CHAPTER 4. BENEFITS, CROWD OUT, AND COST SHARING
IC 12-17.6-4
Chapter 4. Benefits, Crowd Out, and Cost Sharing
IC 12-17.6-4-1
Applicability of chapter
Sec. 1. This chapter does not apply until January 1, 2000.
As added by P.L.273-1999, SEC.177.
IC 12-17.6-4-2
Services covered; prohibition on treatment limitations or financial
requirements; mental health services
Sec. 2. (a) The benefit package provided under the program shall
focus on age appropriate preventive, primary, and acute care
services.
(b) The office shall offer health insurance coverage for the
following basic services:
(1) Inpatient and outpatient hospital services.
(2) Physicians' services provided by a physician (as defined in
42 U.S.C. 1395x(r)).
(3) Laboratory and x-ray services.
(4) Well-baby and well-child care, including:
(A) age appropriate immunizations; and
(B) periodic screening, diagnosis, and treatment services
according to a schedule developed by the office.
The office may offer services in addition to those listed in this
subsection if appropriations to the program exist to pay for the
additional services.
(c) The office shall offer health insurance coverage for the
following additional services if the coverage for the services has an
actuarial value equal to or greater than the actuarial value of the
services provided by the benchmark program determined by the
children's health policy board established by IC 4-23-27-2:
(1) Prescription drugs.
(2) Mental health services.
(3) Vision services.
(4) Hearing services.
(5) Dental services.
(d) Notwithstanding subsections (b) and (c), the office may not
impose treatment limitations or financial requirements on the
coverage of services for a mental illness if similar treatment
limitations or financial requirements are not imposed on coverage for
services for other illnesses. Coverage for mental illness under the
program must include the following:
(1) Inpatient mental health services and substance abuse
services provided in an institution that:
(A) treats mental disease; and
(B) has more than sixteen (16) beds;
unless coverage is prohibited by federal law.
(2) Psychiatric residential treatment services.
(3) Community mental health rehabilitation services.
(4) Outpatient mental health services and substance abuse
services, with no greater limitations on the number of units per
rolling year than are required under the Medicaid program.
However, the office may require prior authorization for the services
specified in subdivisions (1) through (4).
As added by P.L.273-1999, SEC.177. Amended by P.L.103-2009,
SEC.1.
IC 12-17.6-4-2.5
Prescription drug requirements
Sec. 2.5. Prescription drugs provided under the program are
subject to the requirements of IC 12-15-35.5.
As added by P.L.6-2002, SEC.5.
IC 12-17.6-4-3
Limits on premium and cost sharing amounts
Sec. 3. Premium and cost sharing amounts established by the
office are limited by the following:
(1) Deductibles, coinsurance, or other cost sharing is not
permitted with respect to benefits for:
(A) well-baby and well-child care, including age appropriate
immunizations; and
(B) services provided for treatment of an emergency in an
emergency department of a hospital licensed under IC 16-21.
(2) Premiums and other cost sharing may be imposed based on
family income. However, the total annual aggregate cost sharing
with respect to all children in a family under this article may not
exceed five percent (5%) of the family's income for the year.
As added by P.L.273-1999, SEC.177. Amended by P.L.95-2000,
SEC.3.
IC 12-17.6-4-4
Powers of office; cost sharing and crowd out
Sec. 4. The office may do the following:
(1) Determine cost sharing amounts.
(2) Determine waiting periods that may not exceed three (3)
months and exceptions to the requirement of waiting periods for
potential enrollees in the program.
(3) Adopt additional methods for complying with federal
requirements relating to crowd out.
As added by P.L.273-1999, SEC.177.
IC 12-17.6-4-5
Prohibited referrals; mechanisms to minimize incentive for
employer to eliminate or reduce coverage
Sec. 5. (a) It is a violation of IC 27-4-1-4 if an insurer, or an
insurance producer or insurance broker compensated by the insurer,
knowingly or intentionally refers an insured or the dependent of an
insured to the program for health insurance coverage when the
insured already receives health insurance coverage through an
employer's health care plan that is underwritten by the insurer.
(b) The office shall coordinate with the children's health policy
board under IC 4-23-27 to evaluate the need for mechanisms that
minimize the incentive for an employer to eliminate or reduce health
care coverage for an employee's dependents.
As added by P.L.273-1999, SEC.177. Amended by P.L.178-2003,
SEC.3.
IC 12-17.6-4-6
Community health centers
Sec. 6. Community health centers shall be used to provide health
care services.
As added by P.L.273-1999, SEC.177.
IC 12-17.6-4-7
Selection of primary dental provider encouraged
Sec. 7. The office shall encourage the parent of a child who is
enrolled in the program to select a primary dental provider for the
child before the child is eighteen (18) months of age.
As added by P.L.169-2001, SEC.3.
IC 12-17.6-4-8
Use of generic drugs and preferred drug list required
Sec. 8. (a) The office shall require the use of generic drugs in the
program.
(b) The office shall use the preferred drug list implemented under
IC 12-15-35-28.7.
As added by P.L.291-2001, SEC.158. Amended by P.L.107-2002,
SEC.26.
IC 12-17.6-4-9
Reserved
IC 12-17.6-4-10
Brand name drugs not limited
Sec. 10. The office may not limit the number of brand name
prescription drugs a recipient may receive under the program.
As added by P.L.107-2002, SEC.27.