Indiana § 27-8-14-6 - Breast cancer screening mammography; coverage

§ 27-8-14-6. Breast cancer screening mammography; coverage

Sec. 6. (a) Except as provided in subsection (f), an insurer must provide coverage for breast cancer screening mammography in any accident and sickness insurance policy that the insurer issues in Indiana.

(b) Except as provided in subsection (f), the coverage that an insurer must provide under this section must include the following:

(1) If the insured is at least thirty-five (35) but less than forty (40) years of age, coverage for at least one (1) baseline breast cancer screening mammography performed upon the insured before she becomes forty (40) years of age.

(2) If the insured is:

(A) less than forty (40) years of age; and

(B) a woman at risk;

one (1) breast cancer screening mammography performed upon the insured every year.

(3) If the insured is at least forty (40) years of age, one (1) breast cancer screening mammography performed upon the insured every year.

(4) Any additional mammography views that are required for proper evaluation.

(5) Ultrasound services, if determined medically necessary by the physician treating the insured.

(c) Except as provided in subsection (f), the coverage that an insurer must provide under this section must provide reimbursement for breast cancer screening mammography at a level at least as high as:

(1) the limitation on payment for screening mammography services established in 42 CFR 405.534(b)(3) according to the Medicare Economic Index at the time the breast cancer screening mammography is performed; or

(2) the rate negotiated by a contract provider according to the provisions of the insurance policy;

whichever is lower.

(d) Except as provided in subsection (f), the coverage that an insurer must provide under this section may not be subject to dollar limits, deductibles, or coinsurance provisions that are less favorable to the insured than the dollar limits, deductibles, or coinsurance provisions applying to physical illness generally under the accident and sickness insurance policy.

(e) Except as provided in subsection (f), the coverage that an insurer must provide is in addition to any benefits specifically provided for x-rays, laboratory testing, or wellness examinations.

(f) In the case of insurance policies that are not employer based, the insurer must offer to provide the coverage described in subsections (a) through (e).

As added by P.L.119-1991, SEC.3. Amended by P.L.170-1999, SEC.3.

IC 27-8-14.1Chapter 14.1. Coverage for Services Related to Morbid Obesity

27-8-14.1-0.1Application of certain amendments to chapter 27-8-14.1-1"Accident and sickness insurance policy" 27-8-14.1-2"Health care provider" defined 27-8-14.1-3"Morbid obesity" defined 27-8-14.1-4Coverage for nonexperimental, surgical treatment of morbid obesity

IC 27-8-14.1-0.1Application of certain amendments to chapter Sec. 0.1. The amendments made to section 4 of this chapter by P.L.196-2005 apply to an accident and sickness insurance policy that is issued, delivered, amended, or renewed after June 30, 2005.

As added by P.L.220-2011, SEC.444.

IC 27-8-14.1-1"Accident and sickness insurance policy" Sec. 1. (a) As used in this chapter, "accident and sickness insurance policy" means an insurance policy that:

(1) provides one (1) or more of the types of insurance described in IC 27-1-5-1, classes 1(b) and 2(a); and

(2) is issued on a group basis.

(b) As used in this chapter, "accident and sickness insurance policy" does not include the following:

(1) Accident only, credit, dental, vision, Medicare supplement, long term care, or disability income insurance.

(2) Coverage issued as a supplement to liability insurance.

(3) Worker's compensation or similar insurance.

(4) Automobile medical payment insurance.

(5) A specified disease policy.

(6) A short term insurance plan that:

(A) may be renewed for the greater of:

(i) thirty-six (36) months; or

(ii) the maximum period permitted under federal law;

(B) has a term of not more than three hundred sixty-four (364) days; and

(C) has an annual limit of at least two million dollars ($2,000,000).

(7) A policy that provides indemnity benefits not based on any expense incurred requirement, including a plan that provides coverage for:

(A) hospital confinement, critical illness, or intensive care; or

(B) gaps for deductibles or copayments.

(8) A supplemental plan that always pays in addition to other coverage.

(9) A student health plan.

(10) An employer sponsored health benefit plan that is:

(A) provided to individuals who are eligible for Medicare; and

(B) not marketed as, or held out to be, a Medicare supplement policy.

