CHAPTER 12. MANAGED CARE
IC 12-15-12
Chapter 12. Managed Care
IC 12-15-12-0.3
"Emergency medical condition" defined
Sec. 0.3. As used in this chapter, "emergency medical condition"means a medical condition manifesting itself by acute symptoms,including severe pain, of sufficient severity that a prudent lay personwith an average knowledge of health and medicine could reasonablyexpect the absence of immediate medical attention to result in:
(1) serious jeopardy to the health of:
(A) the individual; or
(B) in the case of a pregnant woman, the woman or herunborn child;
(2) serious impairment to bodily functions; or
(3) serious dysfunction of any bodily organ or part.
As added by P.L.223-2001, SEC.4.
IC 12-15-12-0.5
"Emergency services" defined
Sec. 0.5. As used in this chapter, "emergency services" meanscovered inpatient and outpatient services that are:
(1) furnished by a provider qualified to furnish emergencyservices; and
(2) needed to evaluate or stabilize an emergency medicalcondition.
As added by P.L.223-2001, SEC.5.
IC 12-15-12-0.7
"Post-stabilization care services" defined
Sec. 0.7. As used in this chapter, "post-stabilization care services"means covered services related to an emergency medical conditionthat are provided after an enrollee is stabilized in order to maintainthe stabilized condition or, under the circumstances described inIC 12-15-12-17(b)(3), to improve or resolve the enrollee's condition.
As added by P.L.223-2001, SEC.6.
IC 12-15-12-1
Providers from whom recipients may obtain services other thanphysician services; exceptions
Sec. 1. Except as provided in sections 6, 7, and 8 of this chapter,a Medicaid recipient may obtain any Medicaid services, with theexception of physician services, from a provider who has entered intoa provider agreement under IC 12-15-11.
As added by P.L.2-1992, SEC.9.
IC 12-15-12-2
Providers from whom recipients may receive physician services;exceptions
Sec. 2. Except as provided in sections 8 and 9 of this chapter, a
Medicaid recipient may receive physician services from a managedcare provider selected by the recipient from a list of managed careproviders furnished the recipient by the office.
As added by P.L.2-1992, SEC.9.
IC 12-15-12-3
List of managed care providers furnished recipient; providersincluded; exception
Sec. 3. Except as provided in section 9 of this chapter, the list ofmanaged care providers furnished the recipient must include thenames of all managed care providers who meet the followingrequirements:
(1) Have entered into a provider agreement with the officeunder IC 12-15-11 to provide physician services to Medicaidrecipients.
(2) Provide physician services in the geographic area in whichthe recipient resides.
As added by P.L.2-1992, SEC.9.
IC 12-15-12-4
Failure by recipient to select managed care provider withinreasonable time; assignment by office; exception
Sec. 4. Except as provided in section 9 of this chapter, if arecipient fails to select a managed care provider within a reasonabletime after the list is furnished the recipient, the office may assign amanaged care provider to the recipient.
As added by P.L.2-1992, SEC.9.
IC 12-15-12-4.5
Managed care prescription drug program requirements
Sec. 4.5. A managed care provider's contract or provideragreement with the office may include a prescription drug program,subject to IC 12-15-5-5, IC 12-15-35, and IC 12-15-35.5.
As added by P.L.101-2005, SEC.2.
IC 12-15-12-5
Circumstances permitting recipient to receive physician servicesfrom provider other than managed care provider; exceptions
Sec. 5. Except as provided in sections 6 and 7 of this chapter, aMedicaid recipient may not receive physician services from aprovider other than the managed care provider selected by therecipient under section 2 of this chapter, except as follows:
(1) In an emergency.
(2) Upon the written referral of the managed care provider.
(3) As provided in sections 6 through 9 of this chapter.
As added by P.L.2-1992, SEC.9.
IC 12-15-12-6
Admission to hospital by physician other than managed careprovider; notification of managed care provider; services for
which payment made
Sec. 6. (a) A Medicaid recipient may be admitted to a hospital bya physician other than the recipient's managed care provider if therecipient requires immediate medical treatment.
(b) The admitting physician shall notify the recipient's managedcare provider of the recipient's admission not more than forty-eight(48) hours after the recipient's admission.
(c) Payment for services provided a recipient admitted to ahospital under this section shall be made only for services that theoffice or the contractor under IC 12-15-30 determines were medicallyreasonable and necessary.
As added by P.L.2-1992, SEC.9.
