Bill Text: IN SB0461 | 2011 | Regular Session | Enrolled
Bill Title: Federal health care matters.
Spectrum: Slight Partisan Bill (Republican 2-1)
Status: (Passed) 2011-05-18 - SECTIONS 17 through 30 effective retroactive to 09/23/2010 [SB0461 Detail]
Download: Indiana-2011-SB0461-Enrolled.html
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
Additions: Whenever a new statutory provision is being enacted (or a new constitutional provision adopted), the text of the new provision will appear in this style type. Also, the word NEW will appear in that style type in the introductory clause of each SECTION that adds a new provision to the Indiana Code or the Indiana Constitution.
Conflict reconciliation: Text in a statute in this style type or
AN ACT to amend the Indiana Code concerning health insurance.
Chapter 12. Implementation of the Patient Protection and Affordable Care Act
Sec. 1. As used in this chapter, "Patient Protection and Affordable Care Act" refers to the federal Patient Protection and Affordable Care Act (P.L. 111-148), as amended by the federal Health Care and Education Reconciliation Act of 2010 (P.L. 111-152), as amended from time to time, and regulations or guidance issued under those acts.
Sec. 2. As used in the chapter, "health plan" means a policy, contract, certificate, or agreement offered or issued:
(1) by an entity that assumes or carries insurance risk; and
(2) to provide, deliver, arrange for, pay for, or reimburse the costs of health care services.
Sec. 3. Notwithstanding any other law, a resident of Indiana may not be required to purchase coverage under a health plan. A resident may delegate to the resident's employer the resident's authority to purchase or decline to purchase coverage under a health plan.
Sec. 4. The office of the secretary of family and social services
and the department of insurance:
(1) shall investigate; and
(2) may apply for a waiver under;
42 U.S.C. 18052 of the Patient Protection and Affordable Care Act.
(b) The office may request the United States Department of Health and Human Services to approve Indiana's transition, beginning January 1, 2014, as a state that determines eligibility for individuals who are aged, blind, or disabled under Medicaid based on Section 1634 of the federal Social Security Act.
(1) is receiving monthly assistance payments under the federal Supplemental Security Income program; and
(2) meets the income and resource requirements established by
statute or the office unless the state is required to provide medical
assistance to the individual under 42 U.S.C. 1396a(f) or under 42
U.S.C. 1382h;
is eligible to receive Medicaid.
(b) An individual who is receiving monthly disability assistance
payments under the federal Supplemental Security Income program or
the federal Social Security Disability Insurance program must meet the
eligibility requirements specified in IC 12-14-15 unless the state is
required to provide medical assistance to the individual under 42
U.S.C. 1382h.
(c) The office may not apply a spend down requirement to an
individual who is eligible for medical assistance under 42 U.S.C.
1382h.
(d) This section expires December 31, 2013.
(1) Mental health care services.
(2) Inpatient hospital services.
(3) Prescription drug coverage.
(4) Emergency room services.
(5) Physician office services.
(6) Diagnostic services.
(7) Outpatient services, including therapy services.
(8) Comprehensive disease management.
(9) Home health services, including case management.
(10) Urgent care center services.
(11) Preventative care services.
(12) Family planning services:
(A) including contraceptives and sexually transmitted disease testing, as described in federal Medicaid law (42 U.S.C. 1396 et seq.); and
(B) not including abortion or abortifacients.
(13) Hospice services.
(14) Substance abuse services.
(15) A service determined by the secretary to be required by federal law as a benchmark service under the federal Patient Protection and Affordable Care Act.
(b) The plan
(1) Offer coverage for dental and vision services to an individual who participates in the plan.
(2) Pay at least fifty percent (50%) of the premium cost of dental and vision services coverage described in subdivision (1).
(c) An individual who receives the dental or vision coverage offered under subsection (b) shall pay an amount determined by the office for the coverage. The office shall limit the payment to not more than five percent (5%) of the individual's annual household income. The payment required under this subsection is in addition to the payment required under section 11(b)(2) of this chapter for coverage under the plan.
(d) Vision services offered by the plan must include services provided by an optometrist.
(e) The plan must comply with any coverage requirements that apply to an accident and sickness insurance policy issued in Indiana.