As added by P.L.78-2000, SEC.2. Amended by P.L.173-2007, SEC.31; P.L.288-2019, SEC.12.

IC 27-8-14.1-2"Health care provider" defined Sec. 2. As used in this chapter, "health care provider" means a:

(1) physician licensed under IC 25-22.5; or

(2) hospital licensed under IC 16-21;

that provides health care services for surgical treatment of morbid obesity.

As added by P.L.78-2000, SEC.2.

IC 27-8-14.1-3"Morbid obesity" defined Sec. 3. As used in this chapter, "morbid obesity" means:

(1) a body mass index of at least thirty-five (35) kilograms per meter squared, with comorbidity or coexisting medical conditions such as hypertension, cardiopulmonary conditions, sleep apnea, or diabetes; or

(2) a body mass index of at least forty (40) kilograms per meter squared without comorbidity.

For purposes of this section, body mass index is equal to weight in kilograms divided by height in meters squared.

As added by P.L.78-2000, SEC.2. Amended by P.L.196-2005, SEC.4.

IC 27-8-14.1-4Coverage for nonexperimental, surgical treatment of morbid obesity Sec. 4. (a) Except as provided in subsection (b), an insurer that issues an accident and sickness insurance policy shall offer coverage for nonexperimental, surgical treatment by a health care provider of morbid obesity:

(1) that has persisted for at least five (5) years; and

(2) for which nonsurgical treatment that is supervised by a physician has been unsuccessful for at least six (6) consecutive months.

(b) An insurer that issues an accident and sickness insurance policy may not provide coverage for a surgical treatment of morbid obesity for an insured who is less than twenty-one (21) years of age unless two (2) physicians licensed under IC 25-22.5 determine that the surgery is necessary to:

(1) save the life of the insured; or

(2) restore the insured's ability to maintain a major life activity (as defined in IC 4-23-29-6);

and each physician documents in the insured's medical record the reason for the physician's determination.

As added by P.L.78-2000, SEC.2. Amended by P.L.196-2005, SEC.5; P.L.102-2006, SEC.4.

IC 27-8-14.2Chapter 14.2. Insurance Coverage for Pervasive Developmental Disorders

27-8-14.2-1"Accident and sickness insurance policy" 27-8-14.2-2"Insured" defined 27-8-14.2-3"Autism spectrum disorder" 27-8-14.2-4Group coverage required 27-8-14.2-5Individual coverage required

IC 27-8-14.2-1"Accident and sickness insurance policy" Sec. 1. (a) As used in this chapter, "accident and sickness insurance policy" means an insurance policy that provides one (1) or more of the types of insurance described in IC 27-1-5-1, classes 1(b) and 2(a).

(b) The term does not include the following:

(1) Accident only, credit, dental, vision, Medicare supplement, long term care, or disability income insurance.

(2) Coverage issued as a supplement to liability insurance.

(3) Worker's compensation or similar insurance.

(4) Automobile medical payment insurance.

(5) A specified disease policy.

(6) A short term insurance plan that:

(A) may be renewed for the greater of:

(i) thirty-six (36) months; or

(ii) the maximum period permitted under federal law;

(B) has a term of not more than three hundred sixty-four (364) days; and

(C) has an annual limit of at least two million dollars ($2,000,000).

(7) A policy that provides indemnity benefits not based on any expense incurred requirement, including a plan that provides coverage for:

(A) hospital confinement, critical illness, or intensive care; or

(B) gaps for deductibles or copayments.

(8) A supplemental plan that always pays in addition to other coverage.

(9) A student health plan.

(10) An employer sponsored health benefit plan that is:

(A) provided to individuals who are eligible for Medicare; and

(B) not marketed as, or held out to be, a Medicare supplement policy.

As added by P.L.148-2001, SEC.2. Amended by P.L.173-2007, SEC.32; P.L.288-2019, SEC.13.

IC 27-8-14.2-2"Insured" defined Sec. 2. As used in this chapter, "insured" means an individual who is entitled to coverage under a policy of accident and sickness insurance.

As added by P.L.148-2001, SEC.2.

