Indiana § 12-15-43-2 - Rules

§ 12-15-43-2. Rules

Sec. 2. The office may adopt rules under IC 4-22-2 necessary to implement this chapter.

As added by P.L.20-2003, SEC.1.

IC 12-15-44Chapter 44. RepealedRepealed by P.L.3-2008, SEC.269.

IC 12-15-44.1Chapter 44.1. RepealedRepealed by P.L.7-2015, SEC.36.

IC 12-15-44.2Chapter 44.2. Healthy Indiana Plan Trust Fund; Premium Assistance Program

12-15-44.2-1Repealed 12-15-44.2-2Repealed 12-15-44.2-3Repealed 12-15-44.2-4Repealed 12-15-44.2-5Repealed 12-15-44.2-6Repealed 12-15-44.2-7Repealed 12-15-44.2-8Repealed 12-15-44.2-9Repealed 12-15-44.2-10Repealed 12-15-44.2-11Repealed 12-15-44.2-12Repealed 12-15-44.2-13Repealed 12-15-44.2-14Repealed 12-15-44.2-15Expired 12-15-44.2-16Repealed 12-15-44.2-17Healthy Indiana plan trust fund 12-15-44.2-18Repealed 12-15-44.2-19Repealed 12-15-44.2-20Premium assistance program 12-15-44.2-21Repealed 12-15-44.2-22Repealed

IC 12-15-44.2-1RepealedAs added by P.L.3-2008, SEC.98. Amended by P.L.213-2015, SEC.130. Repealed by P.L.30-2016, SEC.5.

IC 12-15-44.2-2RepealedAs added by P.L.3-2008, SEC.98. Repealed by P.L.30-2016, SEC.6.

IC 12-15-44.2-3RepealedAs added by P.L.3-2008, SEC.98. Amended by P.L.213-2015, SEC.131. Repealed by P.L.30-2016, SEC.7.

IC 12-15-44.2-4RepealedAs added by P.L.3-2008, SEC.98. Amended by P.L.160-2011, SEC.7; P.L.209-2015, SEC.13. Repealed by P.L.30-2016, SEC.8.

IC 12-15-44.2-5RepealedAs added by P.L.3-2008, SEC.98. Repealed by P.L.30-2016, SEC.9.

IC 12-15-44.2-6RepealedAs added by P.L.3-2008, SEC.98. Amended by P.L.160-2011, SEC.8. Repealed by P.L.30-2016, SEC.10.

IC 12-15-44.2-7RepealedAs added by P.L.3-2008, SEC.98. Repealed by P.L.30-2016, SEC.11.

IC 12-15-44.2-8RepealedAs added by P.L.3-2008, SEC.98. Repealed by P.L.30-2016, SEC.12.

IC 12-15-44.2-9RepealedAs added by P.L.3-2008, SEC.98. Amended by P.L.160-2011, SEC.9; P.L.278-2013, SEC.14; P.L.213-2015, SEC.132. Repealed by P.L.30-2016, SEC.13.

IC 12-15-44.2-10RepealedAs added by P.L.3-2008, SEC.98. Amended by P.L.160-2011, SEC.10. Repealed by P.L.30-2016, SEC.14.

IC 12-15-44.2-11RepealedAs added by P.L.3-2008, SEC.98. Amended by P.L.160-2011, SEC.11. Repealed by P.L.30-2016, SEC.15.

IC 12-15-44.2-12RepealedAs added by P.L.3-2008, SEC.98. Repealed by P.L.30-2016, SEC.16.

IC 12-15-44.2-13RepealedAs added by P.L.3-2008, SEC.98. Repealed by P.L.30-2016, SEC.17.

IC 12-15-44.2-14RepealedAs added by P.L.3-2008, SEC.98. Amended by P.L.42-2011, SEC.30; P.L.213-2015, SEC.133. Repealed by P.L.30-2016, SEC.18.

IC 12-15-44.2-15ExpiredAs added by P.L.3-2008, SEC.98. Amended by P.L.160-2011, SEC.12. Expired 12-31-2013 by P.L.160-2011, SEC.12.

IC 12-15-44.2-16RepealedAs added by P.L.3-2008, SEC.98. Repealed by P.L.30-2016, SEC.19.

IC 12-15-44.2-17Healthy Indiana plan trust fund Sec. 17. (a) The healthy Indiana plan trust fund is established for the following purposes:

(1) Administering a plan created by the general assembly to provide health insurance coverage for low income residents of Indiana under this chapter and IC 12-15-44.5.

(2) Providing copayments, preventative care services, and premiums for individuals enrolled in the plan.

(3) Funding tobacco use prevention and cessation programs, childhood immunization programs, and other health care initiatives designed to promote the general health and well being of Indiana residents.

(4) Funding amounts necessary to match federal funds for purposes set forth in this section.

The fund is separate from the state general fund.

(b) The fund shall be administered by the office of the secretary of family and social services.

(c) The expenses of administering the fund shall be paid from money in the fund.

(d) The fund shall consist of the following:

(1) Cigarette tax revenues designated by the general assembly to be part of the fund.

(2) Other funds designated by the general assembly to be part of the fund.

(3) Federal funds available for the purposes of the fund.

(4) Gifts or donations to the fund.