(f) The plan may not permit treatment limitations or financial requirements on the coverage of mental health care services or substance abuse services if similar limitations or requirements are not imposed on the coverage of services for other medical or surgical conditions.
(1) An annual individual maximum coverage limitation of three hundred thousand dollars ($300,000).
(2) A lifetime individual maximum coverage limitation of one million dollars ($1,000,000).
(1) The individual is at least eighteen (18) years of age and less than sixty-five (65) years of age.
(2) The individual is a United States citizen and has been a resident of Indiana for at least twelve (12) months.
(3) The individual has an annual household income of not more than the following:
(A) Effective through December 31, 2013, two hundred percent (200%) of the federal income poverty level.
(B) Beginning January 1, 2014, one hundred thirty-three percent (133%) of the federal income poverty level, based on the adjusted gross income provisions set forth in Section 2001(a)(1) of the federal Patient Protection and Affordable
Care Act.
(4) Effective through December 31, 2013, the individual is not
eligible for health insurance coverage through the individual's
employer.
(5) Effective through December 31, 2013, the individual has not
had health insurance coverage for at least six (6) months.
(b) The following individuals are not eligible for the plan:
(1) An individual who participates in the federal Medicare
program (42 U.S.C. 1395 et seq.).
(2) A pregnant woman for purposes of pregnancy related services.
(3) An individual who is otherwise eligible for the Medicaid
program as a disabled person. medical assistance.
(c) The eligibility requirements specified in subsection (a) are
subject to approval for federal financial participation by the United
States Department of Health and Human Services.
(1) The individual.
(2) An employer.
(3) The state.
(4) A nonprofit organization if the nonprofit organization:
(A) is not affiliated with a health care plan; and
(B) does not contribute more than seventy-five percent (75%) of the individual's required payment to the individual's health care account.
(5) An insurer or a health maintenance organization under a contract with the office to provide health insurance coverage under the plan if the payment:
(A) is to provide a health incentive to the individual;
(B) does not count towards the individual's required minimum payment set forth in section 11 of this chapter; and
(C) does not exceed one thousand one hundred dollars ($1,100).
(b) The minimum funding amount for a health care account is the amount required under section 11 of this chapter.
(c) An individual's health care account must be used to pay the individual's deductible for health care services under the plan.
(d) An individual may make payments to the individual's health care
account as follows:
(1) An employer withholding or causing to be withheld from an
employee's wages or salary, after taxes are deducted from the
wages or salary, the individual's contribution under this chapter
and distributed equally throughout the calendar year.
(2) Submission of the individual's contribution under this chapter
to the office to deposit in the individual's health care account in
a manner prescribed by the office.
(3) Another method determined by the office.
(e) An employer may make, from funds not payable by the employer
to the employee, not more than fifty percent (50%) of an individual's
required payment to the individual's health care account.
(f) A nonprofit corporation may make not more than
seventy-five percent (75%) of an individual's required payment to
the individual's health care account.
(b) To participate in the plan, an individual shall do the following:
(1) Apply for the plan on a form prescribed by the office. The office may develop and allow a joint application for a household.
(2) If the individual is approved by the office to participate in the plan, contribute to the individual's health care account the lesser of the following:
(A) One thousand one hundred dollars ($1,100) per year, less any amounts paid by the individual under the:
(i) Medicaid program under IC 12-15;
(ii) children's health insurance program under IC 12-17.6; and
(iii) Medicare program (42 U.S.C. 1395 et seq.);
as determined by the office.
(B) At least one hundred sixty dollars ($160) per year and not more than the following applicable percentage of the individual's annual household income per year, less any amounts paid by the individual under the Medicaid program under IC 12-15, the children's health insurance program under IC 12-17.6, and the Medicare program (42 U.S.C. 1395 et seq.) as determined by the office:
(i) Two percent (2%) of the individual's annual household income per year if the individual has an annual household income of not more than one hundred percent (100%) of the federal income poverty level.
(ii) Three percent (3%) of the individual's annual household income per year if the individual has an annual household income of more than one hundred percent (100%) and not more than one hundred twenty-five percent (125%) of the federal income poverty level.
(iii) Four percent (4%) of the individual's annual household income per year if the individual has an annual household income of more than one hundred twenty-five percent (125%) and not more than one hundred fifty percent (150%) of the federal income poverty level.
