CHAPTER 36. PATIENT PROTECTION; CLINICAL DECISION MAKING; ACCESS TO PERSONNEL AND FACILITIES
IC 27-13-36
Chapter 36. Patient Protection; Clinical Decision Making; Access
to Personnel and Facilities
IC 27-13-36-1
Medical director; individual to develop treatment policies and
consult with treating providers
Sec. 1. (a) Each health maintenance organization shall appoint a
medical director who has an unlimited license to practice medicine
under IC 25-22.5 or an equivalent license issued by another state.
(b) The medical director is responsible for oversight of treatment
policies, protocols, quality assurance activities, and utilization
management decisions of the health maintenance organization.
(c) A health maintenance organization shall contract with or
employ at least one (1) individual who holds an unlimited license to
practice medicine under IC 25-22.5 to do the following:
(1) Develop, in consultation with a group of appropriate
providers, the health maintenance organization's treatment
policies, protocols, and quality assurance activities.
(2) Consult with the treating provider before an adverse
utilization review decision is made.
(d) Compliance with the most current standards or guidelines
developed by the National Committee on Quality Assurance or a
successor organization is sufficient to meet the requirements of this
section.
As added by P.L.69-1998, SEC.14.
IC 27-13-36-2
Sufficient number and type of primary care providers
Sec. 2. Beginning July 1, 1999, each health maintenance
organization shall include a sufficient number and type of primary
care providers and other appropriate providers throughout the health
maintenance organization's service area to:
(1) meet the needs of; and
(2) provide a choice of primary care providers and other
appropriate providers to;
enrollees and subscribers of the health maintenance organization.
Compliance with the most current standards or guidelines developed
by the National Committee on Quality Assurance or a successor
organization is sufficient to meet the requirements of this section.
As added by P.L.69-1998, SEC.14.
IC 27-13-36-2.5
Discrimination on basis of provider's license or certification
prohibited
Sec. 2.5. (a) A health maintenance organization may not
discriminate against a provider acting within the scope of the
provider's license or certification with respect to:
(1) participation;
(2) reimbursement;
(3) indemnification; or
(4) scope of care;
solely on the basis of the provider's license or certification.
(b) This section does not require a health maintenance
organization to enter into a contract with a provider that would allow
the provider to enter the health maintenance organization network.
As added by P.L.233-1999, SEC.13.
IC 27-13-36-3
Adequate number of services and providers within reasonable
proximity of subscribers
Sec. 3. (a) The provisions of this section do not apply until July
1, 1999.
(b) Each health maintenance organization shall demonstrate to the
department that the health maintenance organization offers an
adequate number of:
(1) acute care hospital services;
(2) primary care providers; and
(3) other appropriate providers;
that are located within a reasonable proximity of subscribers of the
health maintenance organization. Compliance with the most current
standards or guidelines developed by the National Committee on
Quality Assurance or a successor organization is sufficient to meet
the requirements of this subsection.
(c) If a health maintenance organization provides coverage for:
(1) specialty medical services, including physical therapy,
occupational therapy, and rehabilitation services;
(2) mental and behavioral care services; or
(3) pharmacy services;
the health maintenance organization shall demonstrate to the
department that the offered services are located within a reasonable
proximity of subscribers of the health maintenance organization.
Compliance with the most current standards or guidelines developed
by the National Committee on Quality Assurance or a successor
organization is sufficient to meet the requirements of this subsection.
As added by P.L.69-1998, SEC.14.
IC 27-13-36-4
Specialty areas of primary care providers
Sec. 4. Beginning July 1, 1999, primary care providers shall
include licensed physicians who practice in one (1) or more of the
following areas:
(1) Family practice.
(2) General practice.
(3) Internal medicine.
(4) As a woman's health care provider, in compliance with
IC 27-8-24.7.
(5) Pediatrics.
As added by P.L.69-1998, SEC.14.
IC 27-13-36-5
Referrals to out of network providers
Sec. 5. (a) The provisions of the section do not apply until July 1,
1999.
(b) When an enrollee's primary care provider determines that the
enrollee needs a particular health care service and the health
maintenance organization determines that the type of health care
service needed by the enrollee to treat a specific condition:
(1) is a covered service; and
(2) is not available from the health maintenance organization's
network of participating providers;
the primary care provider and the health maintenance organization
shall refer the enrollee to an appropriate provider who is not a
participating provider within a reasonable amount of time and within
a reasonable proximity of the enrollee.
(c) When an enrollee receives health care services from a provider
to whom the enrollee was referred as described in subsection (b), the
health maintenance organization shall pay the out of network
provider the lesser of the following:
(1) The usual, customary, and reasonable charge in the health
maintenance organization's service area for the health care
services provided by the out of network provider.
(2) An amount agreed to between the health maintenance
organization and the out of network provider.
The enrollee's treating provider may collect from the enrollee only
the deductible or copayment, if any, that the enrollee would be
responsible to pay if the health care services had been provided by
a participating provider. The enrollee may not be billed by the health
maintenance organization or by the out of network provider for any
difference between the out of network provider's charge and the
amount paid by the health maintenance organization to the out of
network provider as provided in this subsection.
(d) A contract between a health maintenance organization and a
primary care provider may not provide for a financial or other
penalty to the primary care provider for making a determination
allowed under subsection (b).
As added by P.L.69-1998, SEC.14.
IC 27-13-36-6
Continuation of care provisions
Sec. 6. (a) A health maintenance organization shall include
provisions in the health maintenance organization's contracts with
providers to provide for continuation of care in the event that a
provider's contract with the health maintenance organization is
terminated, provided that the termination is not due to a quality of
care issue.