(e) The treasurer of state shall invest the money in the fund not currently needed to meet the obligations of the fund in the same manner as other public money may be invested.

(f) Money must be appropriated before funds are available for use.

(g) Money in the fund does not revert to the state general fund at the end of any fiscal year.

(h) The fund is considered a trust fund for purposes of IC 4-9.1-1-7. Money may not be transferred, assigned, or otherwise removed from the fund by the state board of finance, the budget agency, or any other state agency unless the transfer, assignment, or removal is made in accordance with subsection (a)(4).

(i) As used in this subsection, "costs of the healthy Indiana plan 2.0" includes the costs of all expenses set forth in IC 16-21-10-13.3(b)(1)(A) through IC 16-21-10-13.3(b)(1)(F). Notwithstanding subsection (a), funds on deposit in the fund beginning on the date the office implements the healthy Indiana plan 2.0 (IC 12-15-44.5) and until the healthy Indiana plan 2.0 is terminated shall be used exclusively for the following:

(1) The state share of the costs of the healthy Indiana plan 2.0 that exceed other available funding sources in any given year.

(2) The state share of the expenses of the plan in effect under this chapter immediately before the implementation of the healthy Indiana plan 2.0 that were incurred in the regular course of the plan's operation.

(j) As used in this subsection, "costs of the healthy Indiana plan 2.0" include the costs of all expenses set forth in IC 16-21-10-13.3(b)(1)(A) through IC 16-21-10-13.3(b)(1)(F). Upon implementation of the healthy Indiana plan 2.0 (IC 12-15-44.5), the entirety of the annual cigarette tax amounts designated to the fund by the general assembly shall be used exclusively to fund the state share of the costs of the healthy Indiana plan 2.0. This subsection may not be construed to restrict the annual cigarette tax dollars annually appropriated by the general assembly for childhood immunization programs under subsection (a)(3).

As added by P.L.3-2008, SEC.98. Amended by P.L.213-2015, SEC.134; P.L.216-2025, SEC.9.

IC 12-15-44.2-18RepealedAs added by P.L.3-2008, SEC.98. Repealed by P.L.30-2016, SEC.20.

IC 12-15-44.2-19RepealedAs added by P.L.3-2008, SEC.98. Amended by P.L.1-2010, SEC.59; P.L.213-2015, SEC.135. Repealed by P.L.30-2016, SEC.21.

IC 12-15-44.2-20Premium assistance program Sec. 20. (a) The office may establish a health insurance coverage premium assistance program for individuals who meet the following:

(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.

(c) The office may adopt rules under IC 4-22-2 necessary to implement and administer this section.

As added by P.L.3-2008, SEC.98. Amended by P.L.160-2011, SEC.13; P.L.30-2016, SEC.22.

IC 12-15-44.2-21RepealedAs added by P.L.3-2008, SEC.98. Amended by P.L.160-2011, SEC.14. Repealed by P.L.30-2016, SEC.23.

IC 12-15-44.2-22RepealedAs added by P.L.160-2011, SEC.15. Repealed by P.L.30-2016, SEC.24.

IC 12-15-44.5Chapter 44.5. Healthy Indiana Plan 2.0

12-15-44.5-1Repealed 12-15-44.5-1.5"Office" 12-15-44.5-2"Plan" 12-15-44.5-2.3"Preventative care services" 12-15-44.5-3Establishment of plan; eligibility requirements; oversight of marketing; promotion; standards; provider participation in Medicaid required; exemptions 12-15-44.5-3.5Coverage; vision and dental; preventative care services 12-15-44.5-4Scope of the plan; termination of plan; obligation of state; report to budget committee 12-15-44.5-4.2Amendment of Medicaid state plan; delay of amendment; operation of plan 12-15-44.5-4.5Required health care account; payments 12-15-44.5-4.7Requirements; cost sharing exemption; payments; failure to make payments; contributions; health plan; reimbursement; compliance 12-15-44.5-4.9Eligibility period; renewal; unused share of health care account distribution 12-15-44.5-4.9Eligibility period; renewal; unused share of health care account distribution 12-15-44.5-5Managed care organization responsibilities; reimbursement; cultural competency standards 12-15-44.5-5.5Workforce training and job search program referral 12-15-44.5-5.7Nonemergency services received in an emergency room; copayments; cost sharing 12-15-44.5-6Termination of plan; notice of termination; extension, or amendment of plan 12-15-44.5-7Expired 12-15-44.5-8Requirements for use of money appropriated to the fund; requirements for use of the incremental hospital assessment fee; payment for health care services; administrative costs; profit 12-15-44.5-9Rules 12-15-44.5-10Benefits for adult group; limit enrollment; limitations on negotiations of plan; changes to plan; written report 12-15-44.5-10Benefits for adult group; limiting enrollment; limitations on negotiating and changing plan; verification of compliance; medically frail; limitations

IC 12-15-44.5-1RepealedAs added by P.L.213-2015, SEC.136. Repealed by P.L.216-2025, SEC.10.

IC 12-15-44.5-1.5"Office" Sec. 1.5. As used in this chapter, "office" refers to the office of the secretary.

As added by P.L.63-2026, SEC.16.