IC 27-8-14.2-3"Autism spectrum disorder" Sec. 3. As used in this chapter, "autism spectrum disorder" means a neurological condition, including Asperger's syndrome and autism, as defined in the Diagnostic and Statistical Manual of Mental Disorders.

As added by P.L.148-2001, SEC.2. Amended by P.L.188-2013, SEC.21; P.L.124-2018, SEC.80.

IC 27-8-14.2-4Group coverage required Sec. 4. (a) An accident and sickness insurance policy that is issued on a group basis must provide coverage for the treatment of an autism spectrum disorder of an insured. Coverage provided under this section is limited to treatment that is prescribed by the insured's treating physician in accordance with a treatment plan. An insurer may not deny or refuse to issue coverage on, refuse to contract with, or refuse to renew, refuse to reissue, or otherwise terminate or restrict coverage on an individual under an insurance policy solely because the individual is diagnosed with an autism spectrum disorder.

(b) The coverage required under this section may not be subject to dollar limits, deductibles, or coinsurance provisions that are less favorable to an insured than the dollar limits, deductibles, or coinsurance provisions that apply to physical illness generally under the accident and sickness insurance policy.

As added by P.L.148-2001, SEC.2. Amended by P.L.188-2013, SEC.22.

IC 27-8-14.2-5Individual coverage required Sec. 5. (a) An insurer that issues an accident and sickness insurance policy on an individual basis must offer to provide coverage for the treatment of an autism spectrum disorder of an insured. Coverage provided under this section is limited to treatment that is prescribed by the insured's treating physician in accordance with a treatment plan. An insurer may not deny or refuse to issue coverage on, refuse to contract with, or refuse to renew, refuse to reissue, or otherwise terminate or restrict coverage on an individual under an insurance policy solely because the individual is diagnosed with an autism spectrum disorder.

(b) The coverage that must be offered under this section may not be subject to dollar limits, deductibles, or coinsurance provisions that are less favorable to an insured than the dollar limits, deductibles, or coinsurance provisions that apply to physical illness generally under the accident and sickness insurance policy.

As added by P.L.148-2001, SEC.2. Amended by P.L.188-2013, SEC.23.

IC 27-8-14.3Chapter 14.3. Coverage for Biomarker Testing

27-8-14.3-1Application of chapter 27-8-14.3-2"Accident and sickness policy" 27-8-14.3-3"Biomarker" 27-8-14.3-4"Biomarker testing" 27-8-14.3-5"Consensus statement" 27-8-14.3-6"Covered individual" 27-8-14.3-7"Health plan" 27-8-14.3-8"Nationally recognized clinical practice guidelines" 27-8-14.3-9"State employee health plan" 27-8-14.3-10Coverage for biomarker testing

IC 27-8-14.3-1Application of chapter Sec. 1. This chapter applies to:

(1) a policy of accident and sickness insurance or a health maintenance organization contract that is issued, renewed, or entered into after June 30, 2024;

(2) Medicaid managed care provided by a managed care organization under a contract with the office of Medicaid policy and planning that is entered into or renewed after June 30, 2024; and

(3) coverage provided by a state employee health plan after June 30, 2024.

As added by P.L.37-2024, SEC.2.

IC 27-8-14.3-2"Accident and sickness policy" Sec. 2. (a) As used in this chapter, "accident and sickness policy" means an insurance policy that provides at least one (1) of the types of insurance described in IC 27-1-5-1, Classes 1(b) and 2(a).

(b) The term "accident and sickness policy" does not include the following:

(1) Accident only, credit, dental, vision, Medicare supplement, long term care, or disability income insurance.

(2) Coverage issued as a supplement to liability insurance.

(3) Worker's compensation or similar insurance.

(4) Automobile medical payment insurance.

(5) A specified disease policy.

(6) A short term insurance plan that:

(A) may be renewed for the greater of:

(i) thirty-six (36) months; or

(ii) the maximum period permitted under federal law;

(B) has a term of not more than three hundred sixty-four (364) days; and

(C) has an annual limit of at least two million dollars ($2,000,000).

(7) A policy that provides indemnity benefits not based on any expense incurred requirement, including a plan that provides coverage for:

(A) hospital confinement, critical illness, or intensive care; or

(B) gaps for deductibles or copayments.

