CHAPTER 12. MANAGED CARE
IC 12-15-12
Chapter 12. Managed Care
IC 12-15-12-0.3
"Emergency medical condition" defined
Sec. 0.3. As used in this chapter, "emergency medical condition"
means a medical condition manifesting itself by acute symptoms,
including severe pain, of sufficient severity that a prudent lay person
with an average knowledge of health and medicine could reasonably
expect the absence of immediate medical attention to result in:
(1) serious jeopardy to the health of:
(A) the individual; or
(B) in the case of a pregnant woman, the woman or her
unborn child;
(2) serious impairment to bodily functions; or
(3) serious dysfunction of any bodily organ or part.
As added by P.L.223-2001, SEC.4.
IC 12-15-12-0.5
"Emergency services" defined
Sec. 0.5. As used in this chapter, "emergency services" means
covered inpatient and outpatient services that are:
(1) furnished by a provider qualified to furnish emergency
services; and
(2) needed to evaluate or stabilize an emergency medical
condition.
As added by P.L.223-2001, SEC.5.
IC 12-15-12-0.7
"Post-stabilization care services" defined
Sec. 0.7. As used in this chapter, "post-stabilization care services"
means covered services related to an emergency medical condition
that are provided after an enrollee is stabilized in order to maintain
the stabilized condition or, under the circumstances described in
IC 12-15-12-17(b)(3), to improve or resolve the enrollee's condition.
As added by P.L.223-2001, SEC.6.
IC 12-15-12-1
Providers from whom recipients may obtain services other than
physician services; exceptions
Sec. 1. Except as provided in sections 6, 7, and 8 of this chapter,
a Medicaid recipient may obtain any Medicaid services, with the
exception of physician services, from a provider who has entered into
a provider agreement under IC 12-15-11.
As added by P.L.2-1992, SEC.9.
IC 12-15-12-2
Providers from whom recipients may receive physician services;
exceptions
Sec. 2. Except as provided in sections 8 and 9 of this chapter, a
Medicaid recipient may receive physician services from a managed
care provider selected by the recipient from a list of managed care
providers furnished the recipient by the office.
As added by P.L.2-1992, SEC.9.
IC 12-15-12-3
List of managed care providers furnished recipient; providers
included; exception
Sec. 3. Except as provided in section 9 of this chapter, the list of
managed care providers furnished the recipient must include the
names of all managed care providers who meet the following
requirements:
(1) Have entered into a provider agreement with the office
under IC 12-15-11 to provide physician services to Medicaid
recipients.
(2) Provide physician services in the geographic area in which
the recipient resides.
As added by P.L.2-1992, SEC.9.
IC 12-15-12-4
Failure by recipient to select managed care provider within
reasonable time; assignment by office; exception
Sec. 4. Except as provided in section 9 of this chapter, if a
recipient fails to select a managed care provider within a reasonable
time after the list is furnished the recipient, the office may assign a
managed care provider to the recipient.
As added by P.L.2-1992, SEC.9.
IC 12-15-12-4.5
Managed care prescription drug program requirements
Sec. 4.5. A managed care provider's contract or provider
agreement with the office may include a prescription drug program,
subject to IC 12-15-5-5, IC 12-15-35, and IC 12-15-35.5.
As added by P.L.101-2005, SEC.2.
IC 12-15-12-5
Circumstances permitting recipient to receive physician services
from provider other than managed care provider; exceptions
Sec. 5. Except as provided in sections 6 and 7 of this chapter, a
Medicaid recipient may not receive physician services from a
provider other than the managed care provider selected by the
recipient under section 2 of this chapter, except as follows:
(1) In an emergency.
(2) Upon the written referral of the managed care provider.
(3) As provided in sections 6 through 9 of this chapter.
As added by P.L.2-1992, SEC.9.
IC 12-15-12-6
Admission to hospital by physician other than managed care
provider; notification of managed care provider; services for
which payment made
Sec. 6. (a) A Medicaid recipient may be admitted to a hospital by
a physician other than the recipient's managed care provider if the
recipient requires immediate medical treatment.
(b) The admitting physician shall notify the recipient's managed
care provider of the recipient's admission not more than forty-eight
(48) hours after the recipient's admission.
(c) Payment for services provided a recipient admitted to a
hospital under this section shall be made only for services that the
office or the contractor under IC 12-15-30 determines were medically
reasonable and necessary.
As added by P.L.2-1992, SEC.9.
