(a)This section does not apply to emergency
services.
(b)As used in this section, "covered individual" means an
individual who is entitled to be provided health care services at a cost
established according to a network plan.
(c)As used in this section, "emergency services" means services
that are:
(1)furnished by a provider qualified to furnish emergency
services; and
(2)needed to evaluate or stabilize an emergency medical
condition.
(d)As used in this section, "in network practitioner" means a
practitioner who is required under a network plan to provide health
care services to covered individuals at not more than a preestablished
rate or amount of compensation.
(e)As used in this section, "network plan" means a plan under
which facilities and practitioners are required by contract
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(a) This section does not apply to emergency
services.
(b) As used in this section, "covered individual" means an
individual who is entitled to be provided health care services at a cost
established according to a network plan.
(c) As used in this section, "emergency services" means services
that are:
(1) furnished by a provider qualified to furnish emergency
services; and
(2) needed to evaluate or stabilize an emergency medical
condition.
(d) As used in this section, "in network practitioner" means a
practitioner who is required under a network plan to provide health
care services to covered individuals at not more than a preestablished
rate or amount of compensation.
(e) As used in this section, "network plan" means a plan under
which facilities and practitioners are required by contract to provide
health care services to covered individuals at not more than a
preestablished rate or amount of compensation.
(f) As used in this section, "out of network" means that the health
care services provided by the practitioner to a covered individual are
not subject to the covered individual's health carrier network plan.
(g) As used in this section, "practitioner" means the following:
(1) An individual who holds:
(A) an unlimited license, certificate, or registration;
(B) a limited or probationary license, certificate, or registration;
(C) a temporary license, certificate, registration, or permit;
(D) an intern permit; or
(E) a provisional license;
issued by the board (as defined in IC 25-0.5-11-1) regulating the
profession in question.
(2) An entity that:
(A) is owned by, or employs; or
(B) performs billing for professional health care services
rendered by;
an individual described in subdivision (1).
The term does not include a dentist licensed under IC 25-14, an
optometrist licensed under IC 25-24, or a provider facility (as defined
in IC 25-1-9.8-10).
(h) An in network practitioner who provides covered health care
services to a covered individual may not charge more for the covered
health care services than allowed according to the rate or amount of
compensation established by the individual's network plan.
(i) An out of network practitioner who provides health care services
at an in network facility to a covered individual may not be reimbursed
more for the health care services than allowed according to the rate or
amount of compensation established by the covered individual's
network plan unless all of the following conditions are met:
(1) At least five (5) business days before the health care services
are scheduled to be provided to the covered individual, the
practitioner provides to the covered individual, on a form separate
from any other form provided to the covered individual by the
practitioner, a statement in conspicuous type that meets the
following requirements:
(A) Includes a notice reading substantially as follows: "[Name
of practitioner] is an out of network practitioner providing [type
of care] with [name of in network facility], which is an in
network provider facility within your health carrier's plan.
[Name of practitioner] will not be allowed to bill you the
difference between the price charged by the practitioner and the
rate your health carrier will reimburse for the services during
your care at [name of in network facility] unless you give your
written consent to the charge.".
(B) Sets forth the practitioner's good faith estimate of the
amount that the practitioner intends to charge for the health
care services provided to the covered individual.
(C) Includes a notice reading substantially as follows
concerning the good faith estimate set forth under clause (B):
"The estimate of our intended charge for [name or description
of health care services] set forth in this statement is provided in
good faith and is our best estimate of the amount we will
charge. If our actual charge for [name or description of health
care services] exceeds our estimate by the greater of:
(i) one hundred dollars ($100); or
(ii) five percent (5%);
we will explain to you why the charge exceeds the estimate.".
(2) The covered individual signs the statement provided under
subdivision (1), signifying the covered individual's consent to the
charge for the health care services being greater than allowed
according to the rate or amount of compensation established by
the network plan.
(j) If an out of network practitioner does not meet the requirements
of subsection (i), the out of network practitioner shall include on any
bill remitted to a covered individual a written statement in conspicuous
type stating that the covered individual is not responsible for more than
the rate or amount of compensation established by the covered
individual's network plan plus any required copayment, deductible, or
coinsurance.
(k) If a covered individual's network plan remits reimbursement to
the covered individual for health care services subject to the
reimbursement limitation of subsection (i), the network plan shall
provide with the reimbursement a written statement in conspicuous
type that states that the covered individual is not responsible for more
than the rate or amount of compensation established by the covered
individual's network plan and that is included in the reimbursement
plus any required copayment, deductible, or coinsurance.
(l) If the charge of a practitioner for health care services provided
to a covered individual exceeds the estimate provided to the covered
individual under subsection (i)(1)(B) by the greater of:
(1) one hundred dollars ($100); or
(2) five percent (5%);
the facility or practitioner shall explain in a writing provided to the
covered individual why the charge exceeds the estimate.
(m) An in network practitioner is not required to provide a covered
individual with the good faith estimate if the nonemergency health care
service is scheduled to be performed by the practitioner within two (2)
business days after the health care service is ordered.
(n) The department of insurance shall adopt rules under IC 4-22-2
to specify the requirements of the notifications set forth in subsections
(j) and (k).
(o) The requirements of this section do not apply to a practitioner
who:
(1) is required to comply with; and
(2) is in compliance with;
45 CFR Part 149, Subparts E and G, as may be enforced and amended
by the federal Department of Health and Human Services.