(8) A supplemental plan that always pays in addition to other coverage.

(9) A student health plan.

(10) An employer sponsored health benefit plan that is:

(A) provided to individuals who are eligible for Medicare; and

(B) not marketed as, or held out to be, a Medicare supplement policy.

As added by P.L.37-2024, SEC.2.

IC 27-8-14.3-3"Biomarker" Sec. 3. (a) As used in this chapter, "biomarker" means a characteristic that is objectively measured and evaluated as an indicator of:

(1) normal biological processes;

(2) pathogenic processes; or

(3) pharmacologic responses to a specific therapeutic intervention, including known gene-drug interactions for medications being considered for use or already being administered.

(b) The term includes gene mutations, characteristics of genes, and protein expression.

As added by P.L.37-2024, SEC.2.

IC 27-8-14.3-4"Biomarker testing" Sec. 4. (a) As used in this chapter, "biomarker testing" means the analysis of a patient's tissue, blood, or other biospecimen for the presence of a biomarker.

(b) The term includes:

(1) single-analyte tests;

(2) multiplex panel tests;

(3) protein expression; and

(4) whole exome, whole genome, and whole transcriptome sequencing.

As added by P.L.37-2024, SEC.2.

IC 27-8-14.3-5"Consensus statement" Sec. 5. As used in this chapter, "consensus statement" means a statement that is:

(1) issued by an independent, multidisciplinary panel of experts that:

(A) uses a transparent methodology and reporting structure; and

(B) has a conflict of interest policy;

(2) aimed at specific clinical circumstances;

(3) based on the best available evidence; and

(4) developed for the purpose of optimizing the outcomes of clinical care.

As added by P.L.37-2024, SEC.2.

IC 27-8-14.3-6"Covered individual" Sec. 6. As used in this chapter, "covered individual" means an individual who is entitled to coverage under a health plan.

As added by P.L.37-2024, SEC.2.

IC 27-8-14.3-7"Health plan" Sec. 7. (a) As used in this chapter, "health plan" means any of the following:

(1) A policy of accident and sickness insurance.

(2) A contract with a health maintenance organization (as defined in IC 27-13-1-19) that provides coverage for basic health care services (as defined in IC 27-13-1-4).

(3) The Medicaid risk based managed care program operated under IC 12-15.

(4) A state employee health plan.

(b) The term includes a person that administers a health plan.

As added by P.L.37-2024, SEC.2.

IC 27-8-14.3-8"Nationally recognized clinical practice guidelines" Sec. 8. As used in this chapter, "nationally recognized clinical practice guidelines" means evidence based clinical practice guidelines that:

(1) are developed by an independent organization or medical professional society that:

(A) uses a transparent methodology and reporting structure; and

(B) has a conflict of interest policy;

(2) establish standards of care informed by:

(A) a systematic review of evidence; and

(B) an assessment of the benefits and risks of alternative care options; and

(3) include recommendations intended to optimize patient care.

As added by P.L.37-2024, SEC.2.

IC 27-8-14.3-9"State employee health plan" Sec. 9. (a) As used in this chapter, "state employee health plan" refers to either of the following:

(1) A self-insurance program established under IC 5-10-8-7(b).

(2) A contract with a prepaid health care delivery plan that is entered into or renewed under IC 5-10-8-7(c).

(b) The term includes a person that administers prescription drug benefits on behalf of a state employee health plan.

As added by P.L.37-2024, SEC.2.

IC 27-8-14.3-10Coverage for biomarker testing Sec. 10. (a) A health plan shall provide coverage for biomarker testing for the purposes of diagnosis, treatment, appropriate management, or ongoing monitoring of an enrollee's disease or condition when biomarker testing is supported by medical and scientific evidence, including:

(1) labeled indications for a test approved or cleared by the United States Food and Drug Administration;

(2) indicated tests for a drug approved by the United States Food and Drug Administration;

(3) a warning or precaution on the label of a drug approved by the United States Food and Drug Administration;

(4) a national coverage determination of the Centers for Medicare and Medicaid Services (CMS);

(5) a local coverage determination of a Medicare administrative contractor; or

(6) nationally recognized clinical practice guidelines or consensus statements.

