Indiana § 27-13-36-5 - Referrals to out of network providers

§ 27-13-36-5. Referrals to out of network providers

Sec. 5. (a) The provisions of the section do not apply until July 1, 1999.

(b) When an enrollee's primary care provider determines that the enrollee needs a particular health care service and the health maintenance organization determines that the type of health care service needed by the enrollee to treat a specific condition:

(1) is a covered service; and

(2) is not available from the health maintenance organization's network of participating providers;

the primary care provider and the health maintenance organization shall refer the enrollee to an appropriate provider who is not a participating provider within a reasonable amount of time and within a reasonable proximity of the enrollee.

(c) When an enrollee receives health care services from a provider to whom the enrollee was referred as described in subsection (b), the health maintenance organization shall pay the out of network provider the lesser of the following:

(1) The usual, customary, and reasonable charge in the health maintenance organization's service area for the health care services provided by the out of network provider.

(2) An amount agreed to between the health maintenance organization and the out of network provider.

The enrollee's treating provider may collect from the enrollee only the deductible or copayment, if any, that the enrollee would be responsible to pay if the health care services had been provided by a participating provider. The enrollee may not be billed by the health maintenance organization or by the out of network provider for any difference between the out of network provider's charge and the amount paid by the health maintenance organization to the out of network provider as provided in this subsection.

(d) A contract between a health maintenance organization and a primary care provider may not provide for a financial or other penalty to the primary care provider for making a determination allowed under subsection (b).

As added by P.L.69-1998, SEC.14.