CHAPTER 5. SERVICES PROVIDED
IC 12-15-5
Chapter 5. Services Provided
IC 12-15-5-1
Services and supplies provided; exceptions
Sec. 1. Except as provided in IC 12-15-2-12, IC 12-15-6, andIC 12-15-21, the following services and supplies are provided underMedicaid:
(1) Inpatient hospital services.
(2) Nursing facility services.
(3) Physician's services, including services provided underIC 25-10-1 and IC 25-22.5-1.
(4) Outpatient hospital or clinic services.
(5) Home health care services.
(6) Private duty nursing services.
(7) Physical therapy and related services.
(8) Dental services.
(9) Prescribed laboratory and x-ray services.
(10) Prescribed drugs and services.
(11) Eyeglasses and prosthetic devices.
(12) Optometric services.
(13) Diagnostic, screening, preventive, and rehabilitativeservices.
(14) Podiatric medicine services.
(15) Hospice services.
(16) Services or supplies recognized under Indiana law andspecified under rules adopted by the office.
(17) Family planning services except the performance ofabortions.
(18) Nonmedical nursing care given in accordance with thetenets and practices of a recognized church or religiousdenomination to an individual qualified for Medicaid whodepends upon healing by prayer and spiritual means alone inaccordance with the tenets and practices of the individual'schurch or religious denomination.
(19) Services provided to individuals described in IC 12-15-2-8and IC 12-15-2-9.
(20) Services provided under IC 12-15-34 and IC 12-15-32.
(21) Case management services provided to individualsdescribed in IC 12-15-2-11 and IC 12-15-2-13.
(22) Any other type of remedial care recognized under Indianalaw and specified by the United States Secretary of Health andHuman Services.
(23) Examinations required under IC 16-41-17-2(a)(10).
As added by P.L.2-1992, SEC.9. Amended by P.L.24-1997, SEC.48;P.L.149-2001, SEC.1.
IC 12-15-5-2
Necessity of federal financial participation
Sec. 2. Medicaid does not include a service or supply for which
federal financial participation is not available.
As added by P.L.2-1992, SEC.9.
IC 12-15-5-3
Repealed
(Repealed by P.L.161-2007, SEC.40.)
IC 12-15-5-4
Reserved
IC 12-15-5-5
Office may provide drug coverage; requirements for drug coverage inmanaged care
Sec. 5. (a) The office may provide a prescription drug benefit toa Medicaid recipient in the Medicaid risk based managed careprogram.
(b) If the office provides a prescription drug benefit to a Medicaidrecipient in the Medicaid risk based managed care program:
(1) the office shall develop a procedure and provide therecipient's risk based managed care provider with informationconcerning the recipient's prescription drug utilization for therisk based managed care provider's case management program;and
(2) the provisions of IC 12-15-35.5 apply.
(c) If the office does not provide a prescription drug benefit to aMedicaid recipient in the Medicaid risk based managed careprogram, a Medicaid managed care organization shall providecoverage and reimbursement for outpatient single source legenddrugs subject to IC 12-15-35-46, IC 12-15-35-47, and IC 12-15-35.5.
As added by P.L.231-1999, SEC.1. Amended by P.L.101-2005,SEC.1.
IC 12-15-5-6
Prohibiting limiting the number of brand name prescription drugsa recipient may receive
Sec. 6. The office may not limit the number of brand nameprescription drugs a recipient may receive under the program.
As added by P.L.107-2002, SEC.10.
IC 12-15-5-8
Maintenance drugs; prescriptions; Internet based pharmacies
Sec. 8. (a) As used in this section, "maintenance drug" means amedication that is dispensed under a single prescription for a periodof not less than one hundred eighty (180) days, excluding authorizedrefills, for the ongoing treatment of a chronic medical condition ordisease or congenital condition or disorder.
(b) The office may designate:
(1) a mail order pharmacy;
(2) an Internet based pharmacy (as defined in IC 25-26-18-1);
(3) a pharmacy that agrees to sell a maintenance drug at the
same price as a mail order or an Internet based pharmacy; or
(4) all the pharmacies listed in subdivisions (1) through (3);
through which a recipient may obtain a maintenance drug.
(c) If the office makes a designation under subsection (b), amanaged care organization that has a contract with the office underIC 12-15-12 is not required to use a pharmacy that is designatedunder subsection (b).
(d) If a Medicaid recipient's physician prescribes a maintenanceprescription drug, the Medicaid recipient may purchase themaintenance prescription drug from a pharmacy that is designatedunder subsection (b).