(b) The coverage required by this section must be provided in a manner that limits disruptions in care, including the need for multiple biopsies or biospecimen samples.

(c) Nothing in this section shall be construed to require coverage of biomarker testing for screening purposes.

(d) If a prior authorization requirement applies to biomarker testing under a health plan, the health plan or a third party acting on behalf of the health plan must:

(1) approve or deny a request for prior authorization for biomarker testing; and

(2) notify the covered individual and any person requesting prior authorization of the biomarker testing on behalf of the covered individual;

in not more than five (5) business days after the request in the case of a nonurgent request or in not more than forty-eight (48) hours after the request in the case of an urgent request.

(e) A health plan shall ensure that a covered individual and the practitioner who prescribes biomarker testing for the covered individual have access to a clear, readily accessible, and convenient process for requesting an exception to:

(1) a coverage policy; or

(2) a prior authorization determination;

of the health plan that is adverse to the coverage of biomarker testing for the covered individual. The process required by this subsection shall be made readily accessible on the health plan's website.

As added by P.L.37-2024, SEC.2.

IC 27-8-14.5Chapter 14.5. Coverage for Services Related to Diabetes

27-8-14.5-0.1Application of chapter 27-8-14.5-1"Health insurance plan" 27-8-14.5-2"Insured" defined 27-8-14.5-3"Insurer" defined 27-8-14.5-4Coverage for treatments, supplies, and equipment 27-8-14.5-5Deductible, copayment, and coinsurance provisions 27-8-14.5-6Coverage for diabetes self-management training 27-8-14.5-7Adoption of rules

IC 27-8-14.5-0.1Application of chapter Sec. 0.1. The addition of this chapter by P.L.190-1997 applies to all health insurance plans issued or renewed after December 31, 1997.

As added by P.L.220-2011, SEC.445.

IC 27-8-14.5-1"Health insurance plan" Sec. 1. (a) As used in this chapter, "health insurance plan" means any:

(1) hospital or medical expense incurred policy or certificate;

(2) hospital or medical service plan contract; or

(3) health maintenance organization subscriber contract;

provided to an insured.

(b) The term does not include the following:

(1) Accident only, credit, dental, vision, Medicare supplement, long term care, or disability income insurance.

(2) Coverage issued as a supplement to liability insurance.

(3) Worker's compensation or similar insurance.

(4) Automobile medical payment insurance.

(5) A specified disease policy.

(6) A short term insurance plan that:

(A) may be renewed for the greater of:

(i) thirty-six (36) months; or

(ii) the maximum period permitted under federal law;

(B) has a term of not more than three hundred sixty-four (364) days; and

(C) has an annual limit of at least two million dollars ($2,000,000).

(7) A policy that provides indemnity benefits not based on any expense incurred requirement, including a plan that provides coverage for:

(A) hospital confinement, critical illness, or intensive care; or

(B) gaps for deductibles or copayments.

(8) A supplemental plan that always pays in addition to other coverage.

(9) A student health plan.

(10) An employer sponsored health benefit plan that is:

(A) provided to individuals who are eligible for Medicare; and

(B) not marketed as, or held out to be, a Medicare supplement policy.

As added by P.L.190-1997, SEC.1. Amended by P.L.173-2007, SEC.33; P.L.288-2019, SEC.14.

IC 27-8-14.5-2"Insured" defined Sec. 2. As used in this chapter, "insured" refers to an individual with:

(1) insulin-using diabetes;

(2) non-insulin using diabetes; or

(3) elevated blood glucose levels induced by pregnancy or another medical condition;

who is covered by a health insurance plan issued by an insurer.

As added by P.L.190-1997, SEC.1.

IC 27-8-14.5-3"Insurer" defined Sec. 3. As used in this chapter, "insurer" means any person who provides health insurance and issues health insurance plans in Indiana. The term includes the following:

(1) A licensed insurance company.

(2) A prepaid hospital or medical service plan.

(3) A health maintenance organization.

(4) A state employee health benefit plan.

(5) The state Medicaid plan.

(6) Any person providing a plan of health insurance subject to state insurance law.

As added by P.L.190-1997, SEC.1.

