(a)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 as described in
subsection (b) unless all of the following conditions are met:
(1)At least five (5) business days before the health care service
is scheduled to be provided to the covered individual, the facility
or practitioner provides to the covered individual, on a form
separate from any other form provided to the covered individual
by the facility or practitioner, a statement in conspicuous type that
meets the following requirements:
(A)Includes a notice reading substantially as follows: "[Name
of f
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(a) 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 as described in
subsection (b) unless all of the following conditions are met:
(1) At least five (5) business days before the health care service
is scheduled to be provided to the covered individual, the facility
or practitioner provides to the covered individual, on a form
separate from any other form provided to the covered individual
by the facility or practitioner, a statement in conspicuous type that
meets the following requirements:
(A) Includes a notice reading substantially as follows: "[Name
of facility or 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 facility or practitioner] will not be
allowed to bill you the difference between the price charged for
the services 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 facility's or practitioner's good faith estimate
of the established fee 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 the 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.
(b) If an out of network practitioner does not meet the requirements
of subsection (a), 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.
(c) If a covered individual's network plan remits reimbursement to
the covered individual for health care services that did not meet the
requirements of subsection (a), 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.
(d) If the charge of a facility or practitioner for health care services
provided to a covered individual exceeds the estimate provided to the
covered individual under subsection (a)(1)(B) by an amount greater
than:
(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.
(e) The department shall adopt rules under IC 4-22-2 to specify the
requirements of the notifications set forth in:
(1) subsections (b) and (c); and
(2) IC 25-1-9-23(j) and IC 25-1-9-23(k).