Bill Text: IN SB0065 | 2011 | Regular Session | Amended
Bill Title: Out of network health provider payments.
Spectrum: Partisan Bill (Republican 2-0)
Status: (Introduced - Dead) 2011-02-17 - Amendment 2 (Alting), prevailed; [SB0065 Detail]
Download: Indiana-2011-SB0065-Amended.html
Citations Affected: IC 27-8; IC 27-13.
Synopsis: Out of network health provider payments. Specifies
requirements concerning health benefit payments to providers that have
not entered into payment agreements with health carriers.
Effective: July 1, 2011.
January 5, 2011, read first time and referred to Committee on Health and Provider
Services.
February 10, 2011, amended, reported favorably _ Do Pass.
February 14, 2011, read second time, amended, ordered engrossed.
February 15, 2011, engrossed, returned to second reading.
February 17, 2011, re-read second time, amended, ordered engrossed.
PRINTING CODE. Amendments: Whenever an existing statute (or a section of the Indiana Constitution) is being amended, the text of the existing provision will appear in this style type, additions will appear in this style type, and deletions will appear in
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A BILL FOR AN ACT to amend the Indiana Code concerning
insurance.
Chapter 5.9. Assignment of Benefits
Sec. 1. As used in this chapter, "assignment of benefits" means a written instrument that:
(1) is executed:
(A) by a covered individual; or
(B) for a covered individual by the authorized representative of the covered individual; and
(2) assigns to a provider the covered individual's right to receive reimbursement for health care services provided to the covered individual.
Sec. 2. As used in this chapter, "contracted provider" means a provider that has entered into an agreement with an insurer under IC 27-8-11-3.
Sec. 3. As used in this chapter, "covered individual" means an
individual entitled to benefits under a policy.
Sec. 4. As used in this chapter, "health care services" has the
meaning set forth in IC 27-8-11-1. The term includes ambulance
services.
Sec. 5. As used in this chapter, "insurer" includes the following:
(1) An insurer that issues a policy.
(2) An administrator licensed under IC 27-1-25 that pays or
administers claims for benefits under a policy.
Sec. 6. As used in this chapter, "noncontracted provider" means
a provider that has not entered into an agreement with an insurer
under IC 27-8-11-3.
Sec. 7. As used in this chapter, "policy" refers to a policy of
accident and sickness insurance (as defined in IC 27-8-5-1).
Sec. 8. As used in this chapter, "provider" has the meaning set
forth in IC 27-8-11-1. The term includes the following:
(1) A chiropractor licensed under IC 25-10.
(2) An ambulance service provider.
Sec. 9. (a) Except as provided in subsection (b), if:
(1) a policy provides coverage for a health care service;
(2) the health care service is rendered by a noncontracted
provider; and
(3) the noncontracted provider:
(A) has an assignment of benefits from the covered
individual to whom the health care service is rendered that
assigns to the noncontracted provider the covered
individual's right to reimbursement for the health care
service; and
(B) provides written or electronic notification to the
insurer that the noncontracted provider:
(i) has rendered the health care service to the covered
individual; and
(ii) has the assignment of benefits;
the insurer shall make a benefit payment directly to the
noncontracted provider for the health care service and send
written notice of the payment to the covered individual or the
authorized representative of the covered individual.
(b) An insurer is not required to make a benefit payment
directly to a noncontracted provider described in subsection (a) if
the noncontracted provider has been convicted of fraud.
(c) This section does not require:
(1) coverage for benefits not covered under the terms of a
policy; or
(2) payment to a noncontracted provider that is not eligible for a benefit payment under the terms of a policy.
Sec. 10. If:
(1) a noncontracted provider is entitled to a direct benefit payment under section 9 of this chapter;
(2) the insurer makes the benefit payment directly to the covered individual or the authorized representative of the covered individual rather than to the noncontracted provider; and
(3) the noncontracted provider notifies the insurer that the noncontracted provider has not received the benefit payment;
the insurer, not more than thirty (30) days after receiving the notice from the noncontracted provider, shall make the benefit payment directly to the noncontracted provider.
Sec. 11. If:
(1) a noncontracted provider is entitled to a direct benefit payment under section 9 of this chapter; and
(2) there is a good faith dispute regarding the:
(A) legitimacy of the claim relating to the health care service rendered;
(B) appropriate amount of reimbursement for the claim; or
(C) authorization for the assignment of benefits;
the insurer, not more than fourteen (14) business days after the insurer receives the claim and all documentation reasonably necessary to determine claim payment, shall provide notice of the dispute to the noncontracted provider or the noncontracted provider's agent.
Sec. 12. (a) Except as provided in subsection (c), a noncontracted provider or noncontracted provider's agent shall disclose to a covered individual the following applicable information:
(1) That the noncontracted provider has not entered into an agreement with the insurer to provide health care services to the covered individual.
(2) That the covered individual may be billed for health care services for which payment is not made by the insurer.
(b) A disclosure required by subsection (a) must be:
(1) made in writing; and
(2) if included in a document containing consent for treatment, displayed conspicuously.
(c) A disclosure is not required under subsection (a) if any of the
following apply:
(1) The covered individual is unconscious, incoherent, or
incompetent.
(2) The covered individual:
(A) arrives at a hospital that is required to provide
emergency medical screening or care under 42 U.S.C.
1395dd; and
(B) seeks emergency medical screening or care.
