LEGISLATIVE SERVICES AGENCY
OFFICE OF FISCAL AND MANAGEMENT ANALYSIS
200 W. Washington St., Suite 301
Indianapolis, IN 46204
(317) 233-0696
iga.in.gov
FISCAL IMPACT STATEMENT
LS 6838 NOTE PREPARED: Jan 4, 2024
BILL NUMBER: SB 192 BILL AMENDED:
SUBJECT: Various Health Care Matters.
FIRST AUTHOR: Sen. Johnson BILL STATUS: As Introduced
FIRST SPONSOR:
FUNDS AFFECTED:XGENERAL IMPACT: State & Local
XDEDICATED
XFEDERAL
Summary of Legislation: Administrative Adjudication: The bill makes changes to the law governing
administrative adjudication and to provisions related to managed care organizations.
Physician Payments: The bill provides that if a physician has entered into a provider agreement with the
Office of Medicaid Policy and Planning (OMPP) or a managed care organization and the physician, subject
to the provider agreement, provides professional services to individuals participating in the state Medicaid
program, the OMPP or the managed care organization shall promptly compensate the physician for the
professional services in accordance with the provider agreement. It prohibits any delay in or denial of
compensation to the physician unless the cause of the delay or denial is specifically provided for in: (1) the
Medicaid managed care law; (2) an administrative rule adopted under the Medicaid managed care law; (3)
the federal administrative rules on Medicaid managed care; or (4) the provider agreement.
HIV and AIDS Treatment: The bill defines "antiretroviral" as a drug used to prevent a retrovirus, such as the
human immunodeficiency virus (HIV), from replicating. It provides, for purposes of the Medicaid program
and the Children's Health Insurance Program (CHIP), that an FDA approved drug that is prescribed for the
treatment or prevention of HIV or acquired immunodeficiency syndrome (AIDS), including antiretrovirals,
shall not be subject to: (1) prior authorization; (2) a step therapy protocol; or (3) any other protocol that could
restrict or delay the dispensing of the drug.
The bill also prohibits a health plan (including a policy of accident and sickness insurance, a health
maintenance organization contract, the state employee self-insurance program and prepaid health care
delivery plan, and a Medicaid risk-based managed care program) from imposing or enforcing: (1) a prior
authorization requirement; (2) a step therapy protocol requirement; or (3) any other protocol requirement;
SB 192 1 if imposing or enforcing the requirement could restrict or delay the dispensing to a covered individual of an
FDA approved drug, including an antiretroviral, that is prescribed for the treatment or prevention of HIV or
AIDS.
Preemployment Tuberculosis Testing: The bill states that a home health agency is not required to conduct
a tuberculosis test on a job applicant before the individual has contact with a patient. It repeals a statute that
requires certain personal services agency employees or agents to complete a tuberculosis test.
Home Health Agency Cooperative Agreements: It authorizes the establishment of home health agency
cooperative agreements. (A similar law enacted in 2022 expired on July 1, 2023.) The bill makes statements
and findings of the General Assembly concerning home health agency cooperative agreements. The bill
specifies that a home health agency may contract directly or indirectly through a network of home health
agencies.
Provider Forms: The bill exempts: (1) a remote location of a hospital; and (2) a free standing emergency
department or other provider-based entity; from health care billing requirements.
Pharmacists: The bill allows a pharmacist to administer an immunization that is recommended by the federal
Centers for Disease Control and Prevention Advisory Committee on Immunization Practices to a group of
individuals under a drug order, under a prescription, or according to a protocol approved by a physician if
certain conditions are met. (Current law allows a pharmacist to administer specified immunizations to a
group of individuals under a drug order, under a prescription, or according to a protocol approved by a
physician if certain conditions are met.) It removes a provision allowing a pharmacist to administer
pneumonia immunizations to individuals who are at least 50 years of age.
Effective Date: July 1, 2024.
Explanation of State Expenditures: Final Decision Database: The cost for the Office of Administrative
Law Proceedings (OALP) to establish a public facing data base with searchable final orders, and to redact
private, protected, or other confidential information will vary depending on a variety of factors, including
but not limited to the format of the data to be added to the database, the size of the database, and how the data
is stored. The project could cost between $50,000 to $1.2 M in initial costs, with ongoing annual costs of
$100,000 to $325,000 for licensing, storage, and staff. To the extent that the Management and Performance
Hub (MPH) could be utilized to fulfill the bill's requirements, the project’s costs could be reduced.