(iv) Five percent (5%) of the individual's annual household income per year if the individual has an annual household income of more than one hundred fifty percent (150%) and not more than two hundred percent (200%) of the federal income poverty level.
(c) The state shall contribute the difference to the individual's account if the individual's payment required under subsection (b)(2) is less than one thousand one hundred dollars ($1,100).
(d) If an individual's required payment to the plan is not made within sixty (60) days after the required payment date, the individual may be terminated from participation in the plan. The individual must receive written notice before the individual is terminated from the plan.
(e) After termination from the plan under subsection (d), the individual may not reapply to participate in the plan for twelve (12) months.
(1) has not had health insurance coverage during the previous six (6) months; and
(2) meets the eligibility requirements specified in section 9 of this chapter for participation in the plan but is not enrolled because the plan has reached maximum enrollment.
(b) The insurance underwriting and rating practices applied to health insurance coverage offered under subsection (a):
(1) must not be different from underwriting and rating practices used for the health insurance coverage provided under the plan; and
(2) must be consistent with the federal Patient Protection and Affordable Care Act.
(c) The state:
(1) does not provide funding for health insurance coverage received under this section; and
(2) shall approve the rate applied to the plan in accordance with the federal Patient Protection and Affordable Care Act.
(d) This section expires December 31, 2013.
(1) Have an annual household income of the following:
(A) Through December 31, 2013, not more than two hundred percent (200%) of the federal income poverty level.
(B) Beginning January 1, 2014, not more than one hundred thirty-three percent (133%) of the federal income poverty level, based on the adjusted gross income provisions set forth in Section 2001(a)(1) of the federal Patient Protection and Affordable Care Act.
(2) Are eligible for health insurance coverage through an employer but cannot afford the health insurance coverage premiums.
(b) A program established under this section must:
(1) contain eligibility requirements that are similar to the eligibility requirements of the plan;
(2) include a health care account as a component; and
(3) provide that an individual's payment:
(A) to a health care account; or
(B) for a health insurance coverage premium;
may not exceed five percent (5%) of the individual's annual income.
prohibit the office from implementing any other part of this chapter
that:
(1) is federally approved for federal financial participation; or
(2) does not require federal approval or federal financial
participation.
(b) The secretary may make changes to the plan under this
chapter if the changes are required by one (1) of the following:
(1) The United States Department of Health and Human
Services.
(2) Federal law or regulation.
Chapter 45. Medicaid Waivers and State Plan Amendments
Sec. 1. (a) As used in this section, "family planning services" does not include the performance of abortions or the use of a drug or device intended to terminate fertilization.
(b) As used in this section, "fertilization" means the joining of a human egg cell with a human sperm cell.
(c) As used in this section, "state amendment plan" refers to an amendment to Indiana's Medicaid State Plan as authorized by Section 1902(a)(10)(A)(ii)(XXI) of the federal Social Security Act (42 U.S.C. 1315).
(d) Before January 1, 2012, the office shall do the following:
(1) Apply to the United States Department of Health and Human Services for approval of a state plan amendment to expand the population eligible for family planning services and supplies as permitted by Section 1902(a)(10)(A)(ii)(XXI) of the federal Social Security Act (42 U.S.C. 1315). In determining what population is eligible for this expansion, the state must incorporate the following:
(A) Inclusion of women and men.
(B) Setting income eligibility at one hundred thirty-three percent (133%) of the federal income poverty level.
(C) Adopting presumptive eligibility for services to this population.
(2) Consider the inclusion of additional:
(A) medical diagnosis; and
(B) treatment services;
that are provided for family planning services in a family planning setting for the population designated in subdivision (1) in the state plan amendment.
(e) The office shall report concerning its proposed state plan amendment to the Medicaid oversight committee during its 2011 interim meetings. The Medicaid oversight committee shall review the proposed state plan amendment. The committee may make an advisory recommendation to the office concerning the proposed state plan amendment.
(f) The office may adopt rules under IC 4-22-2 to implement this section.
(g) This chapter expires January 1, 2016.