IC 12-15-44.5-2"Plan" Sec. 2. As used in this chapter, "plan" refers to the healthy Indiana plan established by section 3 of this chapter.

As added by P.L.213-2015, SEC.136. Amended by P.L.30-2016, SEC.25.

IC 12-15-44.5-2.3"Preventative care services" Sec. 2.3. As used in this chapter, "preventative care services" means care that is provided to an individual to prevent disease, diagnose disease, or promote good health.

As added by P.L.30-2016, SEC.26.

IC 12-15-44.5-3Establishment of plan; eligibility requirements; oversight of marketing; promotion; standards; provider participation in Medicaid required; exemptions Sec. 3. (a) The healthy Indiana plan is established. The secretary shall oversee the plan and has the authority to set policy for the plan in compliance with this chapter.

(b) The office, under the direction of the secretary, shall administer the plan.

(c) The adult group described in 42 CFR 435.119 may be eligible for the plan if the conditions in section 4 of this chapter are met and if the individual meets at least one (1) of the following:

(1) Is working at least eighty (80) hours per month.

(2) Is participating in and complying with the requirements of a work program for at least eighty (80) hours per month.

(3) Is volunteering or performing community service at least eighty (80) hours per month.

(4) Undertakes a combination of the activities described in subdivision (1), (2), or (3) for a combined total of at least eighty (80) hours per month.

(5) Participates in and complies with the work requirements of the TANF program or SNAP.

(6) Has:

(A) a monthly income of at least the applicable minimum wage requirement under 29 U.S.C. 206, multiplied by eighty (80) hours; or

(B) an average monthly income in the preceding six (6) months that is not less than the applicable minimum wage requirements under 29 U.S.C. 206, multiplied by eighty (80) hours and is a seasonal worker as defined under 26 U.S.C. 45R(d)(5)(B).

(7) Participates in a drug addiction or alcoholic treatment and rehabilitation program, as defined in 7 U.S.C. 2012(h).

(8) Is medically certified as medically frail (as defined in 42 CFR 440.315(f)).

(9) Is:

(A) pregnant;

(B) entitled to postpartum medical assistance under 42 U.S.C. 1396a(e)(5) or 42 U.S.C. 1396a(e)(16); or

(C) a parent, guardian, or caretaker relative responsible for the care of a dependent child less than fourteen (14) years of age.

(10) Is a family caregiver under Section 2 of the RAISE Family Caregivers Act personally providing the care for an individual with a serious medical condition or a disability.

(11) Is an individual who is an inmate of a public institution.

(12) Is an Indiana resident enrolled in and attending an accredited educational program at least half time.

(13) Is, as set forth in the Indian Health Care Improvement Act:

(A) an Indian;

(B) an urban Indian; or

(C) a California Indian;

or has otherwise been determined eligible as an Indian by the federal Indian Health Service.

(14) Is eligible for medical assistance under 42 U.S.C. 1396a(a)(10)(A)(i)(IX).

(15) Is a veteran with a disability rated as total under 38 U.S.C. 1155.

An individual must meet the Medicaid residency requirements under IC 12-15-4-4 and this article to be eligible for the plan.

(d) 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) An individual who is otherwise eligible and enrolled for medical assistance.

(e) The department of insurance and the office of the secretary shall provide oversight of the marketing practices of the plan.

(f) The office shall promote the plan and provide information to potential eligible individuals who live in medically underserved rural areas of Indiana.

(g) The office shall, to the extent possible, ensure that enrollment in the plan is distributed throughout Indiana in proportion to the number of individuals throughout Indiana who are eligible for participation in the plan.

(h) The office shall establish standards for consumer protection, including the following:

(1) Quality of care standards.

(2) A uniform process for participant grievances and appeals.

(3) Standardized reporting concerning provider performance, consumer experience, and cost.

(i) A health care provider that provides care to an individual who receives health coverage under the plan shall also participate in the Medicaid program under this article.

(j) The following do not apply to the plan:

(1) IC 12-15-12.

(2) IC 12-15-13.

(3) IC 12-15-14.

(4) IC 12-15-15.

(5) IC 12-15-21.

(6) IC 12-15-26.

(7) IC 12-15-31.1.

(8) IC 12-15-34.

(9) IC 12-15-35.

(10) IC 16-42-22-10.

As added by P.L.213-2015, SEC.136. Amended by P.L.30-2016, SEC.27; P.L.152-2017, SEC.32; P.L.241-2023, SEC.16; P.L.126-2025, SEC.9; P.L.63-2026, SEC.17.

IC 12-15-44.5-3.5Coverage; vision and dental; preventative care services Sec. 3.5. (a) The plan must include the following in a manner and to the extent determined by the secretary:

(1) Mental health care services.

(2) Inpatient hospital services.

(3) Prescription drug coverage, including coverage of a long acting, nonaddictive medication assistance treatment drug if the drug is being prescribed for the treatment of substance abuse.

(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) Donated breast milk that meets requirements developed by the office of Medicaid policy and planning.

(16) 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 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.

(c) The plan may provide vision services and dental services only to individuals who regularly make the required monthly contributions for the plan as set forth in section 4.7(c) of this chapter.

(d) The benefit package offered in the plan:

(1) must be benchmarked to a commercial health plan described in 45 CFR 155.100(a)(1) or 45 CFR 155.100(a)(4); and

(2) may not include a benefit that is not present in at least one (1) of these commercial benchmark options.

