CHAPTER 44.2. INDIANA CHECK-UP PLAN
IC 12-15-44.2
Chapter 44.2. Indiana Check-Up Plan
IC 12-15-44.2-1
"Plan"
Sec. 1. As used in this chapter, "plan" refers to the Indianacheck-up plan established by section 3 of this chapter.
As added by P.L.3-2008, SEC.98.
IC 12-15-44.2-2
"Preventative care services"
Sec. 2. As used in this chapter, "preventative care services" meanscare that is provided to an individual to prevent disease, diagnosedisease, or promote good health.
As added by P.L.3-2008, SEC.98.
IC 12-15-44.2-3
Plan established; administration; referral of high risk individuals;inapplicability of laws
Sec. 3. (a) The Indiana check-up plan is established.
(b) The office shall administer the plan.
(c) The department of insurance and the office of the secretaryshall provide oversight of the marketing practices of the plan.
(d) The office shall promote the plan and provide information topotential eligible individuals who live in medically underserved ruralareas of Indiana.
(e) The office shall, to the extent possible, ensure that enrollmentin the plan is distributed throughout Indiana in proportion to thenumber of individuals throughout Indiana who are eligible forparticipation in the plan.
(f) 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.
(g) A health care provider that provides care to an individual whoreceives health insurance coverage under the plan shall participate inthe Medicaid program under IC 12-15.
(h) The office of the secretary may refer an individual who:
(1) has applied for health insurance coverage under the plan;and
(2) is at high risk of chronic disease;
to the Indiana comprehensive health insurance association foradministration of the individual's plan benefits under IC 27-8-10.1.
(i) The following do not apply to the plan:
(1) IC 12-15-6.
(2) IC 12-15-12.
(3) IC 12-15-13.
(4) IC 12-15-14. (5) IC 12-15-15.
(6) IC 12-15-21.
(7) IC 12-15-26.
(8) IC 12-15-31.1.
(9) IC 12-15-34.
(10) IC 12-15-35.
(11) IC 12-15-35.5.
(12) IC 16-42-22-10.
As added by P.L.3-2008, SEC.98.
IC 12-15-44.2-4
Services included in plan
Sec. 4. (a) The plan must include the following in a manner andto the extent determined by the office:
(1) Mental health care services.
(2) Inpatient hospital services.
(3) Prescription drug coverage.
(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 transmitteddisease testing, as described in federal Medicaid law (42U.S.C. 1396 et seq.); and
(B) not including abortion or abortifacients.
(13) Hospice services.
(14) Substance abuse services.
(b) The plan must do the following:
(1) Offer coverage for dental and vision services to anindividual who participates in the plan.
(2) Pay at least fifty percent (50%) of the premium cost ofdental and vision services coverage described in subdivision(1).
(c) An individual who receives the dental or vision coverageoffered under subsection (b) shall pay an amount determined by theoffice for the coverage. The office shall limit the payment to notmore than five percent (5%) of the individual's annual householdincome. The payment required under this subsection is in addition tothe payment required under section 11(b)(2) of this chapter forcoverage under the plan.
(d) Vision services offered by the plan must include servicesprovided by an optometrist.
(e) The plan must comply with any coverage requirements thatapply to an accident and sickness insurance policy issued in Indiana.
(f) The plan may not permit treatment limitations or financial
requirements on the coverage of mental health care services orsubstance abuse services if similar limitations or requirements arenot imposed on the coverage of services for other medical or surgicalconditions.
As added by P.L.3-2008, SEC.98.
IC 12-15-44.2-5
Preventative care
Sec. 5. (a) The office shall provide to an individual whoparticipates in the plan a list of health care services that qualify aspreventative care services for the age, gender, and preexistingconditions of the individual. The office shall consult with the federalCenters for Disease Control and Prevention for a list ofrecommended preventative care services.
(b) The plan shall, at no cost to the individual, provide paymentfor not more than five hundred dollars ($500) of qualifyingpreventative care services per year for an individual who participatesin the plan. Any additional preventative care services covered underthe plan and received by the individual during the year are subject tothe deductible and payment requirements of the plan.
As added by P.L.3-2008, SEC.98.
IC 12-15-44.2-6
Coverage limitations
Sec. 6. The plan has the following per participant coveragelimitations:
(1) An annual individual maximum coverage limitation of threehundred thousand dollars ($300,000).
(2) A lifetime individual maximum coverage limitation of onemillion dollars ($1,000,000).
As added by P.L.3-2008, SEC.98.
IC 12-15-44.2-7
Use of appropriated funds
Sec. 7. The following requirements apply to funds appropriatedby the general assembly to the plan:
(1) At least eighty-five percent (85%) of the funds must be usedto fund payment for health care services.
