CHAPTER 15. PARTICIPATING PROVIDERS; CONTRACTS AND LEGAL ACTIONS
IC 27-13-15
Chapter 15. Participating Providers; Contracts and Legal Actions
IC 27-13-15-1
Contract requirements; enrollee coverage; payment of provider;
application
Sec. 1. (a) A contract between a health maintenance organization
and a participating provider of health care services:
(1) must be in writing;
(2) may not prohibit the participating provider from disclosing:
(A) the terms of the contract as it relates to financial or other
incentives to limit medical services by the participating
provider; or
(B) all treatment options available to an insured, including
those not covered by the insured's policy;
(3) may not provide for a financial or other penalty to a provider
for making a disclosure permitted under subdivision (2); and
(4) must provide that in the event the health maintenance
organization fails to pay for health care services as specified by
the contract, the subscriber or enrollee is not liable to the
participating provider for any sums owed by the health
maintenance organization.
(b) An enrollee is not entitled to coverage of a health care service
under a group or an individual contract unless that health care service
is included in the enrollee's contract.
(c) A provider is not entitled to payment under a contract for
health care services provided to an enrollee unless the provider has
a contract or an agreement with the carrier.
(d) This section applies to a contract entered, renewed, or
modified after June 30, 1996.
As added by P.L.26-1994, SEC.25. Amended by P.L.195-1996,
SEC.7; P.L.192-1996, SEC.3.
IC 27-13-15-2
Contract requirements not met; collection of money owed by
health maintenance organization prohibited
Sec. 2. If:
(1) the contract between a health maintenance organization and
a participating provider has not been reduced to writing as
required by this chapter; or
(2) the contract fails to contain the provision required by section
1(a)(4) of this chapter;
the participating provider may not collect or attempt to collect from
the subscriber or enrollee any sums that are owed by the health
maintenance organization.
As added by P.L.26-1994, SEC.25. Amended by P.L.203-2001,
SEC.25.
IC 27-13-15-3
Actions against subscribers; costs and attorney's fees
Sec. 3. (a) A:
(1) participating provider; or
(2) trustee, an agent, a representative, or an assignee of a
participating provider;
may not bring or maintain any legal action against a subscriber or an
enrollee of a health maintenance organization to collect sums owed
by the health maintenance organization.
(b) Except as provided in subsection (c), if a participating
provider of a health maintenance organization brings or maintains a
legal action against a subscriber or enrollee for an amount owed to
the participating provider by the health maintenance organization, the
participating provider is liable to the subscriber or enrollee for costs
and attorney's fees incurred by the subscriber or enrollee in
defending the legal action.
(c) A participating provider shall not be liable to the subscriber or
enrollee for costs and attorney's fees described in subsection (b) if
the participating provider can demonstrate a reasonable basis for
believing at the time the legal action was brought and while the legal
action was maintained that the health maintenance organization did
not owe the sums the participating provider sought to collect from
the subscriber or enrollee.
As added by P.L.26-1994, SEC.25. Amended by P.L.203-2001,
SEC.26.
IC 27-13-15-4
Participating provider agreement prohibitions
Sec. 4. (a) As used in this section, "health maintenance
organization" includes the following:
(1) A limited service health maintenance organization.
(2) A person that pays or administers claims on behalf of a
health maintenance organization or a limited service health
maintenance organization.
(b) An agreement between a health maintenance organization and
a participating provider under this chapter may not contain a
provision that:
(1) prohibits, or grants the health maintenance organization an
option to prohibit, the participating provider from contracting
with another health maintenance organization to accept lower
payment for health care services than the payment specified in
the agreement;
(2) requires, or grants the health maintenance organization an
option to require, the participating provider to accept a lower
payment from the health maintenance organization if the
participating provider agrees with another health maintenance
organization to accept lower payment for health care services;
(3) requires, or grants the health maintenance organization an
option of, termination or renegotiation of the agreement if the
participating provider agrees with another health maintenance
organization to accept lower payment for health care services;
or
(4) requires the participating provider to disclose the
participating provider's reimbursement rates under contracts
with other health maintenance organizations.
(c) A contract provision that violates this section is void.
As added by P.L.74-2007, SEC.2.
IC 27-13-15-5
Coverage for dialysis treatment
Sec. 5. (a) Notwithstanding IC 27-13-1-12, as used in this section,
"enrollee" refers only to an enrollee who requires dialysis treatment.
(b) As used in this section, "health maintenance organization"
includes the following:
(1) A limited service health maintenance organization.
(2) An agent of a health maintenance organization or a limited
service health maintenance organization.
(c) A health maintenance organization shall not require an
enrollee, as a condition of coverage or reimbursement, to:
(1) if the nearest dialysis facility is located within thirty (30)
miles of the enrollee's home, travel more than thirty (30) miles
from the enrollee's home to obtain dialysis treatment; or
(2) if the nearest dialysis facility is located more than thirty (30)
miles from the enrollee's home, travel a greater distance than
the distance to the nearest dialysis facility to obtain dialysis
treatment;
regardless of whether the enrollee chooses to receive dialysis
treatment at a dialysis facility that is a participating provider or a
dialysis facility that is not a participating provider.
As added by P.L.111-2008, SEC.6.