*HB1200.2*
Reprinted
February 1, 2024
HOUSE BILL No. 1200
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DIGEST OF HB 1200 (Updated January 31, 2024 11:47 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
(Continued next page)
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.
January 31, 2024, read second time, amended, ordered engrossed.
HB 1200—LS 6739/DI 55 Digest Continued
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.
HB 1200—LS 6739/DI 55HB 1200—LS 6739/DI 55 Reprinted
February 1, 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) This section applies after June 30, 2025.
4 (b) As used in this section, "cost sharing" means one (1) or more
5 of the following paid by or on behalf of a covered individual for
6 medical facility services:
7 (1) Coinsurance.
8 (2) A copayment.
9 (3) A deductible.
10 (4) Any other payment of part of the cost of covered medical
11 facility services that is made by the covered individual or by
12 another individual on behalf of the covered individual.
13 (c) As used in this section, "covered individual" means an
14 individual who is:
15 (1) entitled to coverage by a self-insurance program
16 established under section 7(b) of this chapter for the cost of
17 medical facility services provided to the individual; or
HB 1200—LS 6739/DI 55 2
1 (2) entitled to be provided medical facility services through a
2 prepaid health care delivery plan entered into under section
3 7(c) of this chapter.
4 (d) As used in this section, "in network provider" means a
5 medical facility that is required under a network plan to provide
6 health care services to certain covered individuals at not more than
7 a preestablished rate or amount of compensation.
8 (e) As used in this section, "medical facility" means an
9 institution in which health care services are provided to
10 individuals. The term:
11 (1) includes:
12 (A) hospitals and other licensed ambulatory surgical
13 centers; and
14 (B) ambulatory outpatient surgical centers; but
15 (2) does not include:
16 (A) a private mental health institution licensed under
17 IC 12-25;
18 (B) a Medicare certified, freestanding rehabilitation
19 hospital;
20 (C) a federal Centers for Medicare and Medicaid Services
21 (CMS) certified critical access hospital; or
22 (D) a federal Centers for Medicare and Medicaid Services
23 (CMS) certified rural emergency hospital.
24 (f) As used in this section, "medical facility service" means any
25 of the following:
26 (1) An inpatient service provided by a medical facility.
27 (2) An outpatient service provided by a medical facility.
28 (3) Medical supplies provided to a covered individual in
29 connection with:
30 (A) an inpatient service; or
31 (B) an outpatient service;
32 that is provided by a medical facility.
33 (4) Any service for which a claim is submitted using a:
34 (A) HIPAA X12 837I institutional form or its successor
35 form;
36 (B) CMS-1450 form or its successor form; or
37 (C) UB-04 form or its successor form.
38 The term does not include any service for which a claim is
39 submitted using a HIPAA X12 837P electronic claims transaction
40 for professional services or its successor transaction, a CMS-1500
41 form or its successor form, or a HCFA-1500 form or its successor
42 form.
HB 1200—LS 6739/DI 55 3
1 (g) As used in this section, "Medicare program" means the
2 program established and operated under 42 U.S.C. 1395 et seq.
3 (h) As used in this section, "network plan" means a plan under
4 which providers are required by contract to provide health care
5 services to covered individuals at not more than a preestablished
6 rate or amount of compensation.
7 (i) As used in this section, "out of network provider" means a
8 medical facility that is not an in network provider.
9 (j) As used in this section, "payment" means the total
10 compensation for a medical facility service provided to a covered
11 individual that is paid:
12 (1) partly by a state employee health plan; and
13 (2) partly through cost sharing paid by or on behalf of the
14 covered individual.
15 (k) As used in this section, "state employee health plan" means:
16 (1) a self-insurance program established under section 7(b) of
17 this chapter; or
18 (2) a contract with a prepaid health care delivery plan entered
19 into under section 7(c) of this chapter.
20 (l) The payment for a medical facility service provided to a
21 covered individual may not exceed the following:
22 (1) For a medical facility service provided by an in network
23 provider, the lesser of:
24 (A) the rate or amount of compensation established by the
25 network plan for in network providers; or
26 (B) two hundred percent (200%) of the amount paid by the
27 Medicare program:
28 (i) for that type of medical facility service; or
29 (ii) for a medical facility service of a similar type.
30 (2) For a medical facility service provided by an out of
31 network provider, one hundred eighty-five percent (185%) of
32 the amount paid by the Medicare program:
33 (A) for that type of medical facility service; or
34 (B) for a medical facility service of a similar type.