(b) No policy of accident and sickness insurance may be issued or delivered to any person in this state, nor may any application, rider, or endorsement be used in connection with an accident and sickness insurance policy, until a copy of the form of the policy and of the classification of risks and the premium rates, or, in the case of assessment companies, the estimated cost pertaining thereto, have been filed with and reviewed by the commissioner under section 1.5 of this chapter. This section is applicable also to assessment companies and fraternal benefit associations or societies.
(c) This chapter shall be applied in conformity with the requirements of the federal Patient Protection and Affordable Care Act (P.L. 111-148), as amended by the federal Health Care and Education Reconciliation Act of 2010 (P.L. 111-152), as in effect on September 23, 2010.
SECTION 45, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE
SEPTEMBER 23, 2010 (RETROACTIVE)]: Sec. 2. (a) No individual
policy of accident and sickness insurance shall be delivered or issued
for delivery to any person in this state unless it complies with each of
the following:
(1) The entire money and other considerations for the policy are
expressed in the policy.
(2) The time at which the insurance takes effect and terminates is
expressed in the policy.
(3) The policy purports to insure only one (1) person, except that
a policy must insure, originally or by subsequent amendment,
upon the application of any member of a family who shall be
deemed the policyholder and who is at least eighteen (18) years
of age, any two (2) or more eligible members of that family,
including husband, wife, dependent children, or any children who
are less than twenty-four (24) twenty-six (26) years of age, and
any other person dependent upon the policyholder.
(4) The style, arrangement, and overall appearance of the policy
give no undue prominence to any portion of the text, and unless
every printed portion of the text of the policy and of any
endorsements or attached papers is plainly printed in lightface
type of a style in general use, the size of which shall be uniform
and not less than ten point with a lower-case unspaced alphabet
length not less than one hundred and twenty point (the "text" shall
include all printed matter except the name and address of the
insurer, name or title of the policy, the brief description if any,
and captions and subcaptions).
(5) The exceptions and reductions of indemnity are set forth in the
policy and, except those which are set forth in section 3 of this
chapter, are printed, at the insurer's option, either included with
the benefit provision to which they apply, or under an appropriate
caption such as "EXCEPTIONS", or "EXCEPTIONS AND
REDUCTIONS", provided that if an exception or reduction
specifically applies only to a particular benefit of the policy, a
statement of such exception or reduction shall be included with
the benefit provision to which it applies.
(6) Each such form of the policy, including riders and
endorsements, shall be identified by a form number in the lower
left-hand corner of the first page of the policy.
(7) The policy contains no provision purporting to make any
portion of the charter, rules, constitution, or bylaws of the insurer
a part of the policy unless such portion is set forth in full in the
policy, except in the case of the incorporation of or reference to
a statement of rates or classification of risks, or short-rate table
filed with the commissioner.
(8) If an individual accident and sickness insurance policy or
hospital service plan contract or medical service plan contract
provides that hospital or medical expense coverage of a
dependent child terminates upon attainment of the limiting age for
dependent children specified in such policy or contract, the policy
or contract must also provide that attainment of such limiting age
does not operate to terminate the hospital and medical coverage
of such child while the child is and continues to be both:
(A) incapable of self-sustaining employment by reason of
mental retardation or mental or physical disability; and
(B) chiefly dependent upon the policyholder for support and
maintenance.
Proof of such incapacity and dependency must be furnished to the
insurer by the policyholder within thirty-one (31) days of the
child's attainment of the limiting age. The insurer may require at
reasonable intervals during the two (2) years following the child's
attainment of the limiting age subsequent proof of the child's
disability and dependency. After such two (2) year period, the
insurer may require subsequent proof not more than once each
year. The foregoing provision shall not require an insurer to
insure a dependent who is a child who has mental retardation or
a mental or physical disability where such dependent does not
satisfy the conditions of the policy provisions as may be stated in
the policy or contract required for coverage thereunder to take
effect. In any such case the terms of the policy or contract shall
apply with regard to the coverage or exclusion from coverage of
such dependent. This subsection applies only to policies or
contracts delivered or issued for delivery in this state more than
one hundred twenty (120) days after August 18, 1969.