(3) The noncontracted provider does not know and could not
reasonably know that the covered individual is covered under
a policy issued by an insurer for which the noncontracted
provider is not a contracted provider.
(4) The noncontracted provider has been requested to render
health care services to the covered individual after the
covered individual has been admitted for inpatient or
outpatient services and the noncontracted provider's services
were not part of the original treatment plan.
Sec. 13. (a) An insurer that does not comply with this chapter
shall pay interest for each day of noncompliance at the same
interest rate as provided in IC 12-15-21-3(7)(A).
(b) IC 27-8-5.7 applies to payment of a claim submitted to an
insurer by a noncontracted provider in compliance with this
chapter.
Sec. 14. A noncontracted provider, by accepting an assignment
of benefits from a covered individual, does not agree to accept an
insurer's fee schedule or specific payment rate as payment in full,
partial payment, or appropriate payment.
Sec. 15. A policy or contract provision that violates this chapter
is void.
Chapter 36.3. Payment to Nonparticipating Providers
Sec. 1. As used in this chapter, "health care services" includes ambulance services.
Sec. 2. As used in this chapter, "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 limited service health maintenance organization.
Sec. 3. As used in this chapter, "nonparticipating provider"
means a provider that has not entered into an agreement described
in IC 27-13-1-24.
Sec. 4. As used in this chapter, "provider" includes the
following:
(1) A chiropractor licensed under IC 25-10.
(2) An ambulance service provider.
Sec. 5. (a) Except as provided in subsection (b), if:
(1) an individual contract or a group contract provides
coverage for a health care service;
(2) the health care service is rendered by a nonparticipating
provider; and
(3) the nonparticipating provider provides written or
electronic notification to the health maintenance organization
that the nonparticipating provider has rendered the health
care service to an enrollee who is covered under the individual
contract or group contract;
the health maintenance organization shall make a benefit payment
directly to the nonparticipating provider for the health care service
and send written notice of the payment to the enrollee or the
authorized representative of the enrollee.
(b) A health maintenance organization is not required to make
a benefit payment directly to a nonparticipating provider
described in subsection (a) if the nonparticipating provider has
been convicted of fraud.
(c) This section does not require:
(1) coverage for benefits not covered under the terms of an
individual contract or a group contract; or
(2) payment to a nonparticipating provider that is not eligible
for a benefit payment under the terms of an individual
contract or a group contract.
Sec. 6. If:
(1) a nonparticipating provider is entitled to a direct benefit
payment under section 5 of this chapter;
(2) the health maintenance organization makes the benefit
payment directly to the enrollee or the authorized
representative of the enrollee rather than to the
nonparticipating provider; and
(3) the nonparticipating provider notifies the health
maintenance organization that the nonparticipating provider
has not received the benefit payment;
the health maintenance organization, not more than thirty (30)
days after receiving the notice from the nonparticipating provider,
shall make the benefit payment directly to the nonparticipating
provider.
Sec. 7. If:
(1) a nonparticipating provider is entitled to a direct benefit
payment under section 5 of this chapter; and
(2) there is a good faith dispute regarding the:
(A) legitimacy of the claim relating to the health care
service rendered;
(B) appropriate amount of reimbursement for the claim;
or
(C) payment of the claim under the terms of the individual
contract or group contract;
the health maintenance organization, not more than fourteen (14)
business days after the health maintenance organization receives
the claim and all documentation reasonably necessary to determine
claim payment, shall provide notice of the dispute to the
nonparticipating provider or the nonparticipating provider's
agent.
Sec. 8. (a) Except as provided in subsection (c), a
nonparticipating provider or nonparticipating provider's agent
shall disclose to an enrollee the following applicable information:
(1) That the nonparticipating provider has not entered into an
agreement with the health maintenance organization to
provide health care services to the enrollee.
(2) That the enrollee may, subject to IC 27-13-36-5 and
IC 27-13-36-9, be billed for health care services for which
payment is not made by the health maintenance organization.
(b) A disclosure required by subsection (a) must be:
(1) made in writing; and
(2) if included in a document containing consent for
treatment, displayed conspicuously.
(c) A disclosure is not required under subsection (a) if any of the
following apply:
(1) The enrollee is unconscious, incoherent, or incompetent.
(2) The enrollee:
(A) arrives at a hospital that is required to provide
emergency medical screening or care under 42 U.S.C.
1395dd; and
(B) seeks emergency medical screening or care.
(3) The nonparticipating provider does not know and could
not reasonably know that the enrollee is covered under an
individual contract or a group contract entered into by a
health maintenance organization for which the
nonparticipating provider is not a participating provider.
(4) The nonparticipating provider has been requested to
render health care services to the enrollee after the enrollee
has been admitted for inpatient or outpatient services and the
nonparticipating provider's services were not part of the
original treatment plan.
Sec. 9. (a) A health maintenance organization that does not
comply with this chapter shall pay interest for each day of
noncompliance at the same interest rate as provided in
IC 12-15-21-3(7)(A).
(b) IC 27-13-36.2 applies to payment of a claim submitted to a
health maintenance organization by a nonparticipating provider in
compliance with this chapter.
Sec. 10. A nonparticipating provider, by rendering health care
services to an enrollee, does not agree to accept a health
maintenance organization's fee schedule or specific payment rate
as payment in full, partial payment, or appropriate payment.
Sec. 11. A contract provision that violates this chapter is void.