35 The limit on the amount of payment for a medical facility service
36 shall be determined under subdivision (1) or (2) based on the date
37 of service and date of adjudication of the service. The limit
38 applying to the amount of payment for a medical facility service is
39 not subject to an increase after the date of adjudication based on
40 any adjustment that the federal Centers for Medicare and
41 Medicaid Services (CMS) may make in the amount paid by the
42 Medicare program for a type of medical facility service.
HB 1200—LS 6739/DI 55 4
1 (m) A provider that receives payment for a medical facility
2 service in accordance with subsection (l)(1) or (l)(2) may not
3 charge to or collect from:
4 (1) the covered individual; or
5 (2) a person financially responsible for the covered individual;
6 an amount in addition to the amount paid under subsection (l)(1)
7 or (l)(2), other than cost sharing amounts authorized by the terms
8 of the state employee health plan.
9 (n) If a third party administrator making payments for medical
10 facility services for a state employee health plan does not provide
11 payment on a fee-for-service basis, the payment method that the
12 third party administrator uses must take into account the limits
13 specified in subsection (l)(1) and (l)(2). The payment methods used
14 by a third party administrator may include:
15 (1) value based payments;
16 (2) capitation payments; and
17 (3) bundled payments.
18 (o) For purposes of subsection (l)(1)(B)(ii) and (l)(2)(B), a
19 determination of:
20 (1) the state personnel department;
21 (2) a state employee health plan; or
22 (3) a firm providing administrative services to a state
23 employee health plan under section 7(b) of this chapter;
24 that a medical facility service provided to a covered individual is
25 of a type similar to a particular type of medical facility service
26 covered by the Medicare program is conclusive upon the medical
27 facility that provided the medical facility service, the covered
28 individual to whom the medical facility service was provided, and
29 the state employee health plan that provides coverage to the
30 covered individual.
31 (p) This subsection applies if:
32 (1) a medical facility provides drugs to a covered individual;
33 (2) the medical facility bills a state employee health plan for
34 the cost of the drugs; and
35 (3) the medical facility, based on the particular type of drugs
36 provided to the covered individual, would include a "TB"
37 modifier or "JG" modifier in the billing if the medical facility
38 were billing the Medicare program for the drugs instead of
39 billing the state employee health plan.
40 A medical facility described in subdivisions (1) through (3), in
41 billing the state employee health plan, shall include in the billing
42 the same "TB" modifier or "JG" modifier that the medical facility
HB 1200—LS 6739/DI 55 5
1 would include in the billing if the medical facility were billing the
2 Medicare program for the drugs.
HB 1200—LS 6739/DI 55 6
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 7
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.
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HOUSE MOTION
Mr. Speaker: I move that House Bill 1200 be amended to read as
follows:
Page 1, line 3, after "(a)" insert "This section applies after June 30,
2025.
(b)".
Page 1, line 12, delete "(b)" and insert "(c)".
Page 2, line 3, delete "(c)" and insert "(d)".
Page 2, line 7, delete "(d)" and insert "(e)".
Page 2, line 16, delete "or".
Page 2, line 18, delete "hospital." and insert "hospital;".
Page 2, between lines 18 and 19, begin a new line double block
indented and insert:
"(C) a federal Centers for Medicare and Medicaid Services
(CMS) certified critical access hospital; or
(D) a federal Centers for Medicare and Medicaid Services
(CMS) certified rural emergency hospital.".
HB 1200—LS 6739/DI 55 8
Page 2, line 19, delete "(e)" and insert "(f)".
Page 2, line 38, delete "(f)" and insert "(g)".
Page 2, line 40, delete "(g)" and insert "(h)".
Page 3, line 2, delete "(h)" and insert "(i)".
Page 3, line 4, delete "(i)" and insert "(j)".
Page 3, line 10, delete "(j)" and insert "(k)".
Page 3, line 15, delete "(k)" and insert "(l)".
Page 3, line 38, delete "(l)" and insert "(m)".
Page 3, line 39, delete "(k)(1) or (k)(2)" and insert "(l)(1) or (l)(2)".
Page 4, line 1, delete "(k)(1)" and insert "(l)(1)".
Page 4, line 2, delete "(k)(2)," and insert "(l)(2),".
Page 4, line 4, delete "(m)" and insert "(n)".
Page 4, line 8, delete "(k)(1) and (k)(2)." and insert "(l)(1) and
(l)(2).".
Page 4, line 13, delete "(n)" and insert "(o)".
Page 4, line 13, delete "(k)(1)(B)(ii) and (k)(2)(B)," and insert
"(l)(1)(B)(ii) and (l)(2)(B),".
Page 4, line 26, delete "(o)" and insert "(p)".
(Reference is to HB 1200 as printed January 25, 2024.)
MCGUIRE
HB 1200—LS 6739/DI 55