IC 27-8-14.5-4Coverage for treatments, supplies, and equipment Sec. 4. A health insurance plan issued by an insurer must provide coverage to the insured for the medically necessary treatment for diabetes, including medically necessary supplies and equipment as ordered in writing by a physician licensed under IC 25-22.5 or a podiatrist licensed under IC 25-29, subject to the general provisions of the health insurance plan.

As added by P.L.190-1997, SEC.1.

IC 27-8-14.5-5Deductible, copayment, and coinsurance provisions Sec. 5. (a) An insured may not be required to pay an annual deductible or copayment that is greater than an annual deductible or copayment established for similar benefits under the health insurance plan. If the plan does not cover a similar benefit, the copayment or deductible may not be set at a level that materially diminishes the value of the diabetes benefit required by this chapter.

(b) An insured may be subject to coinsurance that is not greater than coinsurance established for similar benefits under the health insurance plan. If the plan does not cover a similar benefit, the coinsurance may not be set at a level that materially diminishes the value of the diabetes benefit required by this chapter.

As added by P.L.190-1997, SEC.1.

IC 27-8-14.5-6Coverage for diabetes self-management training Sec. 6. (a) A health insurance plan issued by an insurer must provide coverage for diabetes self-management training that is:

(1) medically necessary;

(2) ordered in writing by a physician licensed under IC 25-22.5, a podiatrist licensed under IC 25-29, an advanced practice registered nurse licensed under IC 25-23, or a physician assistant licensed under IC 25-27.5; and

(3) provided by a health care professional who:

(A) is licensed, registered, or certified under IC 25; and

(B) has specialized training in the management of diabetes.

(b) Coverage for diabetes self-management training may be limited to the following:

(1) One (1) or more visits after receiving a diagnosis of diabetes.

(2) One (1) or more visits after receiving a diagnosis by a physician licensed under IC 25-22.5 or a podiatrist licensed under IC 25-29 that:

(A) represents a significant change in the insured's symptoms or condition; and

(B) makes changes in the insured's self-management medically necessary.

(3) One (1) or more visits for reeducation or refresher training.

(c) Coverage for diabetes self-management training is subject to the requirements of the health insurance plan regarding the use of participating providers.

As added by P.L.190-1997, SEC.1. Amended by P.L.143-2022, SEC.74.

IC 27-8-14.5-7Adoption of rules Sec. 7. The department may adopt rules under IC 4-22-2 to carry out this chapter.

As added by P.L.190-1997, SEC.1.

IC 27-8-14.7Chapter 14.7. Coverage for Services Related to Prostate Cancer Screening

27-8-14.7-0.1Application of chapter 27-8-14.7-1"Accident and sickness insurance policy" 27-8-14.7-2"Insured" defined 27-8-14.7-3"Prostate specific antigen test" defined 27-8-14.7-4Coverage required

IC 27-8-14.7-0.1Application of chapter Sec. 0.1. The addition of this chapter by P.L.170-1999 applies to accident and sickness insurance policies that are issued, delivered, or renewed after June 30, 1999.

As added by P.L.220-2011, SEC.446.

IC 27-8-14.7-1"Accident and sickness insurance policy" Sec. 1. (a) As used in this chapter, "accident and sickness insurance policy" means an insurance policy that:

(1) provides at least one (1) of the types of insurance described in IC 27-1-5-1, Classes 1(b) and 2(a); and

(2) is issued on a group basis.

(b) "Accident and sickness insurance policy" does not include the following:

(1) Accident only, credit, dental, vision, Medicare supplement, long term care, or disability income insurance.

(2) Coverage issued as a supplement to liability insurance.

(3) Worker's compensation or similar insurance.

(4) Automobile medical payment insurance.

(5) A specified disease policy.

(6) A short term insurance plan that:

(A) may be renewed for the greater of:

(i) thirty-six (36) months; or

(ii) the maximum period permitted under federal law;

(B) has a term of not more than three hundred sixty-four (364) days; and

(C) has an annual limit of at least two million dollars ($2,000,000).

(7) A policy that provides indemnity benefits not based on any expense incurred requirement, including a plan that provides coverage for:

(A) hospital confinement, critical illness, or intensive care; or

(B) gaps for deductibles or copayments.

(8) A supplemental plan that always pays in addition to other coverage.