(b) The contract provisions under subsection (a) shall require that
the provider, upon the request of the enrollee, continue to treat the
enrollee for up to sixty (60) days following the termination of the
provider's contract with the health maintenance organization or, in
the case of a pregnant enrollee in the third trimester of pregnancy,
throughout the term of the enrollee's pregnancy. If the provider is a
hospital, the contract shall provide for continuation of treatment until
the earlier of the following:
(1) Sixty (60) days following the termination of the provider's
contract with the health maintenance organization.
(2) The enrollee is released from inpatient status at the hospital.
(c) During a continuation period under this section, the provider:
(1) shall agree to continue accepting the contract terms and
conditions, together with applicable deductibles and
copayments, as payment in full; and
(2) is prohibited from billing the enrollee for any amounts in
excess of the enrollee's applicable deductible or copayment.
As added by P.L.69-1998, SEC.14.
IC 27-13-36-7
Telephone access for authorization of care
Sec. 7. Each health maintenance organization shall provide the
following:
(1) Telephone access to the health maintenance organization
during business hours to ensure enrollee access for routine care.
(2) Twenty-four (24) hour telephone access to either:
(A) a representative of the health maintenance organization;
or
(B) a participating provider;
for authorization for care.
As added by P.L.69-1998, SEC.14.
IC 27-13-36-8
Guidelines for establishing reasonable periods for appointments
Sec. 8. (a) Each health maintenance organization shall establish
guidelines for establishing reasonable periods of time within which
an enrollee must be given an appointment with a participating
provider, except as provided in section 9 of this chapter regarding
emergency services.
(b) The guidelines described in subsection (a) must include
appointment scheduling guidelines based on the type of health care
services most often requested, including the following:
(1) Prenatal care appointments.
(2) Well-child visits and immunizations.
(3) Routine physicals.
(4) Adult preventive services.
(5) Urgent visits.
As added by P.L.69-1998, SEC.14.
IC 27-13-36-9
Coverage and reimbursement for expenses for care obtained in an
emergency
Sec. 9. (a) As used in this section, "care obtained in an
emergency" means, with respect to an enrollee, covered services that
are:
(1) furnished by a provider within the scope of the provider's
license and as otherwise authorized under law; and
(2) needed to evaluate or stabilize an individual in an
emergency.
(b) As used in this section, "stabilize" means to provide medical
treatment to an individual in an emergency as may be necessary to
assure, within reasonable medical probability, that material
deterioration of the individual's condition is not likely to result from
or during any of the following:
(1) The discharge of the individual from an emergency
department or other care setting where emergency services are
provided to the individual.
(2) The transfer of the individual from an emergency
department or other care setting where emergency services are
provided to the individual to another health care facility.
(3) The transfer of the individual from a hospital emergency
department or other hospital care setting where emergency
services are provided to the individual to the hospital's inpatient
setting.
(c) As described in subsection (d), each health maintenance
organization shall cover and reimburse expenses for care obtained in
an emergency by an enrollee without:
(1) prior authorization; or
(2) regard to the contractual relationship between:
(A) the provider who provided health care services to the
enrollee in an emergency; and
(B) the health maintenance organization;
in a situation where a prudent lay person could reasonably believe
that the enrollee's condition required immediate medical attention.
The emergency care obtained by an enrollee under this section
includes care for the alleviation of severe pain, which is a symptom
of an emergency as provided in IC 27-13-1-11.7.
(d) Each health maintenance organization shall cover and
reimburse expenses for emergency services at a rate equal to the
lesser of the following:
(1) The usual, customary, and reasonable charge in the health
maintenance organization's service area for health care services
provided during the emergency.
(2) An amount agreed to between the health maintenance
organization and the out of network provider.
A provider that provides emergency services to an enrollee under this
section may not charge the enrollee except for an applicable
copayment or deductible. Care and treatment provided to an enrollee
once the enrollee is stabilized is not care obtained in an emergency.
As added by P.L.69-1998, SEC.14.
IC 27-13-36-10
Access plan to meet needs of vulnerable, underserved, and
non-English speaking enrollees
Sec. 10. Each health maintenance organization shall demonstrate
to the commissioner that the health maintenance organization has
developed an access plan to meet the needs of the health maintenance
organization's enrollees, including vulnerable and underserved
enrollees and enrollees from major population groups who speak a
primary language other than English.
As added by P.L.69-1998, SEC.14.
IC 27-13-36-11
Standards for continuity of care
Sec. 11. The health maintenance organization shall develop
standards for continuity of care following enrollment, including
sufficient information on how to access care within the health
maintenance organization.
As added by P.L.69-1998, SEC.14.
IC 27-13-36-12
Payment to enrollee for service rendered by nonparticipating
provider; requirements
Sec. 12. (a) As used in this section, "nonparticipating provider"
means a provider that has not entered into an agreement with a health
maintenance organization to serve as a participating provider.
(b) After September 30, 2009, if a health maintenance
organization makes a payment to an enrollee for a health care service
rendered by a nonparticipating provider, the health maintenance
organization shall include with the payment instrument written notice
to the enrollee that includes the following:
(1) A statement specifying the claims covered by the payment
instrument.
(2) The name and address of the provider submitting each
claim.
(3) The amount paid by the health maintenance organization for
each claim.
(4) Any amount of a claim that is the enrollee's responsibility.
(5) A statement in at least 24 point bold type that:
(A) instructs the enrollee to use the payment to pay the
nonparticipating provider if the enrollee has not paid the
nonparticipating provider in full;
(B) specifies that paying the nonparticipating provider is the
enrollee's responsibility; and
(C) states that the failure to make the payment violates the
law and may result in collection proceedings or criminal
penalties.
As added by P.L.144-2009, SEC.3.