(b) If any policy is issued by an insurer domiciled in this state for
delivery to a person residing in another state, and if the official having
responsibility for the administration of the insurance laws of such other
state shall have advised the commissioner that any such policy is not
subject to approval or disapproval by such official, the commissioner
may by ruling require that such policy meet the standards set forth in
subsection (a) and in section 3 of this chapter.
(c) An insurer may issue a policy described in this section in
electronic or paper form. However, the insurer shall:
(1) inform the insured that the insured may request the policy in
paper form; and
(2) issue the policy in paper form upon the request of the insured.
(b) A health insurance plan provided by a small employer insurer to a small employer must comply with the following:
(1) The benefits provided by a plan to an eligible employee enrolled in the plan may not be excluded, limited, or denied for more than nine (9) months after the effective date of the coverage because of a preexisting condition of the eligible employee, the eligible employee's spouse, or the eligible employee's dependent.
(2) The plan may not define a preexisting condition, rider, or endorsement more restrictively than as a condition for which medical advice, diagnosis, care, or treatment was recommended or received during the six (6) months immediately preceding the effective date of enrollment in the plan.
(1) a determination that a service or proposed service is not appropriate or medically necessary;
(2) a determination that a service or proposed service is experimental or investigational;
(3) the availability of participating providers;
(4) the handling or payment of claims for health care services;
(5) matters pertaining to the contractual relationship between:
(A) a covered individual and an insurer; or
(B) a group policyholder and an insurer; or
(6) an insurer's decision to rescind an accident and sickness insurance policy;
and for which the covered individual has a reasonable expectation that action will be taken to resolve or reconsider the matter that is the subject of dissatisfaction.
(1) The following determinations made by the insurer or an agent of the insurer regarding a service proposed by the treating health care provider:
(A) An adverse determination of appropriateness.
(2) The insurer's decision to rescind an accident and sickness insurance policy.
(1) allow a covered individual, or a covered individual's representative, to file a written request with the insurer for an external grievance review of the insurer's
(A) appeal resolution under IC 27-8-28-17 or
(B) denial of coverage based on a waiver described in IC 27-8-5-2.5(e) (expired July 1, 2007, and removed) or IC 27-8-5-19.2 (expired July 1, 2007, and repealed);
not more than
(2) provide for:
(A) an expedited external grievance review for a grievance related to an illness, a disease, a condition, an injury, or a disability if the time frame for a standard review would seriously jeopardize the covered individual's:
(i) life or health; or
(ii) ability to reach and maintain maximum function; or
(B) a standard external grievance review for a grievance not described in clause (A).
A covered individual may file not more than one (1) external grievance of an insurer's appeal resolution under this chapter.
(b) Subject to the requirements of subsection (d), when a request is filed under subsection (a), the insurer shall:
(1) select a different independent review organization for each external grievance filed under this chapter from the list of independent review organizations that are certified by the department under section 19 of this chapter; and
(2) rotate the choice of an independent review organization among all certified independent review organizations before repeating a selection.
(c) The independent review organization chosen under subsection (b) shall assign a medical review professional who is board certified in the applicable specialty for resolution of an external grievance.
(d) The independent review organization and the medical review professional conducting the external review under this chapter may not have a material professional, familial, financial, or other affiliation with any of the following:
(1) The insurer.
(2) Any officer, director, or management employee of the insurer.
(3) The health care provider or the health care provider's medical group that is proposing the service.
(4) The facility at which the service would be provided.
(5) The development or manufacture of the principal drug, device, procedure, or other therapy that is proposed for use by the treating health care provider.
(6) The covered individual requesting the external grievance review.
However, the medical review professional may have an affiliation under which the medical review professional provides health care services to covered individuals of the insurer and may have an affiliation that is limited to staff privileges at the health facility, if the affiliation is disclosed to the covered individual and the insurer before commencing the review and neither the covered individual nor the insurer objects.
(e) A covered individual shall not pay any of the costs associated with the services of an independent review organization under this chapter. All costs must be paid by the insurer.
(b) The department shall certify a number of independent review organizations determined by the department to be sufficient to fulfill the purposes of this chapter.