(e) The office shall provide to an individual who participates in the plan a list of health care services that qualify as preventative care services for the age, gender, and preexisting conditions of the individual. The office shall consult with the federal Centers for Disease Control and Prevention for a list of recommended preventative care services.

(f) The plan shall, at no cost to the individual, provide payment of preventative care services described in 42 U.S.C. 300gg-13 for an individual who participates in the plan.

(g) The plan shall, at no cost to the individual, provide payments of not more than five hundred dollars ($500) per year for preventative care services not described in subsection (f). Any additional preventative care services covered under the plan and received by the individual during the year are subject to the deductible and payment requirements of the plan.

As added by P.L.30-2016, SEC.28. Amended by P.L.180-2022(ss), SEC.16; P.L.63-2026, SEC.18.

IC 12-15-44.5-4Scope of the plan; termination of plan; obligation of state; report to budget committee Sec. 4. (a) The plan:

(1) is not an entitlement program;

(2) serves as an alternative to health care coverage under Title XIX of the federal Social Security Act (42 U.S.C. 1396 et seq.);

(3) except as provided in section 4.2(a) of this chapter, must not grant eligibility under the state Medicaid plan for medical assistance under 42 U.S.C. 1396a; and

(4) must grant eligibility for the plan through an approved demonstration project under 42 U.S.C. 1315.

(b) If any of the following occurs, the secretary shall terminate the plan in accordance with section 6(b) of this chapter:

(1) The:

(A) percentages of 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 are less than the percentages provided for in Section 2001(a)(3)(B) of the federal Patient Protection and Affordable Care Act; and

(B) office, after considering the modification and the reduction in available funding, does not alter:

(i) the formula established under IC 16-21-10-13.3(b)(1) to cover the amount of the reduction in federal medical assistance; or

(ii) if applicable, the fee formula used to fund the reimbursement for inpatient and outpatient hospital services under IC 16-21-10-8.5 to cover the amount of the reduction in federal medical assistance.

For purposes of this subdivision, "coverage of plan participants" includes reimbursement, payments, contributions, and amounts referred to in IC 16-21-10-13.3(b)(1)(A), IC 16-21-10-13.3(b)(1)(C), and IC 16-21-10-13.3(b)(1)(D), including reimbursement, payments, contributions, and amounts incurred before termination of the plan.

(2) The:

(A) methodology of calculating the incremental fee set forth in IC 16-21-10-13.3 is modified in any way that results in a reduction in available funding;

(B) office, after considering the modification and reduction in available funding, does not alter:

(i) the formula established under IC 16-21-10-13.3(b)(1) to cover the amount of the reduction in fees; or

(ii) if applicable, the fee formula used to fund the reimbursement for inpatient and outpatient hospital services under IC 16-21-10-8.5 to cover the amount of the reduction in fees; and

(C) office does not use alternative financial support to cover the amount of the reduction in fees.

(3) The Medicaid waiver approving the plan is revoked, rescinded, vacated, or otherwise altered in a manner that the state cannot comply with the requirements of this chapter.

(c) If federal financial participation for recipients covered under the plan is less than ninety percent (90%), the secretary may terminate the plan in accordance with section 6(b) of this chapter.

(d) If the plan is terminated under subsection (b), the secretary may implement a plan for coverage of the affected population in a manner consistent with the healthy Indiana plan (IC 12-15-44.2 (before its repeal)) in effect on January 1, 2014:

(1) subject to prior approval of the United States Department of Health and Human Services; and

(2) using funding from the incremental fee set forth in IC 16-21-10-13.3.

(e) The secretary may not operate the plan in a manner that would obligate the state to financial participation beyond the level of state appropriations or funding otherwise authorized for the plan.

(f) The office of the secretary shall submit annually to the budget committee an actuarial analysis of the plan that reflects a determination that sufficient funding is reasonably estimated to be available to operate the plan.

As added by P.L.213-2015, SEC.136. Amended by P.L.30-2016, SEC.29; P.L.216-2025, SEC.11; P.L.126-2025, SEC.10; P.L.216-2025, SEC.12; P.L.63-2026, SEC.19.

IC 12-15-44.5-4.2Amendment of Medicaid state plan; delay of amendment; operation of plan Sec. 4.2. (a) Notwithstanding section 3 of this chapter, the secretary shall amend the Medicaid state plan to not include individuals described in 42 CFR 435.119. The secretary shall delay the effective date of the amendment to not later than upon the completion of negotiations with the United States Department of Health and Human Services for a 3.0 plan waiver and an approved implementation of the waiver.

(b) The secretary shall continue to operate the plan, as in effect on January 1, 2025, until the effective date of a 3.0 plan waiver authorized by the United States Department of Health and Human Services or the expiration, termination, or vacatur of the waiver authorizing the plan. However, the following statutes shall be implemented before the following dates:

(1) Section 3(c) of this chapter, before January 1, 2027.

(2) Section 5.7 of this chapter, before October 2, 2028.

As added by P.L.126-2025, SEC.11. Amended by P.L.63-2026, SEC.20.

