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

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

Sec. 1. (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.

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.