(c) An independent review organization must meet the following minimum requirements for certification by the department:
(1) Medical review professionals assigned by the independent review organization to perform external grievance reviews under this chapter:
(A) must be board certified in the specialty in which a covered individual's proposed service would be provided;
(B) must be knowledgeable about a proposed service through actual clinical experience;
(C) must hold an unlimited license to practice in a state of the United States; and
(D) must not have any history of disciplinary actions or sanctions, including:
(i) loss of staff privileges; or
(ii) restriction on participation;
taken or pending by any hospital, government, or regulatory
body.
(2) The independent review organization must have a quality
assurance mechanism to ensure:
(A) the timeliness and quality of reviews;
(B) the qualifications and independence of medical review
professionals;
(C) the confidentiality of medical records and other review
materials; and
(D) the satisfaction of covered individuals with the procedures
utilized by the independent review organization, including the
use of covered individual satisfaction surveys.
(3) The independent review organization must file with the
department the following information on or before March 1 of
each year:
(A) The number and percentage of determinations made in
favor of covered individuals.
(B) The number and percentage of determinations made in
favor of insurers.
(C) The average time to process a determination.
(D) The number of external grievance reviews terminated
due to reconsideration of the insurer before a
determination was made.
(D) (E) Any other information required by the department.
The information required under this subdivision must be specified
for each insurer for which the independent review organization
performed reviews during the reporting year.
(4) The independent review organization must retain all
records related to an external grievance review for at least
three (3) years after a determination is made under section 15
of this chapter.
(4) (5) Any additional requirements established by the
department.
(d) The department may not certify an independent review
organization that is one (1) of the following:
(1) A professional or trade association of health care providers or
a subsidiary or an affiliate of a professional or trade association
of health care providers.
(2) An insurer, a health maintenance organization, or a health
plan association, or a subsidiary or an affiliate of an insurer,
health maintenance organization, or health plan association.
(e) The department may suspend or revoke an independent review
organization's certification if the department finds that the independent
review organization is not in substantial compliance with the
certification requirements under this section.
(f) The department shall make available to insurers a list of all
certified independent review organizations.
(g) The department shall make the information provided to the
department under subsection (c)(3) available to the public in a format
that does not identify individual covered individuals.
(1) the enrollee or subscriber regarding any aspect of the health maintenance organization relative to the enrollee or subscriber; or
(2) an individual who would be an enrollee or a subscriber under an individual contract or a group contract regarding the health maintenance organization's decision to rescind the individual contract or group contract.
(1) The name and address of the health maintenance organization.
(2) Eligibility requirements.
(3) Benefits and services within the service area.
(4) Emergency care benefits and services.
(5) Any out-of-area benefits and services.
(6) Copayments, deductibles, and other out-of-pocket costs.
(7) Limitations and exclusions.
(8) Enrollee termination provisions.
(9) Any enrollee reinstatement provisions.
(10) Claims procedures.
(11) Enrollee grievance procedures.
(12) Continuation of coverage provisions.
(13) Conversion provisions.
(14) Extension of benefit provisions.
(15) Coordination of benefit provisions.
(16) Any subrogation provisions.
(17) A description of the service area.
(18) The entire contract provisions.
(19) The term of the coverage provided by the contract.
(20) Any right of cancellation of the group or individual contract
holder.
(21) Right of renewal provisions.
(22) Provisions regarding reinstatement of a group or an
individual contract holder.
(23) Grace period provisions.
(24) A provision on conformity with state law.
(25) A provision or provisions that comply with the:
(A) guaranteed renewability; and
(B) group portability;
requirements of the federal Health Insurance Portability and
Accountability Act of 1996 (26 U.S.C. 9801(c)(1)).
(26) That the contract provides, upon request of the subscriber,
coverage for a child of the subscriber until the date the child
becomes twenty-four (24) twenty-six (26) years of age.
(b) For purposes of subsection (a), an evidence of coverage which
is filed with a contract may be considered part of the contract.
(1) The following determinations made by the health maintenance organization or an agent of the health maintenance organization regarding a service proposed by the treating physician:
(A) An adverse utilization review determination (as defined in IC 27-8-17-8).
(2) The health maintenance organization's decision to rescind an individual contract or a group contract.