IC 12-15-12-7
Providers from whom recipients may obtain eye care services other
than surgical services
Sec. 7. A Medicaid recipient may obtain eye care services, except
for surgical services, from any provider licensed under IC 25-22.5 or
IC 25-24 who has entered into a provider agreement under
IC 12-15-11.
As added by P.L.2-1992, SEC.9.
IC 12-15-12-8
Providers from whom recipients may obtain foot care services
Sec. 8. A Medicaid recipient may obtain foot care services from
any provider licensed under IC 25-22.5 or IC 25-29 who has entered
into a provider agreement under IC 12-15-11.
As added by P.L.2-1992, SEC.9.
IC 12-15-12-9
Providers from whom recipients may obtain psychiatric services
Sec. 9. A Medicaid recipient may obtain psychiatric services from
any provider licensed under IC 25-22.5 who has entered into a
provider agreement under IC 12-15-11.
As added by P.L.2-1992, SEC.9.
IC 12-15-12-10
Selection or assignment of managed care provider; selection of new
provider; exception
Sec. 10. (a) A Medicaid recipient who has selected or been
assigned a managed care provider under this chapter may not select
a new managed care provider for twelve (12) months after the
managed care provider was selected or assigned.
(b) The office may make an exception to the requirement under
subsection (a) if the office determines that circumstances warrant a
change.
As added by P.L.2-1992, SEC.9.
IC 12-15-12-11
Waiver from Department of Health and Human Services;
implementation of chapter
Sec. 11. The office shall seek the necessary waiver under 42
U.S.C. 1396n(b)(1) from the United States Department of Health and
Human Services to implement this chapter.
As added by P.L.2-1992, SEC.9.
IC 12-15-12-12
Payments to providers
Sec. 12. For a managed care program or demonstration project
established or authorized by the office, or established or authorized
by another entity or agency working in conjunction with or under
agreement with the office, the office must provide for payment to
providers in the managed care program that the office finds is
reasonable and adequate to meet the costs that must be incurred by
efficiently and economically operated providers in order to:
(1) provide care and services in conformity with applicable state
and federal laws, regulations, and quality and safety standards;
and
(2) ensure that individuals eligible for medical assistance under
the managed care program or demonstration project have
reasonable access (taking into account geographic location and
reasonable travel time) to the services provided by the managed
care program.
As added by P.L.93-1995, SEC.3.
IC 12-15-12-13
Permitted forms
Sec. 13. (a) The office and an entity with which the office
contracts for the payment of claims shall accept claims submitted on
any of the following forms by an individual or organization that is a
contractor or subcontractor of the office:
(1) HCFA-1500.
(2) HCFA-1450 (UB92).
(3) American Dental Association (ADA) claim form.
(4) Pharmacy and compound drug form.
(b) The office and an entity with which the office contracts for the
payment of claims:
(1) may designate as acceptable claim forms other than a form
listed in subsection (a); and
(2) may not mandate the use of a crossover claim form.
As added by P.L.256-2001, SEC.2.
IC 12-15-12-14
Enrollment in risk-based managed care program required
Sec. 14. (a) This section applies to a Medicaid recipient:
(1) who is determined by the office to be eligible for enrollment
in a Medicaid managed care program;
(2) whose Medicaid eligibility is not based on the individual's
aged, blind, or disabled status; and
(3) who resides in a county having a population of:
(A) more than one hundred eighty-two thousand seven
hundred ninety (182,790) but less than two hundred
thousand (200,000);
(B) more than one hundred seventy thousand (170,000) but
less than one hundred eighty thousand (180,000);
(C) more than two hundred thousand (200,000) but less than
three hundred thousand (300,000);
(D) more than three hundred thousand (300,000) but less
than four hundred thousand (400,000); or
(E) more than four hundred thousand (400,000) but less than
seven hundred thousand (700,000).
(b) Not later than January 1, 2003, the office shall require a
recipient described in subsection (a) to enroll in the risk-based
managed care program.
(c) The office:
(1) shall apply to the United States Department of Health and
Human Services for any approval necessary; and
(2) may adopt rules under IC 4-22-2;
to implement this section.
As added by P.L.291-2001, SEC.160. Amended by P.L.170-2002,
SEC.81; P.L.107-2002, SEC.11; P.L.1-2003, SEC.55.
IC 12-15-12-15
Coverage for emergency services
Sec. 15. The office, for purposes of the primary care case
management program, and a managed care contractor, for purposes
of the risk-based managed care program, shall:
(1) cover and pay for all medically necessary screening services
provided to an individual who presents to an emergency
department with an emergency medical condition; and
(2) beginning July 1, 2001, not deny or fail to process a claim
for reimbursement for emergency services on the basis that the
enrollee's primary care provider's authorization code for the
services was not obtained before or after the services were
rendered.