(2) An amount determined by the office of the secretary to fund:
(A) administrative costs of; and
(B) any profit made by;
an insurer or a health maintenance organization under a contractwith the office to provide health insurance coverage under theplan. The amount determined under this subdivision may notexceed fifteen percent (15%) of the funds.
As added by P.L.3-2008, SEC.98.
IC 12-15-44.2-8
Not an entitlement; maximum enrollment
Sec. 8. The plan is not an entitlement program. The maximum
enrollment of individuals who may participate in the plan isdependent on funding appropriated for the plan.
As added by P.L.3-2008, SEC.98.
IC 12-15-44.2-9
Eligibility requirements
Sec. 9. (a) An individual is eligible for participation in the plan ifthe individual meets the following requirements:
(1) The individual is at least eighteen (18) years of age and lessthan sixty-five (65) years of age.
(2) The individual is a United States citizen and has been aresident of Indiana for at least twelve (12) months.
(3) The individual has an annual household income of not morethan two hundred percent (200%) of the federal income povertylevel.
(4) The individual is not eligible for health insurance coveragethrough the individual's employer.
(5) The individual has not had health insurance coverage for atleast six (6) months.
(b) The following individuals are not eligible for the plan:
(1) An individual who participates in the federal Medicareprogram (42 U.S.C. 1395 et seq.).
(2) A pregnant woman for purposes of pregnancy relatedservices.
(3) An individual who is eligible for the Medicaid program asa disabled person.
(c) The eligibility requirements specified in subsection (a) aresubject to approval for federal financial participation by the UnitedStates Department of Health and Human Services.
As added by P.L.3-2008, SEC.98.
IC 12-15-44.2-10
Health care account; funding
Sec. 10. (a) An individual who participates in the plan must havea health care account to which payments may be made for theindividual's participation in the plan only by the following:
(1) The individual.
(2) An employer.
(3) The state.
(b) The minimum funding amount for a health care account is theamount required under section 11 of this chapter.
(c) An individual's health care account must be used to pay theindividual's deductible for health care services under the plan.
(d) An individual may make payments to the individual's healthcare account as follows:
(1) An employer withholding or causing to be withheld from anemployee's wages or salary, after taxes are deducted from thewages or salary, the individual's contribution under this chapterand 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 careaccount in a manner prescribed by the office.
(3) Another method determined by the office.
(e) An employer may make, from funds not payable by theemployer to the employee, not more than fifty percent (50%) of anindividual's required payment to the individual's health care account.
As added by P.L.3-2008, SEC.98.
IC 12-15-44.2-11
Participation requirements; contributions to health care account;nonpayment
Sec. 11. (a) An individual's participation in the plan does notbegin until an initial payment is made for the individual'sparticipation in the plan. A required payment to the plan for theindividual's participation may not exceed one-twelfth (1/12) of theannual payment required under subsection (b).
(b) To participate in the plan, an individual shall do the following:
(1) Apply for the plan on a form prescribed by the office. Theoffice may develop and allow a joint application for ahousehold.
(2) If the individual is approved by the office to participate inthe plan, contribute to the individual's health care account thelesser of the following:
(A) One thousand one hundred dollars ($1,100) per year,less any amounts paid by the individual under the:
(i) Medicaid program under IC 12-15;
(ii) children's health insurance program under IC 12-17.6;and
(iii) Medicare program (42 U.S.C. 1395 et seq.);
as determined by the office.
(B) Not more than the following applicable percentage of theindividual's annual household income per year, less anyamounts paid by the individual under the Medicaid programunder IC 12-15, the children's health insurance programunder IC 12-17.6, and the Medicare program (42 U.S.C.1395 et seq.) as determined by the office:
(i) Two percent (2%) of the individual's annual householdincome per year if the individual has an annual householdincome of not more than one hundred percent (100%) ofthe federal income poverty level.
(ii) Three percent (3%) of the individual's annualhousehold income per year if the individual has an annualhousehold income of more than one hundred percent(100%) and not more than one hundred twenty-fivepercent (125%) of the federal income poverty level.
(iii) Four percent (4%) of the individual's annualhousehold income per year if the individual has an annualhousehold income of more than one hundred twenty-fivepercent (125%) and not more than one hundred fiftypercent (150%) of the federal income poverty level. (iv) Five percent (5%) of the individual's annual householdincome per year if the individual has an annual householdincome of more than one hundred fifty percent (150%) andnot more than two hundred percent (200%) of the federalincome poverty level.
(c) The state shall contribute the difference to the individual'saccount if the individual's payment required under subsection (b)(2)is less than one thousand one hundred dollars ($1,100).