IC 12-15-12-7
Providers from whom recipients may obtain eye care services otherthan surgical services
Sec. 7. A Medicaid recipient may obtain eye care services, exceptfor surgical services, from any provider licensed under IC 25-22.5 orIC 25-24 who has entered into a provider agreement underIC 12-15-11.
As added by P.L.2-1992, SEC.9.
IC 12-15-12-8
Providers from whom recipients may obtain foot care services
Sec. 8. A Medicaid recipient may obtain foot care services fromany provider licensed under IC 25-22.5 or IC 25-29 who has enteredinto a provider agreement under IC 12-15-11.
As added by P.L.2-1992, SEC.9.
IC 12-15-12-9
Providers from whom recipients may obtain psychiatric services
Sec. 9. A Medicaid recipient may obtain psychiatric services fromany provider licensed under IC 25-22.5 who has entered into aprovider agreement under IC 12-15-11.
As added by P.L.2-1992, SEC.9.
IC 12-15-12-10
Selection or assignment of managed care provider; selection of newprovider; exception
Sec. 10. (a) A Medicaid recipient who has selected or beenassigned a managed care provider under this chapter may not selecta new managed care provider for twelve (12) months after themanaged care provider was selected or assigned.
(b) The office may make an exception to the requirement undersubsection (a) if the office determines that circumstances warrant achange.
As added by P.L.2-1992, SEC.9.
IC 12-15-12-11
Waiver from Department of Health and Human Services;
implementation of chapter
Sec. 11. The office shall seek the necessary waiver under 42U.S.C. 1396n(b)(1) from the United States Department of Health andHuman Services to implement this chapter.
As added by P.L.2-1992, SEC.9.
IC 12-15-12-12
Payments to providers
Sec. 12. For a managed care program or demonstration projectestablished or authorized by the office, or established or authorizedby another entity or agency working in conjunction with or underagreement with the office, the office must provide for payment toproviders in the managed care program that the office finds isreasonable and adequate to meet the costs that must be incurred byefficiently and economically operated providers in order to:
(1) provide care and services in conformity with applicable stateand federal laws, regulations, and quality and safety standards;and
(2) ensure that individuals eligible for medical assistance underthe managed care program or demonstration project havereasonable access (taking into account geographic location andreasonable travel time) to the services provided by the managedcare program.
As added by P.L.93-1995, SEC.3.
IC 12-15-12-13
Permitted forms
Sec. 13. (a) The office and an entity with which the officecontracts for the payment of claims shall accept claims submitted onany of the following forms by an individual or organization that is acontractor or subcontractor of the office:
(1) HCFA-1500.
(2) HCFA-1450 (UB92).
(3) American Dental Association (ADA) claim form.
(4) Pharmacy and compound drug form.
(b) The office and an entity with which the office contracts for thepayment of claims:
(1) may designate as acceptable claim forms other than a formlisted in subsection (a); and
(2) may not mandate the use of a crossover claim form.
As added by P.L.256-2001, SEC.2.
IC 12-15-12-14
Enrollment in risk-based managed care program required
Sec. 14. (a) This section applies to a Medicaid recipient:
(1) who is determined by the office to be eligible for enrollmentin a Medicaid managed care program;
(2) whose Medicaid eligibility is not based on the individual'saged, blind, or disabled status; and
(3) who resides in a county having a population of: (A) more than one hundred eighty-two thousand sevenhundred ninety (182,790) but less than two hundredthousand (200,000);
(B) more than one hundred seventy thousand (170,000) butless than one hundred eighty thousand (180,000);
(C) more than two hundred thousand (200,000) but less thanthree hundred thousand (300,000);
(D) more than three hundred thousand (300,000) but lessthan four hundred thousand (400,000); or
(E) more than four hundred thousand (400,000) but less thanseven hundred thousand (700,000).
(b) Not later than January 1, 2003, the office shall require arecipient described in subsection (a) to enroll in the risk-basedmanaged care program.
(c) The office:
(1) shall apply to the United States Department of Health andHuman Services for any approval necessary; and
(2) may adopt rules under IC 4-22-2;
to implement this section.
As added by P.L.291-2001, SEC.160. Amended by P.L.170-2002,SEC.81; P.L.107-2002, SEC.11; P.L.1-2003, SEC.55.
IC 12-15-12-15
Coverage for emergency services
Sec. 15. The office, for purposes of the primary care casemanagement program, and a managed care contractor, for purposesof the risk-based managed care program, shall:
(1) cover and pay for all medically necessary screening servicesprovided to an individual who presents to an emergencydepartment with an emergency medical condition; and
(2) beginning July 1, 2001, not deny or fail to process a claimfor reimbursement for emergency services on the basis that theenrollee's primary care provider's authorization code for theservices was not obtained before or after the services wererendered.