IC 12-15-44.5-4.5Required health care account; payments Sec. 4.5. (a) An individual who participates in the plan must have a health care account to which payments may be made for the individual's participation in the plan.

(b) An individual's health care account must be used to pay the individual's deductible for health care services under the plan.

(c) An individual's deductible must be at least two thousand five hundred dollars ($2,500) per year.

(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 secretary.

(3) Another method determined by the secretary.

As added by P.L.30-2016, SEC.30. Amended by P.L.63-2026, SEC.21.

IC 12-15-44.5-4.7Requirements; cost sharing exemption; payments; failure to make payments; contributions; health plan; reimbursement; compliance Sec. 4.7. (a) To participate in the plan, an individual must:

(1) apply for the plan on a form prescribed by the secretary;

(2) comply with the requirements of section 3(c) of this chapter for the three (3) consecutive months immediately preceding the month the individual applies to the plan; and

(3) provide documentary evidence of compliance with subdivision (2).

The secretary may not accept self-attestation by the applicant as evidence of compliance. The secretary may develop and allow a joint application for a household.

(b) A pregnant woman is not subject to the cost sharing provisions of the plan. Subsections (c) through (g) do not apply to a pregnant woman participating in the plan.

(c) An applicant who is approved to participate in the plan does not begin benefits under the plan until a payment of at least:

(1) one-twelfth (1/12) of the annual income contribution amount; or

(2) ten dollars ($10);

is made to the individual's health care account established under section 4.5 of this chapter for the individual's participation in the plan. To continue to participate in the plan, an individual must contribute to the individual's health care account at least two percent (2%) of the individual's annual household income per year or an amount determined by the secretary that is based on the individual's annual household income per year, but not less than one dollar ($1) per month. The amount determined by the secretary under this subsection must be approved by the United States Department of Health and Human Services and must be budget neutral to the state as determined by the state budget agency.

(d) If an applicant who is approved to participate in the plan fails to make the initial payment into the individual's health care account, at least the following must occur:

(1) If the individual has an annual income that is at or below one hundred percent (100%) of the federal poverty income level, the individual's benefits are reduced as specified in subsection (e)(1).

(2) If the individual has an annual income of more than one hundred percent (100%) of the federal poverty income level, the individual is not enrolled in the plan.

(e) If an enrolled individual's required monthly payment to the plan is not made within sixty (60) days after the required payment date, the following, at a minimum, occur:

(1) For an individual who has an annual income that is at or below one hundred percent (100%) of the federal income poverty level, the individual is:

(A) transferred to a plan that has a material reduction in benefits, including the elimination of benefits for vision and dental services; and

(B) required to make copayments for the provision of services that may not be paid from the individual's health care account.

(2) For an individual who has an annual income of more than one hundred percent (100%) of the federal poverty income level, the individual shall be terminated from the plan and may not reenroll in the plan for at least six (6) months.

(f) The state shall contribute to the individual's health care account the difference between the individual's payment required under this section and the plan deductible set forth in section 4.5(c) of this chapter.

(g) A member shall remain enrolled with the same managed care organization during the member's benefit period. A member may change managed care organizations as follows:

(1) Without cause:

(A) before making a contribution or before finalizing enrollment in accordance with subsection (d)(1); or

(B) during the annual plan renewal process.

(2) For cause, as determined by the office under the direction of the secretary.

(h) The office may reimburse medical providers at the appropriate Medicaid fee schedule rate for certified medical claims incurred prior to the beginning of benefits under subsection (c) provided that the claims:

(1) were incurred not more than one (1) month prior to the individual's application; and

(2) are on behalf of an individual who:

(A) is approved to participate in the plan;

(B) is enrolled in the plan subject to the provisions in subsection (d); and

(C) was eligible for the plan at the time care and services were furnished.

(i) An enrolled individual in the plan must be in compliance with section 3(c) of this chapter in each month in order to remain enrolled in the plan.

As added by P.L.30-2016, SEC.31. Amended by P.L.152-2017, SEC.33; P.L.126-2025, SEC.12; P.L.63-2026, SEC.22.

IC 12-15-44.5-4.9Eligibility period; renewal; unused share of health care account distribution Note: This version of section effective until 1-1-2027. See also following version of this section, effective 1-1-2027.

Sec. 4.9. (a) An individual who is approved to participate in the plan is eligible for a twelve (12) month plan period if the individual continues to meet the plan requirements specified in this chapter.

(b) If an individual chooses to renew participation in the plan, the individual is subject to an annual renewal process at the end of the benefit period to determine continued eligibility for participating in the plan. If the individual does not complete the renewal process, the individual may not reenroll in the plan for at least six (6) months.

(c) This subsection applies to participants who consistently made the required payments in the individual's health care account. If the individual receives the qualified preventative services recommended to the individual during the year, the individual is eligible to have the individual's unused share of the individual's health care account at the end of the plan period, determined by the office, matched by the state and carried over to the subsequent plan period to reduce the individual's required payments. If the individual did not, during the plan period, receive all qualified preventative services recommended to the individual, only the nonstate contribution to the health care account may be used to reduce the individual's payments for the subsequent plan period.