(9) A student health plan.

(10) An employer sponsored health benefit plan that is:

(A) provided to individuals who are eligible for Medicare; and

(B) not marketed as, or held out to be, a Medicare supplement policy.

As added by P.L.170-1999, SEC.4. Amended by P.L.173-2007, SEC.34; P.L.288-2019, SEC.15.

IC 27-8-14.7-2"Insured" defined Sec. 2. As used in this chapter, "insured" means a male individual who is entitled to coverage under a policy of accident and sickness insurance.

As added by P.L.170-1999, SEC.4.

IC 27-8-14.7-3"Prostate specific antigen test" defined Sec. 3. As used in this chapter, "prostate specific antigen test" means a standard blood test performed to determine the level of prostate specific antigen in the blood.

As added by P.L.170-1999, SEC.4.

IC 27-8-14.7-4Coverage required Sec. 4. (a) Except as provided in subsection (f), an insurer shall provide coverage for prostate specific antigen testing in any accident and sickness insurance policy that the insurer issues in Indiana.

(b) Except as provided in subsection (f), the coverage required under subsection (a) must include the following:

(1) At least one (1) prostate specific antigen test annually for an insured who is at least fifty (50) years of age.

(2) At least one (1) prostate specific antigen test annually for an insured who is less than fifty (50) years of age and who is at high risk for prostate cancer according to the American Cancer Society guidelines.

(c) An insured may not be required to pay an annual deductible or coinsurance that is greater than an annual deductible or coinsurance established for similar benefits under the accident and sickness insurance policy. If the policy does not cover a similar benefit, the deductible or coinsurance may not be set at a level that materially diminishes the value of the prostate specific antigen testing benefit required by this chapter.

(d) Except as provided in subsection (f), the coverage that an insurer must provide under this chapter may not be subject to dollar limits, deductibles, or coinsurance provisions that are less favorable to the insured than the dollar limits, deductibles, or coinsurance provisions applying to physical illness generally under the accident and sickness insurance policy.

(e) Except as provided in subsection (f), the coverage that an insurer must provide is in addition to any benefits specifically provided for x-rays, laboratory testing, or wellness examinations.

(f) In the case of insurance policies that are not employer based, the insurer must offer to provide the coverage described in subsections (a) through (e).

As added by P.L.170-1999, SEC.4. Amended by P.L.124-2018, SEC.81.

IC 27-8-14.8Chapter 14.8. Coverage for Services Related to Colorectal Cancer Screening

27-8-14.8-1"Accident and sickness insurance policy" 27-8-14.8-2"Insured" defined 27-8-14.8-3Coverage for colorectal cancer screening; exception for grandfathered health plans

IC 27-8-14.8-1"Accident and sickness insurance policy" Sec. 1. (a) As used in this chapter, "accident and sickness insurance policy" means an insurance policy that:

(1) provides at least one (1) of the types of insurance described in IC 27-1-5-1, Classes 1(b) and 2(a); and

(2) is issued on a group basis.

(b) "Accident and sickness insurance policy" does not include the following:

(1) Accident only, credit, dental, vision, Medicare supplement, long term care, or disability income insurance.

(2) Coverage issued as a supplement to liability insurance.

(3) Worker's compensation or similar insurance.

(4) Automobile medical payment insurance.

(5) A specified disease policy.

(6) A short term insurance plan that:

(A) may be renewed for the greater of:

(i) thirty-six (36) months; or

(ii) the maximum period permitted under federal law;

(B) has a term of not more than three hundred sixty-four (364) days; and

(C) has an annual limit of at least two million dollars ($2,000,000).

(7) A policy that provides indemnity benefits not based on any expense incurred requirement, including a plan that provides coverage for:

(A) hospital confinement, critical illness, or intensive care; or

(B) gaps for deductibles or copayments.

(8) A supplemental plan that always pays in addition to other coverage.

(9) A student health plan.

(10) An employer sponsored health benefit plan that is:

(A) provided to individuals who are eligible for Medicare; and

(B) not marketed as, or held out to be, a Medicare supplement policy.

As added by P.L.54-2000, SEC.2. Amended by P.L.173-2007, SEC.35; P.L.288-2019, SEC.16.

