IC 27-13-15
    Chapter 15. Participating Providers; Contracts and Legal Actions

IC 27-13-15-1
Contract requirements; enrollee coverage; payment of provider;application
    Sec. 1. (a) A contract between a health maintenance organizationand a participating provider of health care services:
        (1) must be in writing;
        (2) may not prohibit the participating provider from disclosing:
            (A) the terms of the contract as it relates to financial or otherincentives to limit medical services by the participatingprovider; or
            (B) all treatment options available to an insured, includingthose not covered by the insured's policy;
        (3) may not provide for a financial or other penalty to a providerfor making a disclosure permitted under subdivision (2); and
        (4) must provide that in the event the health maintenanceorganization fails to pay for health care services as specified bythe contract, the subscriber or enrollee is not liable to theparticipating provider for any sums owed by the healthmaintenance organization.
    (b) An enrollee is not entitled to coverage of a health care serviceunder a group or an individual contract unless that health care serviceis included in the enrollee's contract.
    (c) A provider is not entitled to payment under a contract forhealth care services provided to an enrollee unless the provider hasa contract or an agreement with the carrier.
    (d) This section applies to a contract entered, renewed, ormodified after June 30, 1996.
As added by P.L.26-1994, SEC.25. Amended by P.L.195-1996,SEC.7; P.L.192-1996, SEC.3.

IC 27-13-15-2
Contract requirements not met; collection of money owed byhealth maintenance organization prohibited
    Sec. 2. If:
        (1) the contract between a health maintenance organization anda participating provider has not been reduced to writing asrequired by this chapter; or
        (2) the contract fails to contain the provision required by section1(a)(4) of this chapter;
the participating provider may not collect or attempt to collect fromthe subscriber or enrollee any sums that are owed by the healthmaintenance organization.
As added by P.L.26-1994, SEC.25. Amended by P.L.203-2001,SEC.25.

IC 27-13-15-3
Actions against subscribers; costs and attorney's fees    Sec. 3. (a) A:
        (1) participating provider; or
        (2) trustee, an agent, a representative, or an assignee of aparticipating provider;
may not bring or maintain any legal action against a subscriber or anenrollee of a health maintenance organization to collect sums owedby the health maintenance organization.
    (b) Except as provided in subsection (c), if a participatingprovider of a health maintenance organization brings or maintains alegal action against a subscriber or enrollee for an amount owed tothe participating provider by the health maintenance organization, theparticipating provider is liable to the subscriber or enrollee for costsand attorney's fees incurred by the subscriber or enrollee indefending the legal action.
    (c) A participating provider shall not be liable to the subscriber orenrollee for costs and attorney's fees described in subsection (b) ifthe participating provider can demonstrate a reasonable basis forbelieving at the time the legal action was brought and while the legalaction was maintained that the health maintenance organization didnot owe the sums the participating provider sought to collect fromthe subscriber or enrollee.
As added by P.L.26-1994, SEC.25. Amended by P.L.203-2001,SEC.26.

IC 27-13-15-4
Participating provider agreement prohibitions
    Sec. 4. (a) As used in this section, "health maintenanceorganization" includes the following:
        (1) A limited service health maintenance organization.
        (2) A person that pays or administers claims on behalf of ahealth maintenance organization or a limited service healthmaintenance organization.
    (b) An agreement between a health maintenance organization anda participating provider under this chapter may not contain aprovision that:
        (1) prohibits, or grants the health maintenance organization anoption to prohibit, the participating provider from contractingwith another health maintenance organization to accept lowerpayment for health care services than the payment specified inthe agreement;
        (2) requires, or grants the health maintenance organization anoption to require, the participating provider to accept a lowerpayment from the health maintenance organization if theparticipating provider agrees with another health maintenanceorganization to accept lower payment for health care services;
        (3) requires, or grants the health maintenance organization anoption of, termination or renegotiation of the agreement if theparticipating provider agrees with another health maintenanceorganization to accept lower payment for health care services;or        (4) requires the participating provider to disclose theparticipating provider's reimbursement rates under contractswith other health maintenance organizations.
    (c) A contract provision that violates this section is void.
As added by P.L.74-2007, SEC.2.

IC 27-13-15-5
Coverage for dialysis treatment
    Sec. 5. (a) Notwithstanding IC 27-13-1-12, as used in this section,"enrollee" refers only to an enrollee who requires dialysis treatment.
    (b) As used in this section, "health maintenance organization"includes the following:
        (1) A limited service health maintenance organization.
        (2) An agent of a health maintenance organization or a limitedservice health maintenance organization.
    (c) A health maintenance organization shall not require anenrollee, as a condition of coverage or reimbursement, to:
        (1) if the nearest dialysis facility is located within thirty (30)miles of the enrollee's home, travel more than thirty (30) milesfrom the enrollee's home to obtain dialysis treatment; or
        (2) if the nearest dialysis facility is located more than thirty (30)miles from the enrollee's home, travel a greater distance thanthe distance to the nearest dialysis facility to obtain dialysistreatment;
regardless of whether the enrollee chooses to receive dialysistreatment at a dialysis facility that is a participating provider or adialysis facility that is not a participating provider.
As added by P.L.111-2008, SEC.6.