(1) allow an enrollee or the enrollee's representative to file a written request with the health maintenance organization for an appeal of the health maintenance organization's grievance
resolution under IC 27-13-10-8 not later than forty-five (45) one
hundred twenty (120) days after the enrollee is notified of the
resolution under IC 27-13-10-8; and
(2) provide for:
(A) an expedited appeal for a grievance related to an illness,
a disease, a condition, an injury, or a disability that would
seriously jeopardize the enrollee's:
(i) life or health; or
(ii) ability to reach and maintain maximum function; or
(B) a standard appeal for a grievance not described in clause
(A).
An enrollee may file not more than one (1) appeal of a health
maintenance organization's grievance resolution under this chapter.
(b) Subject to the requirements of subsection (d), when a request is
filed under subsection (a), the health maintenance organization shall:
(1) select a different independent review organization for each
appeal filed under this chapter from the list of independent review
organizations that are certified by the department under section 8
of this chapter; and
(2) rotate the choice of an independent review organization
among all certified independent review organizations before
repeating a selection.
(c) The independent review organizations shall assign a medical
review professional who is board certified in the applicable specialty
for resolution of an appeal.
(d) The independent review organization and the medical review
professional conducting the external review under this chapter may not
have a material professional, familial, financial, or other affiliation with
any of the following:
(1) The health maintenance organization.
(2) Any officer, director, or management employee of the health
maintenance organization.
(3) The physician or the physician's medical group that is
proposing the service.
(4) The facility at which the service would be provided.
(5) The development or manufacture of the principal drug, device,
procedure, or other therapy that is proposed by the treating
physician.
However, the medical review professional may have an affiliation
under which the medical review professional provides health care
services to enrollees of the health maintenance organization and may
have an affiliation that is limited to staff privileges at the health facility
if the affiliation is disclosed to the enrollee and the health maintenance
organization before commencing the review and neither the enrollee
nor the health maintenance organization objects.
(e) The enrollee may be required to pay not more than twenty-five
dollars ($25) of the costs associated with the services of an independent
review organization under this chapter. All additional costs must be
paid by the health maintenance organization.
(b) The department shall certify a number of independent review organizations determined by the department to be sufficient to fulfill the purposes of this chapter.
(c) An independent review organization shall meet the following minimum requirements for certification by the department:
(1) Medical review professionals assigned by the independent review organization to perform external grievance reviews under this chapter:
(A) must be board certified in the specialty in which an enrollee's proposed service would be provided;
(B) must be knowledgeable about a proposed service through actual clinical experience;
(C) must hold an unlimited license to practice in a state of the United States; and
(D) must have no history of disciplinary actions or sanctions including:
(i) loss of staff privileges; or
(ii) restriction on participation;
taken or pending by any hospital, government, or regulatory body.
(2) The independent review organization must have a quality assurance mechanism to ensure the:
(A) timeliness and quality of reviews;
(B) qualifications and independence of medical review professionals;
(C) confidentiality of medical records and other review materials; and
(D) satisfaction of enrollees with the procedures utilized by the independent review organization, including the use of enrollee satisfaction surveys.
(3) The independent review organization must file with the
department the following information before March 1 of each
year:
(A) The number and percentage of determinations made in
favor of enrollees.
(B) The number and percentage of determinations made in
favor of health maintenance organizations.
(C) The average time to process a determination.
(D) The number of external grievance reviews terminated
due to reconsideration of the health maintenance
organization before a determination was made.
(D) (E) Any other information required by the department.
The information required under this subdivision must be specified
for each health maintenance organization for which the
independent review organization performed reviews during the
reporting year.
(4) The independent review organization must retain all
records related to an external grievance review for at least
three (3) years after a determination is made under section 4
of this chapter.
(4) (5) Any additional requirements established by the
department.
(d) The department may not certify an independent review
organization that is one (1) of the following:
(1) A professional or trade association of health care providers or
a subsidiary or an affiliate of a professional or trade association
of health care providers.
(2) A health insurer, health maintenance organization, or health
plan association or a subsidiary or an affiliate of a health insurer,
health maintenance organization, or health plan association.
(e) The department may suspend or revoke an independent review
organization's certification if the department finds that the independent
review organization is not in substantial compliance with the
certification requirements under this section.
(f) The department shall make available to health maintenance
organizations a list of all certified independent review organizations.
(g) The department shall make the information provided to the
department under subsection (c)(3) available to the public in a format
that does not identify individual enrollees.
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