As added by P.L.223-2001, SEC.7.
IC 12-15-12-16
Reserved
IC 12-15-12-17
Coverage for post-stabilization care services
Sec. 17. (a) This section applies to post-stabilization care servicesprovided to an individual enrolled in:
(1) the Medicaid risk-based managed care program; or
(2) the Medicaid primary care case management program.
(b) The office, if the individual is enrolled in the primary carecase management program, or the managed care organization, if theindividual is enrolled in the risk-based managed care program, isfinancially responsible for the following services provided to an
enrollee:
(1) Post-stabilization care services that are pre-approved by arepresentative of the office or the managed care organization,as applicable.
(2) Post-stabilization care services that are not pre-approved bya representative of the office or the managed care organization,as applicable, but that are administered to maintain theenrollee's stabilized condition within one (1) hour of a requestto the office or the managed care organization for pre-approvalof further post-stabilization care services.
(3) Post-stabilization care services provided after an enrollee isstabilized that are not pre-approved by a representative of theoffice or the managed care organization, as applicable, but thatare administered to maintain, improve, or resolve the enrollee'sstabilized condition if the office or the managed careorganization:
(A) does not respond to a request for preapproval within one(1) hour;
(B) cannot be contacted; or
(C) cannot reach an agreement with the enrollee's treatingphysician concerning the enrollee's care, and a physicianrepresenting the office or the managed care organization, asapplicable, is not available for consultation.
(c) If the conditions described in subsection (b)(3)(C) exist, theoffice or the managed care organization, as applicable, shall give theenrollee's treating physician an opportunity to consult with aphysician representing the office or the managed care organization.The enrollee's treating physician may continue with care of theenrollee until a physician representing the office or the managed careorganization, as applicable, is reached or until one (1) of thefollowing criteria is met:
(1) A physician:
(A) representing the office or the managed care organization,as applicable; and
(B) who has privileges at the treating hospital;
assumes responsibility for the enrollee's care.
(2) A physician representing the office or the managed careorganization, as applicable, assumes responsibility for theenrollee's care through transfer.
(3) A representative of the office or the managed careorganization, as applicable, and the treating physician reach anagreement concerning the enrollee's care.
(4) The enrollee is discharged from the treating hospital.
(d) This subsection applies to post-stabilization care servicesprovided under subsection (b)(1), (b)(2), and (b)(3) to an individualenrolled in the Medicaid risk-based managed care program by aprovider who has not contracted with a Medicaid risk-based managedcare organization to provide post-stabilization care services undersubsection (b)(1), (b)(2), and (b)(3) to the individual. Payment forpost-stabilization care services provided under subsection (b)(1),
(b)(2), and (b)(3) must be in an amount equal to one hundred percent(100%) of the current Medicaid fee for service reimbursement ratesfor such services.
(e) This section does not prohibit a managed care organizationfrom entering into a subcontract with another Medicaid risk-basedmanaged care organization providing for the latter organization toassume financial responsibility for making the payments requiredunder this section.
(f) This section does not limit the ability of the office or themanaged care organization to:
(1) review; and
(2) make a determination of;
the medical necessity of the post-stabilization care services providedto an enrollee for purposes of determining coverage for suchservices.
As added by P.L.223-2001, SEC.8.
IC 12-15-12-18
Payment for emergency services
Sec. 18. (a) Except as provided in subsection (b), this sectionapplies to:
(1) emergency services provided to an individual enrolled in theMedicaid risk-based managed care program; and
(2) medically necessary screening services provided to anindividual enrolled in the Medicaid risk-based managed careprogram;
who presents to an emergency department with an emergencymedical condition.
(b) This section does not apply to emergency services or screeningservices provided to an individual enrolled in the Medicaidrisk-based managed care program by a provider who has contractedwith a Medicaid risk-based managed care organization to provideemergency services to the individual.
(c) Payment for emergency services and medically necessaryscreening services in the emergency department of a hospitallicensed under IC 16-21 must be in an amount equal to one hundredpercent (100%) of the current Medicaid fee for servicereimbursement rates for such services.
(d) Payment under subsection (c) is the responsibility of theenrollee's risk-based managed care organization. This subsectiondoes not prohibit the risk-based managed care organization fromentering into a subcontract with another Medicaid risk-basedmanaged care organization providing for the latter organization toassume financial responsibility for making the payments requiredunder this section.
