:
215204 (A) HIPAA X12 837I institutional form or its successor
216205 form;
217206 (B) CMS-1450 form or its successor form; or
218207 (C) UB-04 form or its successor form.
219208 The term does not include any service for which a claim is
220209 submitted using a HIPAA X12 837P electronic claims transaction
221210 for professional services or its successor transaction, a CMS-1500
222211 form or its successor form, or a HCFA-1500 form or its successor
223212 form. ".
224213 Page 3, delete lines 7 through 11, begin a new line block indented
225214 and insert:
226215 "(1) For a medical facility service provided by an in network
227216 provider, the lesser of:
228217 (A) the rate or amount of compensation established by the
229218 network plan for in network providers; or
230219 (B) two hundred percent (200%) of the amount paid by the
231220 Medicare program:
232221 (i) for that type of medical facility service; or
233222 (ii) for a medical facility service of a similar type.".
234223 Page 3, between lines 16 and 17, begin a new line blocked left and
235224 insert:
236225 "The limit on the amount of payment for a medical facility service
237226 shall be determined under subdivision (1) or (2) based on the date
238227 of service and date of adjudication of the service. The limit
239228 applying to the amount of payment for a medical facility service is
240229 not subject to an increase after the date of adjudication based on
241230 any adjustment that the federal Centers for Medicare and
242231 Medicaid Services (CMS) may make in the amount paid by the
243232 Medicare program for a type of medical facility service.
244233 (l) A provider that receives payment for a medical facility
245234 service in accordance with subsection (k)(1) or (k)(2) may not
246235 charge to or collect from:
247236 (1) the covered individual; or
248237 (2) a person financially responsible for the covered individual;
249-HB 1200—LS 6739/DI 55 7
238+HB 1200—LS 6739/DI 55 6
250239 an amount in addition to the amount paid under subsection (k)(1)
251240 or (k)(2), other than cost sharing amounts authorized by the terms
252241 of the state employee health plan.
253242 (m) If a third party administrator making payments for medical
254243 facility services for a state employee health plan does not provide
255244 payment on a fee-for-service basis, the payment method that the
256245 third party administrator uses must take into account the limits
257246 specified in subsection (k)(1) and (k)(2). The payment methods used
258247 by a third party administrator may include:
259248 (1) value based payments;
260249 (2) capitation payments; and
261250 (3) bundled payments.".
262251 Page 3, line 17, delete "(l)" and insert "(n)".
263252 Page 3, line 17, delete "(k)(1)(B)" and insert "(k)(1)(B)(ii)".
264253 Page 3, line 30, delete "(m)" and insert "(o)".
265254 and when so amended that said bill do pass.
266255 (Reference is to HB 1200 as introduced.)
267256 CARBAUGH
268257 Committee Vote: yeas 9, nays 4.
269-_____
270-HOUSE MOTION
271-Mr. Speaker: I move that House Bill 1200 be amended to read as
272-follows:
273-Page 1, line 3, after "(a)" insert "This section applies after June 30,
274-2025.
275-(b)".
276-Page 1, line 12, delete "(b)" and insert "(c)".
277-Page 2, line 3, delete "(c)" and insert "(d)".
278-Page 2, line 7, delete "(d)" and insert "(e)".
279-Page 2, line 16, delete "or".
280-Page 2, line 18, delete "hospital." and insert "hospital;".
281-Page 2, between lines 18 and 19, begin a new line double block
282-indented and insert:
283-"(C) a federal Centers for Medicare and Medicaid Services
284-(CMS) certified critical access hospital; or
285-(D) a federal Centers for Medicare and Medicaid Services
286-(CMS) certified rural emergency hospital.".
287-HB 1200—LS 6739/DI 55 8
288-Page 2, line 19, delete "(e)" and insert "(f)".
289-Page 2, line 38, delete "(f)" and insert "(g)".
290-Page 2, line 40, delete "(g)" and insert "(h)".
291-Page 3, line 2, delete "(h)" and insert "(i)".
292-Page 3, line 4, delete "(i)" and insert "(j)".
293-Page 3, line 10, delete "(j)" and insert "(k)".
294-Page 3, line 15, delete "(k)" and insert "(l)".
295-Page 3, line 38, delete "(l)" and insert "(m)".
296-Page 3, line 39, delete "(k)(1) or (k)(2)" and insert "(l)(1) or (l)(2)".
297-Page 4, line 1, delete "(k)(1)" and insert "(l)(1)".
298-Page 4, line 2, delete "(k)(2)," and insert "(l)(2),".
299-Page 4, line 4, delete "(m)" and insert "(n)".
300-Page 4, line 8, delete "(k)(1) and (k)(2)." and insert "(l)(1) and
301-(l)(2).".
302-Page 4, line 13, delete "(n)" and insert "(o)".
303-Page 4, line 13, delete "(k)(1)(B)(ii) and (k)(2)(B)," and insert
304-"(l)(1)(B)(ii) and (l)(2)(B),".
305-Page 4, line 26, delete "(o)" and insert "(p)".
306-(Reference is to HB 1200 as printed January 25, 2024.)
307-MCGUIRE
308258 HB 1200—LS 6739/DI 55