As added by P.L.223-2001, SEC.7.
IC 12-15-12-16
Reserved
IC 12-15-12-17
Coverage for post-stabilization care services
Sec. 17. (a) This section applies to post-stabilization care services
provided to an individual enrolled in:
(1) the Medicaid risk-based managed care program; or
(2) the Medicaid primary care case management program.
(b) The office, if the individual is enrolled in the primary care
case management program, or the managed care organization, if the
individual is enrolled in the risk-based managed care program, is
financially responsible for the following services provided to an
enrollee:
(1) Post-stabilization care services that are pre-approved by a
representative of the office or the managed care organization,
as applicable.
(2) Post-stabilization care services that are not pre-approved by
a representative of the office or the managed care organization,
as applicable, but that are administered to maintain the
enrollee's stabilized condition within one (1) hour of a request
to the office or the managed care organization for pre-approval
of further post-stabilization care services.
(3) Post-stabilization care services provided after an enrollee is
stabilized that are not pre-approved by a representative of the
office or the managed care organization, as applicable, but that
are administered to maintain, improve, or resolve the enrollee's
stabilized condition if the office or the managed care
organization:
(A) does not respond to a request for preapproval within one
(1) hour;
(B) cannot be contacted; or
(C) cannot reach an agreement with the enrollee's treating
physician concerning the enrollee's care, and a physician
representing the office or the managed care organization, as
applicable, is not available for consultation.
(c) If the conditions described in subsection (b)(3)(C) exist, the
office or the managed care organization, as applicable, shall give the
enrollee's treating physician an opportunity to consult with a
physician representing the office or the managed care organization.
The enrollee's treating physician may continue with care of the
enrollee until a physician representing the office or the managed care
organization, as applicable, is reached or until one (1) of the
following criteria is met:
(1) A physician:
(A) representing the office or the managed care organization,
as applicable; and
(B) who has privileges at the treating hospital;
assumes responsibility for the enrollee's care.
(2) A physician representing the office or the managed care
organization, as applicable, assumes responsibility for the
enrollee's care through transfer.
(3) A representative of the office or the managed care
organization, as applicable, and the treating physician reach an
agreement concerning the enrollee's care.
(4) The enrollee is discharged from the treating hospital.
(d) This subsection applies to post-stabilization care services
provided under subsection (b)(1), (b)(2), and (b)(3) to an individual
enrolled in the Medicaid risk-based managed care program by a
provider who has not contracted with a Medicaid risk-based managed
care organization to provide post-stabilization care services under
subsection (b)(1), (b)(2), and (b)(3) to the individual. Payment for
post-stabilization care services provided under subsection (b)(1),
(b)(2), and (b)(3) must be in an amount equal to one hundred percent
(100%) of the current Medicaid fee for service reimbursement rates
for such services.
(e) This section does not prohibit a managed care organization
from entering into a subcontract with another Medicaid risk-based
managed care organization providing for the latter organization to
assume financial responsibility for making the payments required
under this section.
(f) This section does not limit the ability of the office or the
managed care organization to:
(1) review; and
(2) make a determination of;
the medical necessity of the post-stabilization care services provided
to an enrollee for purposes of determining coverage for such
services.
As added by P.L.223-2001, SEC.8.
IC 12-15-12-18
Payment for emergency services
Sec. 18. (a) Except as provided in subsection (b), this section
applies to:
(1) emergency services provided to an individual enrolled in the
Medicaid risk-based managed care program; and
(2) medically necessary screening services provided to an
individual enrolled in the Medicaid risk-based managed care
program;
who presents to an emergency department with an emergency
medical condition.
(b) This section does not apply to emergency services or screening
services provided to an individual enrolled in the Medicaid
risk-based managed care program by a provider who has contracted
with a Medicaid risk-based managed care organization to provide
emergency services to the individual.
(c) Payment for emergency services and medically necessary
screening services in the emergency department of a hospital
licensed under IC 16-21 must be in an amount equal to one hundred
percent (100%) of the current Medicaid fee for service
reimbursement rates for such services.
(d) Payment under subsection (c) is the responsibility of the
enrollee's risk-based managed care organization. This subsection
does not prohibit the risk-based managed care organization from
entering into a subcontract with another Medicaid risk-based
managed care organization providing for the latter organization to
assume financial responsibility for making the payments required
under this section.