(d) For individuals participating in the plan who, in the past, did not make consistent payments into the individual's health care account while participating in the plan, but:

(1) had a balance remaining in the individual's health care account; and

(2) received all of the required preventative care services;

the office may elect to offer a discount on the individual's required payments to the individual's health care account for the subsequent benefit year. The amount of the discount under this subsection must be related to the percentage of the health care account balance at the end of the plan year but not to exceed a fifty percent (50%) discount of the required contribution.

(e) If an individual is no longer eligible for the plan, does not renew participation in the plan at the end of the plan period, or is terminated from the plan for nonpayment of a required payment, the office shall, not more than one hundred twenty (120) days after the last date of the plan benefit period, refund to the individual the amount determined under subsection (f) of any funds remaining in the individual's health care account as follows:

(1) An individual who is no longer eligible for the plan or does not renew participation in the plan at the end of the plan period shall receive the amount determined under STEP FOUR of subsection (f).

(2) An individual who is terminated from the plan due to nonpayment of a required payment shall receive the amount determined under STEP SIX of subsection (f).

The office may charge a penalty for any voluntary withdrawals from the health care account by the individual before the end of the plan benefit year. The individual may receive the amount determined under STEP SIX of subsection (f).

(f) The office shall determine the amount payable to an individual described in subsection (e) as follows:

STEP ONE: Determine the total amount paid into the individual's health care account under this chapter.

STEP TWO: Determine the total amount paid into the individual's health care account from all sources.

STEP THREE: Divide STEP ONE by STEP TWO.

STEP FOUR: Multiply the ratio determined in STEP THREE by the total amount remaining in the individual's health care account.

STEP FIVE: Subtract any nonpayments of a required payment.

STEP SIX: Multiply the amount determined under STEP FIVE by at least seventy-five hundredths (0.75).

As added by P.L.30-2016, SEC.32. Amended by P.L.114-2018, SEC.6.

IC 12-15-44.5-4.9Eligibility period; renewal; unused share of health care account distribution Note: This version of section effective 1-1-2027. See also preceding version of this section, effective until 1-1-2027.

Sec. 4.9. (a) An individual who is approved to participate in the plan is eligible if the individual continues to meet the plan requirements specified in this chapter.

(b) If an individual chooses to renew participation in the plan, the individual is subject to a semiannual renewal process to determine continued eligibility for participating in the plan.

(c) This subsection applies to participants who consistently made the required payments in the individual's health care account. If the individual receives the qualified preventative services recommended to the individual during the year, the individual is eligible to have the individual's unused share of the individual's health care account at the end of the plan period, determined by the office, matched by the state and carried over to the subsequent plan period to reduce the individual's required payments. If the individual did not, during the plan period, receive all qualified preventative services recommended to the individual, only the nonstate contribution to the health care account may be used to reduce the individual's payments for the subsequent plan period.

(d) For individuals participating in the plan who, in the past, did not make consistent payments into the individual's health care account while participating in the plan, but:

(1) had a balance remaining in the individual's health care account; and

(2) received all of the required preventative care services;

the secretary may elect to offer a discount on the individual's required payments to the individual's health care account for the subsequent benefit year. The amount of the discount under this subsection must be related to the percentage of the health care account balance at the end of the plan year but not to exceed a fifty percent (50%) discount of the required contribution.

(e) If an individual is no longer eligible for the plan, does not renew participation in the plan at the end of the plan period, or is terminated from the plan for nonpayment of a required payment, the office shall, not more than one hundred twenty (120) days after the last date of the plan benefit period, refund to the individual the amount determined under subsection (f) of any funds remaining in the individual's health care account as follows:

(1) An individual who is no longer eligible for the plan or does not renew participation in the plan at the end of the plan period shall receive the amount determined under STEP FOUR of subsection (f).

(2) An individual who is terminated from the plan due to nonpayment of a required payment shall receive the amount determined under STEP SIX of subsection (f).

The office may charge a penalty for any voluntary withdrawals from the health care account by the individual before the end of the plan benefit year. The individual may receive the amount determined under STEP SIX of subsection (f).

(f) The office, under the direction of the secretary, shall determine the amount payable to an individual described in subsection (e) as follows:

STEP ONE: Determine the total amount paid into the individual's health care account under this chapter.

STEP TWO: Determine the total amount paid into the individual's health care account from all sources.

STEP THREE: Divide STEP ONE by STEP TWO.

STEP FOUR: Multiply the ratio determined in STEP THREE by the total amount remaining in the individual's health care account.

STEP FIVE: Subtract any nonpayments of a required payment.

STEP SIX: Multiply the amount determined under STEP FIVE by at least seventy-five hundredths (0.75).

(g) The office of the secretary shall conduct an eligibility redetermination for each plan participant at least one (1) time every six (6) months.

As added by P.L.30-2016, SEC.32. Amended by P.L.114-2018, SEC.6; P.L.63-2026, SEC.23.

IC 12-15-44.5-5Managed care organization responsibilities; reimbursement; cultural competency standards Sec. 5. (a) A managed care organization that contracts with the office to provide health coverage, dental coverage, or vision coverage to an individual who participates in the plan:

(1) is responsible for the claim processing for the coverage;

(2) shall reimburse providers at a rate that is not less than the rate established by the secretary; and

(3) may not deny coverage to an eligible individual who has been approved by the office to participate in the plan.