Administrative Adjudication and Physician Payments: The bill could increase the number and change the
timing of claims paid by Medicaid managed care organizations (MCO) by limiting MCOs’ prepayment
reviews to those required by the Office of Medicaid Policy and Planning (OMPP). Also, the conditions for
prepayment review could increase the workload and/or the cost of prepayment reviews and result in
additional administrative actions if the procedures are not followed. The bill makes an administrative law
judge (ALJ) the ultimate authority for Medicaid administrative appeals, reducing the workload for the Office
of the Secretary (FSSA) which is currently the ultimate authority. However, increased review and
responsibility for final decisions could increase the workload for the OALP beyond the current resources.
The bill requires all administrative actions in which the ALJ is the ultimate authority to use the judicial
standard of review concerning the burden of proof. An agency may pay attorney’s fees if an ALJ or ultimate
authority invalidates an action because it is not based on duly enacted laws, agency rules, or judicial
opinions. The FSSA uses manuals and bulletins to communicate procedures and policies to providers.
SB 192 2 Transferring these communications into rules may result in workload beyond the FSSA’s current
responsibilities.
Home Health Agencies (HHA): The bill’s requirements represent an additional workload and expenditure
on the FSSA outside of the FSSA’s routine administrative functions, and existing staffing and resource
levels, if currently being used to capacity, may be insufficient for full implementation. The additional funds
and resources required could be supplied through existing staff and resources currently being used in another
program or with new appropriations. Ultimately, the source of funds and resources required to satisfy the
requirements of this bill will depend on legislative and administrative actions.
Provider Forms: Location of service errors in payment include differences in payment rates for inpatient and
outpatient services and bundled rate services billed separately. Exempting certain entities from the use
requirements for a provider form may have minimal potential increase in service payments by increasing the
number of location service errors for the State Employee Health Plan (SEHP), Medicaid, and Children’s
Health Insurance Program (CHIP).
Pharmacists: Insurers, including Medicaid and the State Employee Health Plans, may be responsible for
reimbursing providers for vaccine administration fees. To the extent that this bill results in more Medicaid
and State Employee Health Plan members receiving the vaccine than otherwise would have received it in a
primary care or other setting, the state may experience an indeterminate increase in costs for vaccine
administration fees. Under Indiana’s Medicaid and CHIP programs, reimbursement rates for immunization
administration are typically between $8 and $18 per dose. The typical state share of these costs would be
between $2 and $6 per dose.
Explanation of State Revenues: Insurance Premium Tax: If premium collections in the state increase as
the result of prohibitions on prior authorization, step therapy protocol, or other protocol requirements for
these prescription drugs or the immunization administration fees, revenue to the state General Fund from the
corporate Adjusted Gross Income Tax and the Insurance Premium Tax would increase.
Additional Information - The impact of these prohibitions on premium collections may be minimal to the
extent that pre-exposure prophylaxis is part a preventative care benefit of the Affordable Care Act. However,
the state benchmark plan for essential health benefits does not include a detailed list of medications that are
exempt from prior authorization or step-therapy protocols.
Explanation of Local Expenditures: Preemployment Tuberculosis Testing: County hospital owned or
operated home health agencies may have reduced workload and expenditures with the repeal of tuberculosis
testing.
Prescription Drugs for the Treatment of HIV or AIDS: Local units providing covered insurance policy or
health maintenance organization could have higher premiums. Any increase in premiums cost may be
mitigated with adjustments to other benefits or to employee compensation packages, or through the division
of premium costs between the local unit and its employees.
Additional Information: The tuberculosis test currently required by the Indiana Department of Health is
either the Mantoux skin test or the Quantiferon-TB assay blood test. The average cost for a Mantoux skin
test is $20 - $25 and a Quantiferon-TB assay is roughly $35. Costs may vary since tests are offered by local
health departments.
SB 192 3 Explanation of Local Revenues:
State Agencies Affected: Office of Administrative Law Proceedings; Office of Medicaid Policy and
Planning; Office of the Secretary of Family and Social Services; Management and Performance Hub; State
Personnel Department
Local Agencies Affected: County hospital owned or operated home health agencies; local units providing
health care coverage.
Information Sources: https://www.in.gov/health/files/AC-HHA-2019-01-TB-Advisory.pdf;
https://co.johnson.in.us/topic/index.php?topicid=97&structureid=31;
https://health.elkhartcounty.com/en/patient-services/about-patient-services/tuberculosis-tb-clinic/;
https://www.clarkhealth.net/index.php/public-health-nurse/tuberculosis-tb-testing;
Indiana Essential Benchmark Plan available at
https://www.cms.gov/marketplace/resources/data/essential-health-benefits#Indiana;
Pre-Exposure Prophylaxis available at hiv.gov, updated November 20, 2023; Legislative Services Agency,
Office of Technology Services.
Fiscal Analyst: Karen Rossen, 317-234-2106; Jasmine Noel, 317-234-1360.
SB 192 4