CHAPTER 4. BENEFITS, CROWD OUT, AND COST SHARING

IC 12-17.6-4
    Chapter 4. Benefits, Crowd Out, and Cost Sharing

IC 12-17.6-4-1
Applicability of chapter
    Sec. 1. This chapter does not apply until January 1, 2000.
As added by P.L.273-1999, SEC.177.

IC 12-17.6-4-2
Services covered; prohibition on treatment limitations or financialrequirements; mental health services
    Sec. 2. (a) The benefit package provided under the program shallfocus on age appropriate preventive, primary, and acute careservices.
    (b) The office shall offer health insurance coverage for thefollowing basic services:
        (1) Inpatient and outpatient hospital services.
        (2) Physicians' services provided by a physician (as defined in42 U.S.C. 1395x(r)).
        (3) Laboratory and x-ray services.
        (4) Well-baby and well-child care, including:
            (A) age appropriate immunizations; and
            (B) periodic screening, diagnosis, and treatment servicesaccording to a schedule developed by the office.
The office may offer services in addition to those listed in thissubsection if appropriations to the program exist to pay for theadditional services.
    (c) The office shall offer health insurance coverage for thefollowing additional services if the coverage for the services has anactuarial value equal to or greater than the actuarial value of theservices provided by the benchmark program determined by thechildren's health policy board established by IC 4-23-27-2:
        (1) Prescription drugs.
        (2) Mental health services.
        (3) Vision services.
        (4) Hearing services.
        (5) Dental services.
    (d) Notwithstanding subsections (b) and (c), the office may notimpose treatment limitations or financial requirements on thecoverage of services for a mental illness if similar treatmentlimitations or financial requirements are not imposed on coverage forservices for other illnesses. Coverage for mental illness under theprogram must include the following:
        (1) Inpatient mental health services and substance abuseservices provided in an institution that:
            (A) treats mental disease; and
            (B) has more than sixteen (16) beds;
        unless coverage is prohibited by federal law.
        (2) Psychiatric residential treatment services.
        (3) Community mental health rehabilitation services.        (4) Outpatient mental health services and substance abuseservices, with no greater limitations on the number of units perrolling year than are required under the Medicaid program.
However, the office may require prior authorization for the servicesspecified in subdivisions (1) through (4).
As added by P.L.273-1999, SEC.177. Amended by P.L.103-2009,SEC.1.

IC 12-17.6-4-2.5
Prescription drug requirements
    Sec. 2.5. Prescription drugs provided under the program aresubject to the requirements of IC 12-15-35.5.
As added by P.L.6-2002, SEC.5.

IC 12-17.6-4-3
Limits on premium and cost sharing amounts
    Sec. 3. Premium and cost sharing amounts established by theoffice are limited by the following:
        (1) Deductibles, coinsurance, or other cost sharing is notpermitted with respect to benefits for:
            (A) well-baby and well-child care, including age appropriateimmunizations; and
            (B) services provided for treatment of an emergency in anemergency department of a hospital licensed under IC 16-21.
        (2) Premiums and other cost sharing may be imposed based onfamily income. However, the total annual aggregate cost sharingwith respect to all children in a family under this article may notexceed five percent (5%) of the family's income for the year.
As added by P.L.273-1999, SEC.177. Amended by P.L.95-2000,SEC.3.

IC 12-17.6-4-4
Powers of office; cost sharing and crowd out
    Sec. 4. The office may do the following:
        (1) Determine cost sharing amounts.
        (2) Determine waiting periods that may not exceed three (3)months and exceptions to the requirement of waiting periods forpotential enrollees in the program.
        (3) Adopt additional methods for complying with federalrequirements relating to crowd out.
As added by P.L.273-1999, SEC.177.

IC 12-17.6-4-5
Prohibited referrals; mechanisms to minimize incentive foremployer to eliminate or reduce coverage
    Sec. 5. (a) It is a violation of IC 27-4-1-4 if an insurer, or aninsurance producer or insurance broker compensated by the insurer,knowingly or intentionally refers an insured or the dependent of aninsured to the program for health insurance coverage when theinsured already receives health insurance coverage through an

employer's health care plan that is underwritten by the insurer.
    (b) The office shall coordinate with the children's health policyboard under IC 4-23-27 to evaluate the need for mechanisms thatminimize the incentive for an employer to eliminate or reduce healthcare coverage for an employee's dependents.
As added by P.L.273-1999, SEC.177. Amended by P.L.178-2003,SEC.3.

IC 12-17.6-4-6
Community health centers
    Sec. 6. Community health centers shall be used to provide healthcare services.
As added by P.L.273-1999, SEC.177.

IC 12-17.6-4-7
Selection of primary dental provider encouraged
    Sec. 7. The office shall encourage the parent of a child who isenrolled in the program to select a primary dental provider for thechild before the child is eighteen (18) months of age.
As added by P.L.169-2001, SEC.3.

IC 12-17.6-4-8
Use of generic drugs and preferred drug list required
    Sec. 8. (a) The office shall require the use of generic drugs in theprogram.
    (b) The office shall use the preferred drug list implemented underIC 12-15-35-28.7.
As added by P.L.291-2001, SEC.158. Amended by P.L.107-2002,SEC.26.

IC 12-17.6-4-9
Reserved

IC 12-17.6-4-10
Brand name drugs not limited
    Sec. 10. 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.27.