(d) If an individual's required payment to the plan is not madewithin sixty (60) days after the required payment date, the individualmay be terminated from participation in the plan. The individualmust receive written notice before the individual is terminated fromthe plan.
(e) After termination from the plan under subsection (d), theindividual may not reapply to participate in the plan for twelve (12)months.
As added by P.L.3-2008, SEC.98.
IC 12-15-44.2-12
Plan period; renewal; termination; refund of payments to healthcare account
Sec. 12. (a) An individual who is approved to participate in theplan is eligible for a twelve (12) month plan period. An individualwho participates in the plan may not be refused renewal ofparticipation in the plan for the sole reason that the plan has reachedthe plan's maximum enrollment.
(b) If the individual chooses to renew participation in the plan, theindividual shall complete a renewal application and any necessarydocumentation, and submit to the office the documentation andapplication on a form prescribed by the office.
(c) If the individual chooses not to renew participation in the plan,the individual may not reapply to participate in the plan for at leasttwelve (12) months.
(d) Any funds remaining in the health care account of anindividual who renews participation in the plan at the end of theindividual's twelve (12) month plan period must be used to reducethe individual's payments for the subsequent plan period. However,if the individual did not, during the plan period, receive all qualifiedpreventative services recommended as provided in section 5 of thischapter, the state's contribution to the health care account may not beused to reduce the individual's payments for the subsequent planperiod.
(e) If an individual is no longer eligible for the plan, does notrenew participation in the plan at the end of the plan period, or isterminated from the plan for nonpayment of a required payment, theoffice shall, not more than sixty (60) days after the last date ofparticipation in the plan, refund to the individual the amountdetermined under subsection (f) of any funds remaining in theindividual'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 periodshall receive the amount determined under STEP FOUR ofsubsection (f).
(2) An individual who is terminated from the plan due tononpayment of a required payment shall receive the amountdetermined under STEP FIVE of subsection (f).
(f) The office shall determine the amount payable to an individualdescribed in subsection (e) as follows:
STEP ONE: Determine the total amount paid into theindividual's health care account under section 10(d) of thischapter.
STEP TWO: Determine the total amount paid into theindividual's health care account from all sources.
STEP THREE: Divide STEP ONE by STEP TWO.
STEP FOUR: Multiply the ratio determined in STEP THREEby the total amount remaining in the individual's health careaccount.
STEP FIVE: Multiply the amount determined under STEPFOUR by seventy-five hundredths (0.75).
As added by P.L.3-2008, SEC.98.
IC 12-15-44.2-13
Payment for nonemergency services in emergency room
Sec. 13. Subject to appeal to the office, an individual may be heldresponsible under the plan for receiving nonemergency services in anemergency room setting, including prohibiting the individual fromusing funds in the individual's health care account to pay for thenonemergency services. However, an individual may not beprohibited from using funds in the individual's health care account topay for nonemergency services provided in an emergency roomsetting for a medical condition that arises suddenly and unexpectedlyand manifests itself by acute symptoms of such severity, includingsevere pain, that the absence of immediate medical attention couldreasonably be expected by a prudent layperson who possesses anaverage knowledge of health and medicine to:
(1) place an individual's health in serious jeopardy;
(2) result in serious impairment to the individual's bodilyfunctions; or
(3) result in serious dysfunction of a bodily organ or part of theindividual.
As added by P.L.3-2008, SEC.98.
IC 12-15-44.2-14
Claim processing; provider reimbursement; cultural competency
Sec. 14. (a) An insurer or health maintenance organization thatcontracts with the office to provide health insurance coverage, dentalcoverage, or vision coverage to an individual that participates in theplan:
(1) is responsible for the claim processing for the coverage;
(2) shall reimburse providers at a reimbursement rate of: (A) not less than the federal Medicare reimbursement ratefor the service provided; or
(B) at a rate of one hundred thirty percent (130%) of theMedicaid reimbursement rate for a service that does not havea Medicare reimbursement rate; and
(3) may not deny coverage to an eligible individual who hasbeen approved by the office to participate in the plan, unless theindividual has met the coverage limitations described in section6 of this chapter.
(b) An insurer or a health maintenance organization that contractswith the office to provide health insurance coverage under the planmust incorporate cultural competency standards established by theoffice. The standards must include standards for nonEnglishspeaking, minority, and disabled populations.
As added by P.L.3-2008, SEC.98.
IC 12-15-44.2-15
Offer of coverage to eligible individuals when maximumenrollment reached
Sec. 15. (a) An insurer or a health maintenance organization thatcontracts with the office to provide health insurance coverage underthe plan or an affiliate of an insurer or a health maintenanceorganization that contracts with the office to provide health insurancecoverage under the plan shall offer to provide the same healthinsurance coverage to an individual who:
(1) has not had health insurance coverage during the previoussix (6) months; and
(2) meets the eligibility requirements specified in section 9 ofthis chapter for participation in the plan but is not enrolledbecause the plan has reached maximum enrollment.
