This text of Indiana § 16-21-10-8.5 (Authorization to implement state directed payment program;
limitations; payments to managed care organizations; review by budget
committee; classes of hospitals) is published on Counsel Stack Legal Research, covering Indiana primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.
5.
(a)Subject to subsection (b), beginning
July 1, 2025, or thereafter, the office may implement a state directed
payment program in which payments are made for inpatient and
outpatient hospital services as follows:
(1)Subject to available state share funding and federal medical
assistance available to the plan for coverage of plan participants
described in Section 1902(a)(10)(A)(i)(VIII) of the federal Social
Security Act in effect on January 1, 2025, the reimbursement rates
for inpatient and outpatient hospital services under the state
directed payment program may be established at a rate greater
than Medicare equivalent reimbursement rates, but may not
exceed the maximum reimbursement rates established by federal
law.
(2)The office may implement the state directed payment program
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5. (a) Subject to subsection (b), beginning
July 1, 2025, or thereafter, the office may implement a state directed
payment program in which payments are made for inpatient and
outpatient hospital services as follows:
(1) Subject to available state share funding and federal medical
assistance available to the plan for coverage of plan participants
described in Section 1902(a)(10)(A)(i)(VIII) of the federal Social
Security Act in effect on January 1, 2025, the reimbursement rates
for inpatient and outpatient hospital services under the state
directed payment program may be established at a rate greater
than Medicare equivalent reimbursement rates, but may not
exceed the maximum reimbursement rates established by federal
law.
(2) The office may implement the state directed payment program
through the establishment of classes of hospitals with different
rates of reimbursement among the classes, as set forth in
subsection (c), and in a manner that is consistent with federal law.
(3) Before January 1, 2026, the office shall apply to the United
States Department of Health and Human Services for the review
and approval of a state directed payment program. The office may
receive input from hospitals and other interested parties in the
development of the documentation submitted with the application
under this subdivision.
(4) The office may not implement the state directed payment
program without the approval of the United States Department of
Health and Human Services. To the extent allowed by the United
States Department of Health and Human Services, the office shall
implement the state directed payment program on or after July 1,
2025.
(5) The office may not implement a fee under the state directed
payment program without the approval of the fee by the United
States Department of Health and Human Services, including any
waiver related to the fee, to fund the state share of the payments
under the state directed payment program. To the extent allowed
by the United States Department of Health and Human Services,
the office shall use the fee to fund the state directed payment
program on or after July 1, 2025.
(6) The office shall make payments under the state directed
payment program to managed care organizations that contract
with the office to provide medical assistance to Medicaid
recipients as follows:
(A) Except as provided in clause (B), capitation payments at
levels necessary to pay inpatient and outpatient hospital
services at reimbursement rates equal to the reimbursement
rates established under subdivision (1). The fee must be used to
pay the state share of the part of the capitation payments that
fund the portion of the reimbursement rates that exceed the
reimbursement rates in effect on June 30, 2011. However, the
fees collected under this section and sections 8 and 13.3 of this
chapter may not fund the state share of the capitation payments
of the managed care assessment fee under IC 27-1-50.3.
(B) For plan enrollees described in section 13.3(b)(1)(A) of this
chapter, capitation payments at a level sufficient to pay
inpatient and outpatient hospital services at reimbursement
rates equal to the reimbursement rates established by
subdivision (1). The incremental fee shall fund the entire state
share of these capitation payments. However, the fees collected
under this section and sections 8 and 13.3 of this chapter may
not fund the state share of the capitation payments of the
managed care assessment fee under IC 27-1-50.3.
(b) The office may only implement a state directed payment
program under this section if the budget committee has conducted a
review of the state directed payment program.
(c) The classes of hospitals may be constructed as follows:
(1) Class 1 hospitals consist of critical access hospitals and rural
hospitals.
(2) Class 2 hospitals consist of a hospital licensed under IC 16-21-2 that is not described in subdivision (1) and that is:
(A) established and governed under IC 16-22-2, IC 16-22-8, or
IC 16-23; or
(B) an Indiana nonprofit hospital system that has a net patient
revenue derived in Indiana of less than two billion dollars
($2,000,000,000), as determined by the hospital's most recently
submitted audited financial statement.
(3) Class 3 hospitals consist of psychiatric hospitals, rehabilitative
hospitals, and acute long term care hospitals and that are not
described in subdivision (1) or (2).
(4) Class 4 hospitals consist of any hospital not described in
subdivision (1) through (3) and that are subject to this chapter.