(b) A managed care organization that contracts with the office to provide health coverage under the plan must incorporate cultural competency standards established by the secretary. The standards must include standards for non-English speaking, minority, and disabled populations.

As added by P.L.213-2015, SEC.136. Amended by P.L.152-2017, SEC.34; P.L.201-2023, SEC.136; P.L.63-2026, SEC.24.

IC 12-15-44.5-5.5Workforce training and job search program referral Sec. 5.5. The office, under the direction of the secretary, shall refer any member of the plan who:

(1) is employed for less than twenty (20) hours per week; and

(2) is not a full-time student;

to a workforce training and job search program.

As added by P.L.30-2016, SEC.33. Amended by P.L.63-2026, SEC.25.

IC 12-15-44.5-5.7Nonemergency services received in an emergency room; copayments; cost sharing Sec. 5.7. (a) Subject to appeal to the office and except as provided in subsection (b), an individual shall be held responsible under the plan for receiving nonemergency services in an emergency room setting, including prohibiting the individual from using funds in the individual's health care account to pay for the nonemergency services and paying a copayment for the services of at least:

(1) eight dollars ($8) for an individual who has an income of one hundred percent (100%) or less of the federal poverty level; or

(2) thirty-five dollars ($35) for an individual who has an income of more than one hundred percent (100%) of the federal poverty level;

for the nonemergency use of a hospital emergency department.

(b) An individual may not be prohibited from using funds in the individual's health care account to pay for nonemergency services provided in an emergency room setting for a medical condition that arises suddenly and unexpectedly and manifests itself by acute symptoms of such severity, including severe pain, that the absence of immediate medical attention could reasonably be expected by a prudent layperson who possesses an average knowledge of health and medicine to:

(1) place an individual's health in serious jeopardy;

(2) result in serious impairment to the individual's bodily functions; or

(3) result in serious dysfunction of a bodily organ or part of the individual.

(c) In addition to the copayments described in subsection (a), the office of the secretary shall require a plan participant who has an income above one hundred percent (100%) of the federal poverty level to pay additional cost sharing requirements established by the office of the secretary in the amount of at least one dollar ($1) and not more than thirty-five dollars ($35).

(d) Unless otherwise allowed by federal law, the total aggregate amount of cost sharing charges imposed on a quarterly basis for a plan participant under this chapter may not exceed five percent (5%) of the plan participant's family income.

As added by P.L.30-2016, SEC.34. Amended by P.L.114-2018, SEC.7; P.L.63-2026, SEC.26.

IC 12-15-44.5-6Termination of plan; notice of termination; extension, or amendment of plan Sec. 6. (a) For a state fiscal year beginning July 1, 2018, and before July 1, 2024, the office, after review by the state budget committee, may determine that no incremental fees collected under IC 16-21-10-13.3 are required to be deposited into the phase out trust fund established under section 7 of this chapter. This subsection expires July 1, 2024.

(b) If the plan is to be terminated for any reason, the secretary shall, if required, provide notice of termination of the plan to the United States Department of Health and Human Services and begin the process of phasing out the plan.

(c) Before submitting:

(1) an extension of; or

(2) a material amendment to;

the plan to the United States Department of Health and Human Services, the secretary shall inform the Indiana Hospital Association of the extension or material amendment to the plan.

As added by P.L.213-2015, SEC.136. Amended by P.L.108-2019, SEC.198; P.L.93-2024, SEC.111; P.L.216-2025, SEC.13; P.L.63-2026, SEC.27.

IC 12-15-44.5-7ExpiredAs added by P.L.213-2015, SEC.136. Amended by P.L.93-2024, SEC.112. Expired 7-1-2024 by P.L.93-2024, SEC.112.

IC 12-15-44.5-8Requirements for use of money appropriated to the fund; requirements for use of the incremental hospital assessment fee; payment for health care services; administrative costs; profit Sec. 8. The following requirements apply to funds appropriated by the general assembly to the plan and the incremental fee used for purposes of IC 16-21-10-13.3:

(1) At least eighty-seven percent (87%) of the funds must be used to fund payment for health care services.

(2) An amount determined by the secretary to fund:

(A) administrative costs of; and

(B) any profit made by;

a managed care organization under a contract with the office to provide health coverage under the plan. The amount determined under this subdivision may not exceed thirteen percent (13%) of the funds.

As added by P.L.213-2015, SEC.136. Amended by P.L.152-2017, SEC.35; P.L.63-2026, SEC.28.

IC 12-15-44.5-9Rules Sec. 9. The secretary may adopt rules under IC 4-22-2 necessary to implement:

(1) this chapter; or

(2) a Section 1115 Medicaid demonstration waiver concerning the plan that is approved by the United States Department of Health and Human Services.

As added by P.L.213-2015, SEC.136. Amended by P.L.93-2024, SEC.113; P.L.63-2026, SEC.29.

IC 12-15-44.5-10Benefits for adult group; limit enrollment; limitations on negotiations of plan; changes to plan; written report Note: This version of section effective until 1-1-2027. See also following version of this section, effective 1-1-2027.

Sec. 10. (a) The secretary has the authority to provide benefits to individuals eligible under the adult group described in 42 CFR 435.119 only in accordance with this chapter.