(e) This section does not limit the ability of the managed care
organization to:
(1) review; and
(2) make a determination of;
the medical necessity of the services provided in a hospital's
emergency department for purposes of determining coverage for such
services.
As added by P.L.223-2001, SEC.9.
IC 12-15-12-19
Disease management program; case management program
Sec. 19. (a) This section applies to an individual who is a
Medicaid recipient.
(b) Subject to subsection (c), the office shall develop the
following programs regarding individuals described in subsection
(a):
(1) A disease management program for recipients with any of
the following chronic diseases:
(A) Asthma.
(B) Diabetes.
(C) Congestive heart failure or coronary heart disease.
(D) Hypertension.
(E) Kidney disease.
(2) A case management program for recipients described in
subsection (a) who are at high risk of chronic disease, that is
based on a combination of cost measures, clinical measures, and
health outcomes identified and developed by the office with
input and guidance from the state department of health and
other experts in health care case management or disease
management programs.
(c) The office shall implement:
(1) a pilot program for at least two (2) of the diseases listed in
subsection (b) not later than July 1, 2003; and
(2) a statewide chronic disease program as soon as practicable
after the office has done the following:
(A) Evaluated a pilot program described in subdivision (1).
(B) Made any necessary changes in the program based on
the evaluation performed under clause (A).
(d) The office shall develop and implement a program required
under this section in cooperation with the state department of health
and shall use the following persons to the extent possible:
(1) Community health centers.
(2) Federally qualified health centers (as defined in 42 U.S.C.
1396d(l)(2)(B)).
(3) Rural health clinics (as defined in 42 U.S.C. 1396d(l)(1)).
(4) Local health departments.
(5) Hospitals.
(6) Public and private third party payers.
(e) The office may contract with an outside vendor or vendors to
assist in the development and implementation of the programs
required under this section.
(f) The office and the state department of health shall provide the
select joint commission on Medicaid oversight established by
IC 2-5-26-3 with an evaluation and recommendations on the costs,
benefits, and health outcomes of the pilot programs required under
this section. The evaluations required under this subsection must be
provided not more than twelve (12) months after the implementation
date of the pilot programs.
(g) The office and the state department of health shall report to the
select joint commission on Medicaid oversight established by
IC 2-5-26-3 not later than November 1 of each year regarding the
programs developed under this section.
(h) The disease management program services for a recipient
diagnosed with diabetes or hypertension must include education for
the recipient on kidney disease and the benefits of having evaluations
and treatment for chronic kidney disease according to accepted
practice guidelines.
As added by P.L.291-2001, SEC.161. Amended by P.L.66-2002,
SEC.2; P.L.212-2003, SEC.1; P.L.13-2004, SEC.1; P.L.48-2005,
SEC.1; P.L.18-2007, SEC.1.
IC 12-15-12-20
Child lead poisoning screening
Sec. 20. The office shall develop the following:
(1) A measure to evaluate the performance of a Medicaid
managed care organization in screening a child who is less than
six (6) years of age for lead poisoning.
(2) A system to maintain the results of an evaluation under
subdivision (1) in written form.
(3) A performance incentive program for Medicaid managed
care organizations evaluated under subdivision (1).
As added by P.L.135-2005, SEC.1.
IC 12-15-12-21
Accreditation
Sec. 21. (a) Not later than January 1, 2011, the following must be
accredited by the National Committee for Quality Assurance or its
successor:
(1) A managed care organization that has contracted with the
office before July 1, 2008, to provide Medicaid services under
the risk based managed care program.
(2) A behavioral health managed care organization that has
contracted before July 1, 2008, with a managed care
organization described in subdivision (1).
(b) A:
(1) managed care organization that has contracted with the
office after June 30, 2008, to provide Medicaid services under
the risk based managed care program; or
(2) behavioral health managed care organization that has
contracted after June 30, 2008, with a managed care
organization described in subdivision (1);
must begin the accreditation process and obtain accreditation by the
National Committee for Quality Assurance or its successor at the
earliest time that the National Committee for Quality Assurance
allows a managed care organization to be accredited.
As added by P.L.113-2008, SEC.6.
IC 12-15-12-22
Accepting, receiving, and processing electronic claims
Sec. 22. A:
(1) managed care organization that has a contract with the
office to provide Medicaid services under the risk based
managed care program; or
(2) behavioral health managed care organization that has
contracted with a managed care organization described in
subdivision (1);
shall accept, receive, and process claims for payment that are filed
electronically by a Medicaid provider.
As added by P.L.113-2008, SEC.7.