(e) This section does not limit the ability of the managed careorganization to:
(1) review; and
(2) make a determination of;
the medical necessity of the services provided in a hospital's
emergency department for purposes of determining coverage for suchservices.
As added by P.L.223-2001, SEC.9.
IC 12-15-12-19
Disease management program; case management program
Sec. 19. (a) This section applies to an individual who is aMedicaid recipient.
(b) Subject to subsection (c), the office shall develop thefollowing programs regarding individuals described in subsection(a):
(1) A disease management program for recipients with any ofthe following chronic diseases:
(A) Asthma.
(B) Diabetes.
(C) Congestive heart failure or coronary heart disease.
(D) Hypertension.
(E) Kidney disease.
(2) A case management program for recipients described insubsection (a) who are at high risk of chronic disease, that isbased on a combination of cost measures, clinical measures, andhealth outcomes identified and developed by the office withinput and guidance from the state department of health andother experts in health care case management or diseasemanagement programs.
(c) The office shall implement:
(1) a pilot program for at least two (2) of the diseases listed insubsection (b) not later than July 1, 2003; and
(2) a statewide chronic disease program as soon as practicableafter the office has done the following:
(A) Evaluated a pilot program described in subdivision (1).
(B) Made any necessary changes in the program based onthe evaluation performed under clause (A).
(d) The office shall develop and implement a program requiredunder this section in cooperation with the state department of healthand shall use the following persons to the extent possible:
(1) Community health centers.
(2) Federally qualified health centers (as defined in 42 U.S.C.1396d(l)(2)(B)).
(3) Rural health clinics (as defined in 42 U.S.C. 1396d(l)(1)).
(4) Local health departments.
(5) Hospitals.
(6) Public and private third party payers.
(e) The office may contract with an outside vendor or vendors toassist in the development and implementation of the programsrequired under this section.
(f) The office and the state department of health shall provide theselect joint commission on Medicaid oversight established byIC 2-5-26-3 with an evaluation and recommendations on the costs,benefits, and health outcomes of the pilot programs required under
this section. The evaluations required under this subsection must beprovided not more than twelve (12) months after the implementationdate of the pilot programs.
(g) The office and the state department of health shall report to theselect joint commission on Medicaid oversight established byIC 2-5-26-3 not later than November 1 of each year regarding theprograms developed under this section.
(h) The disease management program services for a recipientdiagnosed with diabetes or hypertension must include education forthe recipient on kidney disease and the benefits of having evaluationsand treatment for chronic kidney disease according to acceptedpractice guidelines.
As added by P.L.291-2001, SEC.161. Amended by P.L.66-2002,SEC.2; P.L.212-2003, SEC.1; P.L.13-2004, SEC.1; P.L.48-2005,SEC.1; P.L.18-2007, SEC.1.
IC 12-15-12-20
Child lead poisoning screening
Sec. 20. The office shall develop the following:
(1) A measure to evaluate the performance of a Medicaidmanaged care organization in screening a child who is less thansix (6) years of age for lead poisoning.
(2) A system to maintain the results of an evaluation undersubdivision (1) in written form.
(3) A performance incentive program for Medicaid managedcare organizations evaluated under subdivision (1).
As added by P.L.135-2005, SEC.1.
IC 12-15-12-21
Accreditation
Sec. 21. (a) Not later than January 1, 2011, the following must beaccredited by the National Committee for Quality Assurance or itssuccessor:
(1) A managed care organization that has contracted with theoffice before July 1, 2008, to provide Medicaid services underthe risk based managed care program.
(2) A behavioral health managed care organization that hascontracted before July 1, 2008, with a managed careorganization described in subdivision (1).
(b) A:
(1) managed care organization that has contracted with theoffice after June 30, 2008, to provide Medicaid services underthe risk based managed care program; or
(2) behavioral health managed care organization that hascontracted after June 30, 2008, with a managed careorganization described in subdivision (1);
must begin the accreditation process and obtain accreditation by theNational Committee for Quality Assurance or its successor at theearliest time that the National Committee for Quality Assuranceallows a managed care organization to be accredited.As added by P.L.113-2008, SEC.6.
IC 12-15-12-22
Accepting, receiving, and processing electronic claims
Sec. 22. A:
(1) managed care organization that has a contract with theoffice to provide Medicaid services under the risk basedmanaged care program; or
(2) behavioral health managed care organization that hascontracted with a managed care organization described insubdivision (1);
shall accept, receive, and process claims for payment that are filedelectronically by a Medicaid provider.
As added by P.L.113-2008, SEC.7.