§ 27-13-15-1 — Contract requirements; enrollee coverage; payment of provider; rate schedule

Indiana § 27-13-15-1

• Jurisdiction: Indiana
• Title 27: INSURANCE
• Art. 13: HEALTH MAINTENANCE ORGANIZATIONS
• Ch. 15: Participating Providers; Contracts and Legal Actions

Text

(a) A contract between a health maintenance
organization and a participating provider of health care services:
(1) must be in writing;
(2) may not prohibit the participating provider from disclosing:
(A) the terms of the contract as it relates to financial or other
incentives to limit medical services by the participating
provider; or
(B) all treatment options available to an insured, including
those not covered by the insured's policy;
(3) may not provide for a financial or other penalty to a provider
for making a disclosure permitted under subdivision (2); and
(4) must provide that in the event the health maintenance
organization fails to pay for health care services as specified by
the contract, the subscriber or enrollee is not liable to the
participating provider for any sums owed by the health
maintenance organization.
(b) An enrollee is not entitled to coverage of a health care service
under a group or an individual contract unless that health care service
is included in the enrollee's contract.
(c) A provider is not entitled to payment under a contract for health
care services provided to an enrollee unless the provider has a contract
or an agreement with the carrier.
(d) This subsection does not apply to a rate schedule maintained by
state or federal government payers. A health maintenance organization
that enters into a contract with a participating provider must provide
the participating provider with a current reimbursement rate schedule:
(1) every two (2) years; and
(2) when three (3) or more CPT code (as defined in IC 27-1-37.5-3) rates under the contract change in a twelve (12)
month period.

Legislative History

As added by P.L.26-1994, SEC.25. Amended by P.L.195-1996, SEC.7; P.L.192-1996, SEC.3; P.L.190-2023, SEC.33.