(b) The insurance underwriting and rating practices applied tohealth insurance coverage offered under subsection (a) must not bedifferent from underwriting and rating practices used for the healthinsurance coverage provided under the plan.
(c) The state does not provide funding for health insurancecoverage received under this section.
As added by P.L.3-2008, SEC.98.
IC 12-15-44.2-16
Offer of coverage to ineligible individuals
Sec. 16. (a) An insurer or a health maintenance organization thatcontracts with the office to provide health insurance coverage underthe plan or an affiliate of an insurer or a health maintenanceorganization that contracts with the office to provide health insurancecoverage under the plan shall offer to provide the same healthinsurance coverage to an individual who:
(1) has not had health insurance coverage during the previoussix (6) months; and
(2) does not meet the eligibility requirements specified insection 9 of this chapter for participation in the plan. (b) An insurer, a health maintenance organization, or an affiliatedescribed in subsection (a) may apply to health insurance coverageoffered under subsection (a) the insurer's, health maintenanceorganization's, or affiliate's standard individual or small groupinsurance underwriting and rating practices.
(c) The state does not provide funding for health insurancecoverage received under this section.
As added by P.L.3-2008, SEC.98.
IC 12-15-44.2-17
Indiana check-up fund
Sec. 17. (a) The Indiana check-up plan trust fund is established forthe following purposes:
(1) Administering a plan created by the general assembly toprovide health insurance coverage for low income residents ofIndiana under this chapter.
(2) Providing copayments, preventative care services, andpremiums for individuals enrolled in the plan.
(3) Funding tobacco use prevention and cessation programs,childhood immunization programs, and other health careinitiatives designed to promote the general health and wellbeing of Indiana residents.
The fund is separate from the state general fund.
(b) The fund shall be administered by the office of the secretaryof family and social services.
(c) The expenses of administering the fund shall be paid frommoney in the fund.
(d) The fund shall consist of the following:
(1) Cigarette tax revenues designated by the general assemblyto be part of the fund.
(2) Other funds designated by the general assembly to be partof 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 notcurrently needed to meet the obligations of the fund in the samemanner 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 atthe end of any fiscal year.
(h) The fund is considered a trust fund for purposes ofIC 4-9.1-1-7. Money may not be transferred, assigned, or otherwiseremoved from the fund by the state board of finance, the budgetagency, or any other state agency.
As added by P.L.3-2008, SEC.98.
IC 12-15-44.2-18
Requirements for implementation
Sec. 18. (a) The office may not:
(1) enroll applicants; (2) approve any contracts with vendors to provide services oradminister the plan;
(3) incur costs other than costs necessary to study and plan forthe implementation of the plan; or
(4) create financial obligations for the state;
unless both of the conditions of subsection (b) are satisfied.
(b) The office may not take any action described in subsection (a)unless:
(1) there is a specific appropriation from the general assemblyto implement the plan; and
(2) after review by the budget committee, the budget agencyapproves an actuarial analysis that reflects a determination thatsufficient funding is reasonably estimated to be available tooperate the plan for at least the following five (5) years.
The actuarial analysis approved under subdivision (2) must clearlyindicate the cost and revenue assumptions used in reaching thedetermination.
(c) The office may not operate the plan in a manner that wouldobligate the state to financial participation beyond the level of stateappropriations authorized for the plan.
As added by P.L.3-2008, SEC.98.
IC 12-15-44.2-19
Rules
Sec. 19. (a) The office may adopt rules under IC 4-22-2 necessaryto implement this chapter.
(b) The office may adopt emergency rules under IC 4-22-2-37.1to implement the plan on an emergency basis.
As added by P.L.3-2008, SEC.98. Amended by P.L.1-2010, SEC.59.
IC 12-15-44.2-20
Premium assistance program
Sec. 20. (a) The office may establish a health insurance coveragepremium assistance program for individuals who:
(1) have an annual household income of not more than twohundred percent (200%) of the federal income poverty level;and
(2) are eligible for health insurance coverage through anemployer but cannot afford the health insurance coveragepremiums.
(b) A program established under this section must:
(1) contain eligibility requirements that are similar to theeligibility 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 annualincome.
As added by P.L.3-2008, SEC.98.
IC 12-15-44.2-21
Federal approval; severability
Sec. 21. A denial of federal approval and federal financialparticipation that applies to any part of this chapter does not prohibitthe office from implementing any other part of this chapter that:
(1) is federally approved for federal financial participation; or
(2) does not require federal approval or federal financialparticipation.
As added by P.L.3-2008, SEC.98.