IC 27-8-14.8-2"Insured" defined Sec. 2. As used in this chapter, "insured" means an individual who is entitled to coverage under an accident and sickness insurance policy.

As added by P.L.54-2000, SEC.2.

IC 27-8-14.8-3Coverage for colorectal cancer screening; exception for grandfathered health plans Sec. 3. (a) As used in this section, "follow-up colonoscopy" means a colonoscopy that is performed as a follow-up to a colorectal cancer screening test, other than a colonoscopy, that is assigned a grade of "A" or "B" by the United States Preventive Services Task Force and for which the result was positive.

(b) Except as provided in subsection (e), an insurer shall provide coverage for colorectal cancer examinations and laboratory tests for cancer for any nonsymptomatic insured in any accident and sickness insurance policy that the insurer issues in Indiana or issues for delivery in Indiana. Except as provided in subsection (f), covered services must include:

(1) a colorectal cancer screening test assigned either an "A" or "B" grade by the United States Preventive Services Task Force; and

(2) a follow-up colonoscopy.

(c) For an insured who is:

(1) at least forty-five (45) years of age; or

(2) less than forty-five (45) years of age and at high risk for colorectal cancer;

the coverage required under this section must meet the requirements set forth in subsection (d), except as provided in subsection (f).

(d) An insured may not be required to pay an additional annual deductible or coinsurance for the colorectal cancer examination and laboratory testing benefit required by this section that is greater than an annual deductible or coinsurance established for similar benefits under the accident and sickness insurance policy under which the insured is covered. If the accident and sickness insurance policy does not cover a similar benefit, a deductible or coinsurance for the colorectal cancer examination and laboratory testing benefit may not be set at a level that materially diminishes the value of the colorectal cancer examination and laboratory testing benefit.

(e) In the case of an accident and sickness insurance policy that is not employer based, the insurer shall offer to provide the coverage described in this section.

(f) The requirements imposed under subsection (b)(2) do not apply to grandfathered health plans as defined in 45 CFR 147.140.

As added by P.L.54-2000, SEC.2. Amended by P.L.124-2018, SEC.82; P.L.36-2020, SEC.2; P.L.165-2022, SEC.12.

IC 27-8-15Chapter 15. Small Employer Group Health Insurance

27-8-15-0.1Application of certain amendments to chapter 27-8-15-1Application of chapter 27-8-15-2Repealed 27-8-15-3"Actuarial certification" 27-8-15-4"Base premium rate" 27-8-15-5"Benefit design characteristics" 27-8-15-6"Case characteristics" 27-8-15-7"Commissioner" 27-8-15-8"Department" 27-8-15-8.5"Eligible employee" 27-8-15-9"Health insurance plan" 27-8-15-10"Insurer" 27-8-15-10.5"Late enrollee" 27-8-15-11"Midpoint rate" 27-8-15-12"New business premium rate" 27-8-15-13"Rating period" 27-8-15-14"Small employer" 27-8-15-15"Small employer insurer" 27-8-15-16Premium rates 27-8-15-17Rating factors 27-8-15-18Offer to transfer 27-8-15-19Cancellation or refusal of renewal of plans 27-8-15-20Renewal cessation; notice 27-8-15-21Renewal cessation; prohibitions 27-8-15-22Disclosure of premium rate changes 27-8-15-23Maintenance of rating and renewal practice information and documentation 27-8-15-24Maintenance of actuarial certification; submission to department 27-8-15-25Availability of information and documentation to commissioner; disclosure by commissioner 27-8-15-26Suspension of premium rate provisions 27-8-15-27Application in conformity with act; compliance 27-8-15-28Waiver of exclusion and limitation period 27-8-15-29Application in conformity with act; exclusion of coverage 27-8-15-30Plan modifications prohibited 27-8-15-31Conversion policy 27-8-15-31.1Continuing coverage 27-8-15-32Employees becoming eligible after employer's commencement of health insurance plan entitled to coverage 27-8-15-33Mandatory coverage by employer insurer to all employer's eligible employees and employees' dependents; employees declining coverage; minimum participation and contribution requirements 27-8-15-34Repealed 27-8-15-34.1All products required to be offered; all employers required to be accepted