(b) The secretary shall limit enrollment in the plan to the number of individuals that ensures that financial participation does not exceed the level of state appropriations or other funding for the plan.

(c) The secretary may negotiate and make changes to the plan, except that the secretary may not negotiate or change the plan in a way that would do the following:

(1) Reduce the following:

(A) Contribution amounts below the minimum levels set forth in section 4.7 of this chapter.

(B) Deductible amounts below the minimum amount established in section 4.5(c) of this chapter.

(C) The number of hours required to satisfy the work requirements specified in section 3(c)(1) of this chapter unless expressly required by federal law.

(2) Remove or reduce the penalties for nonpayment set forth in section 4.7 of this chapter.

(3) Revise the use of the health care account requirement set forth in section 4.5 of this chapter.

(4) Include noncommercial benefits or add additional plan benefits in a manner inconsistent with section 3.5 of this chapter.

(5) Allow services to begin:

(A) without the payment established or required by; or

(B) earlier than the time frames otherwise established by;

section 4.7 of this chapter.

(6) Reduce financial penalties for the inappropriate use of the emergency room below the minimum levels set forth in section 5.7 of this chapter.

(7) Permit members to change health plans without cause in a manner inconsistent with section 4.7(g) of this chapter.

(8) Operate the plan in a manner that would obligate the state to financial participation beyond the level of state appropriations or funding otherwise authorized for the plan.

(d) The secretary may make changes to the plan under this chapter if the changes are required by federal law or regulation and the office provides a written report of the changes to the state budget committee.

As added by P.L.213-2015, SEC.136. Amended by P.L.30-2016, SEC.35; P.L.126-2025, SEC.13.

IC 12-15-44.5-10Benefits for adult group; limiting enrollment; limitations on negotiating and changing plan; verification of compliance; medically frail; limitations Note: This version of section effective 1-1-2027. See also preceding version of this section, effective until 1-1-2027.

Sec. 10. (a) The secretary has the authority to provide benefits to individuals eligible under the adult group described in 42 CFR 435.119 only in accordance with this chapter.

(b) The secretary shall limit enrollment in the plan to the number of individuals that ensures that financial participation does not exceed the level of state appropriations or other funding for the plan.

(c) The secretary may negotiate and make changes to the plan, except that the secretary may not negotiate or change the plan in a way that would do the following:

(1) Reduce the following:

(A) Contribution amounts below the minimum levels set forth in section 4.7 of this chapter.

(B) Deductible amounts below the minimum amount established in section 4.5(c) of this chapter.

(C) The number of hours required to satisfy the work requirements specified in section 3(c)(1) of this chapter unless expressly required by federal law.

(2) Remove or reduce the penalties for nonpayment set forth in section 4.7 of this chapter.

(3) Revise the use of the health care account requirement set forth in section 4.5 of this chapter.

(4) Include noncommercial benefits or add additional plan benefits in a manner inconsistent with section 3.5 of this chapter.

(5) Allow services to begin:

(A) without the payment established or required by; or

(B) earlier than the time frames otherwise established by;

section 4.7 of this chapter.

(6) Reduce financial penalties for the inappropriate use of the emergency room below the minimum levels set forth in section 5.7 of this chapter.

(7) Permit members to change health plans without cause in a manner inconsistent with section 4.7(g) of this chapter.

(8) Operate the plan in a manner that would obligate the state to financial participation beyond the level of state appropriations or funding otherwise authorized for the plan.

(d) The secretary may make changes to the plan under this chapter if the changes are required by federal law or regulation and the office provides a written report of the changes to the state budget committee.

(e) The secretary shall verify an individual's compliance with the requirements of section 3(c) of this chapter on an ongoing, and at least quarterly, basis. The secretary may not accept any of the following methods as being sufficient to verify compliance:

(1) A plan participant's self-attestation of compliance.

(2) Designations, approvals, or determinations of compliance by a managed care organization.

(f) The secretary may accept a medically frail status set forth in section 3(c)(8) of this chapter only if the individual has been medically certified as medically frail (as defined in 42 CFR 440.315(f)) by any of the following:

(1) A physician.

(2) A physician's assistant.

(3) An advanced practice registered nurse.

(4) A nurse.

(5) A designated representative of a physician's office, on behalf of an individual described in subdivisions (1) through (4).

(6) A psychologist.

(7) A social worker.

(g) The secretary may not do any of the following:

(1) Expand the definition of medically frail for purposes of this chapter beyond the definition set forth in 42 CFR 440.315(f).

(2) Request the implementation of any additional exemptions other than the exemptions set forth in section 3 of this chapter.

As added by P.L.213-2015, SEC.136. Amended by P.L.30-2016, SEC.35; P.L.126-2025, SEC.13; P.L.63-2026, SEC.30.

IC 12-15-45Chapter 45. RepealedRepealed by P.L.6-2012, SEC.93; P.L.6-2012, SEC.94.

IC 12-15-46Chapter 46. RepealedRepealed by P.L.85-2017, SEC.60.

IC 12-15-47Chapter 47. Long Acting Reversible Contraceptives

12-15-47-1"Long acting reversible contraceptive" 12-15-47-2Transfer of long acting reversible contraceptive; required conditions 12-15-47-3Expired 12-15-47-4Expired