(e) The office shall apply to amend the state Medicaid plan if theoffice determines that an amendment is necessary to carry out thissection.
(f) The office may require a recipient to pay the maximumcopayment allowable under federal law if the recipient obtains amaintenance drug from a pharmacy other than a pharmacy describedin subsection (b).
As added by P.L.246-2005, SEC.105.
IC 12-15-5-9
Provision of self-directed care options
Sec. 9. The office shall have self-directed care options andservices available for an eligible individual who:
(1) is a Medicaid waiver recipient; and
(2) chooses self-directed care services.
As added by P.L.47-2009, SEC.3.
IC 12-15-5-9.2
Coverage for care related to cancer clinical trials
Sec. 9.2. (a) As used in this section, "care method" means the useof a particular drug or device in a particular manner.
(b) As used in this section, "clinical trial" means a Phase I, II, III,or IV research study:
(1) that is conducted:
(A) using a particular care method to prevent, diagnose, ortreat a cancer for which:
(i) there is no clearly superior, noninvestigationalalternative care method; and
(ii) available clinical or preclinical data provides areasonable basis from which to believe that the caremethod used in the research study is at least as effective asany noninvestigational alternative care method;
(B) in a facility where personnel providing the care methodto be followed in the research study have:
(i) received training in providing the care method;
(ii) expertise in providing the type of care required for theresearch study; and
(iii) experience providing the type of care required for theresearch study to a sufficient volume of patients to
maintain expertise; and
(C) to scientifically determine the best care method toprevent, diagnose, or treat the cancer; and
(2) that is approved or funded by one (1) of the following:
(A) A National Institutes of Health institute.
(B) A cooperative group of research facilities that has anestablished peer review program that is approved by aNational Institutes of Health institute or center.
(C) The federal Food and Drug Administration.
(D) The United States Department of Veterans Affairs.
(E) The United States Department of Defense.
(F) The institutional review board of an institution locatedin Indiana that has a multiple project assurance contractapproved by the National Institutes of Health Office forProtection from Research Risks as provided in 45 CFR46.103.
(G) A research entity that meets eligibility criteria for asupport grant from a National Institutes of Health center.
(c) As used in this section, "routine care cost" means the cost ofmedically necessary services related to the care method that is underevaluation in a clinical trial. The term does not include the following:
(1) The drug or device that is under evaluation in a clinical trial.
(2) Items or services that are:
(A) provided solely for data collection and analysis and notin the direct clinical management of an individual enrolledin a clinical trial;
(B) customarily provided at no cost by a research sponsor toan individual enrolled in a clinical trial; or
(C) provided solely to determine eligibility of an individualfor participation in a clinical trial.
(d) The Medicaid program must provide coverage for routine carecosts that are incurred in the course of a clinical trial if the Medicaidprogram would provide coverage for the same routine care costs notincurred in a clinical trial.
(e) The coverage that must be provided under this section issubject to the terms, conditions, restrictions, exclusions, andlimitations that apply generally under the Medicaid program,including terms, conditions, restrictions, exclusions, or limitationsthat apply to health care services rendered by participating providersand nonparticipating providers.
(f) This section does not do any of the following:
(1) Require the Medicaid program to provide coverage forclinical trial services rendered by a participating provider.
(2) Prohibit the Medicaid program from providing coverage forclinical trial services rendered by a participating provider.
(3) Require reimbursement for services that are rendered in aclinical trial by a nonparticipating provider at the same rate ofreimbursement that would apply to the same services renderedby a participating provider.
As added by P.L.109-2009, SEC.2.
IC 12-15-5-10
Care available for individuals receiving Medicaid waiver services;eligibility not affected by receipt of services
Sec. 10. (a) An individual who receives Medicaid servicesthrough a Medicaid waiver shall receive the following:
(1) The development of a care plan addressing the individual'sneeds.
(2) Advocacy on behalf of the individual's interests.
(3) The monitoring of the quality of community and home careservices provided to the individual.
(4) Information and referral services concerning community andhome care services if the individual is eligible for theseservices.
(b) The use by or on behalf of an individual receiving Medicaidwaiver services of any of the following services or devices does notmake the individual ineligible for services under a Medicaid waiver:
(1) Skilled nursing assistance.
(2) Supervised community and home care services, includingskilled nursing supervision.
(3) Adaptive medical equipment and devices.
(4) Adaptive nonmedical equipment and devices.
As added by P.L.47-2009, SEC.4.