IC 27-13-36
    Chapter 36. Patient Protection; Clinical Decision Making; Accessto Personnel and Facilities

IC 27-13-36-1
Medical director; individual to develop treatment policies andconsult with treating providers
    Sec. 1. (a) Each health maintenance organization shall appoint amedical director who has an unlimited license to practice medicineunder IC 25-22.5 or an equivalent license issued by another state.
    (b) The medical director is responsible for oversight of treatmentpolicies, protocols, quality assurance activities, and utilizationmanagement decisions of the health maintenance organization.
    (c) A health maintenance organization shall contract with oremploy at least one (1) individual who holds an unlimited license topractice medicine under IC 25-22.5 to do the following:
        (1) Develop, in consultation with a group of appropriateproviders, the health maintenance organization's treatmentpolicies, protocols, and quality assurance activities.
        (2) Consult with the treating provider before an adverseutilization review decision is made.
    (d) Compliance with the most current standards or guidelinesdeveloped by the National Committee on Quality Assurance or asuccessor organization is sufficient to meet the requirements of thissection.
As added by P.L.69-1998, SEC.14.

IC 27-13-36-2
Sufficient number and type of primary care providers
    Sec. 2. Beginning July 1, 1999, each health maintenanceorganization shall include a sufficient number and type of primarycare providers and other appropriate providers throughout the healthmaintenance organization's service area to:
        (1) meet the needs of; and
        (2) provide a choice of primary care providers and otherappropriate providers to;
enrollees and subscribers of the health maintenance organization.Compliance with the most current standards or guidelines developedby the National Committee on Quality Assurance or a successororganization is sufficient to meet the requirements of this section.
As added by P.L.69-1998, SEC.14.

IC 27-13-36-2.5
Discrimination on basis of provider's license or certificationprohibited
    Sec. 2.5. (a) A health maintenance organization may notdiscriminate against a provider acting within the scope of theprovider's license or certification with respect to:
        (1) participation;
        (2) reimbursement;        (3) indemnification; or
        (4) scope of care;
solely on the basis of the provider's license or certification.
    (b) This section does not require a health maintenanceorganization to enter into a contract with a provider that would allowthe provider to enter the health maintenance organization network.
As added by P.L.233-1999, SEC.13.

IC 27-13-36-3
Adequate number of services and providers within reasonableproximity of subscribers
    Sec. 3. (a) The provisions of this section do not apply until July1, 1999.
    (b) Each health maintenance organization shall demonstrate to thedepartment that the health maintenance organization offers anadequate number of:
        (1) acute care hospital services;
        (2) primary care providers; and
        (3) other appropriate providers;
that are located within a reasonable proximity of subscribers of thehealth maintenance organization. Compliance with the most currentstandards or guidelines developed by the National Committee onQuality Assurance or a successor organization is sufficient to meetthe requirements of this subsection.
    (c) If a health maintenance organization provides coverage for:
        (1) specialty medical services, including physical therapy,occupational therapy, and rehabilitation services;
        (2) mental and behavioral care services; or
        (3) pharmacy services;
the health maintenance organization shall demonstrate to thedepartment that the offered services are located within a reasonableproximity of subscribers of the health maintenance organization.Compliance with the most current standards or guidelines developedby the National Committee on Quality Assurance or a successororganization is sufficient to meet the requirements of this subsection.
As added by P.L.69-1998, SEC.14.

IC 27-13-36-4
Specialty areas of primary care providers
    Sec. 4. Beginning July 1, 1999, primary care providers shallinclude licensed physicians who practice in one (1) or more of thefollowing areas:
        (1) Family practice.
        (2) General practice.
        (3) Internal medicine.
        (4) As a woman's health care provider, in compliance withIC 27-8-24.7.
        (5) Pediatrics.
As added by P.L.69-1998, SEC.14.
IC 27-13-36-5
Referrals to out of network providers
    Sec. 5. (a) The provisions of the section do not apply until July 1,1999.
    (b) When an enrollee's primary care provider determines that theenrollee needs a particular health care service and the healthmaintenance organization determines that the type of health careservice needed by the enrollee to treat a specific condition:
        (1) is a covered service; and
        (2) is not available from the health maintenance organization'snetwork of participating providers;
the primary care provider and the health maintenance organizationshall refer the enrollee to an appropriate provider who is not aparticipating provider within a reasonable amount of time and withina reasonable proximity of the enrollee.
    (c) When an enrollee receives health care services from a providerto whom the enrollee was referred as described in subsection (b), thehealth maintenance organization shall pay the out of networkprovider the lesser of the following:
        (1) The usual, customary, and reasonable charge in the healthmaintenance organization's service area for the health careservices provided by the out of network provider.
        (2) An amount agreed to between the health maintenanceorganization and the out of network provider.
The enrollee's treating provider may collect from the enrollee onlythe deductible or copayment, if any, that the enrollee would beresponsible to pay if the health care services had been provided bya participating provider. The enrollee may not be billed by the healthmaintenance organization or by the out of network provider for anydifference between the out of network provider's charge and theamount paid by the health maintenance organization to the out ofnetwork provider as provided in this subsection.
    (d) A contract between a health maintenance organization and aprimary care provider may not provide for a financial or otherpenalty to the primary care provider for making a determinationallowed under subsection (b).
As added by P.L.69-1998, SEC.14.

IC 27-13-36-6
Continuation of care provisions
    Sec. 6. (a) A health maintenance organization shall includeprovisions in the health maintenance organization's contracts withproviders to provide for continuation of care in the event that aprovider's contract with the health maintenance organization isterminated, provided that the termination is not due to a quality ofcare issue.
    (b) The contract provisions under subsection (a) shall require thatthe provider, upon the request of the enrollee, continue to treat theenrollee for up to sixty (60) days following the termination of theprovider's contract with the health maintenance organization or, in

the case of a pregnant enrollee in the third trimester of pregnancy,throughout the term of the enrollee's pregnancy. If the provider is ahospital, the contract shall provide for continuation of treatment untilthe earlier of the following:
        (1) Sixty (60) days following the termination of the provider'scontract with the health maintenance organization.
        (2) The enrollee is released from inpatient status at the hospital.
    (c) During a continuation period under this section, the provider:
        (1) shall agree to continue accepting the contract terms andconditions, together with applicable deductibles andcopayments, as payment in full; and
        (2) is prohibited from billing the enrollee for any amounts inexcess of the enrollee's applicable deductible or copayment.
As added by P.L.69-1998, SEC.14.

IC 27-13-36-7
Telephone access for authorization of care
    Sec. 7. Each health maintenance organization shall provide thefollowing:
        (1) Telephone access to the health maintenance organizationduring business hours to ensure enrollee access for routine care.
        (2) Twenty-four (24) hour telephone access to either:
            (A) a representative of the health maintenance organization;or
            (B) a participating provider;
        for authorization for care.
As added by P.L.69-1998, SEC.14.

IC 27-13-36-8
Guidelines for establishing reasonable periods for appointments
    Sec. 8. (a) Each health maintenance organization shall establishguidelines for establishing reasonable periods of time within whichan enrollee must be given an appointment with a participatingprovider, except as provided in section 9 of this chapter regardingemergency services.
    (b) The guidelines described in subsection (a) must includeappointment scheduling guidelines based on the type of health careservices most often requested, including the following:
        (1) Prenatal care appointments.
        (2) Well-child visits and immunizations.
        (3) Routine physicals.
        (4) Adult preventive services.
        (5) Urgent visits.
As added by P.L.69-1998, SEC.14.

IC 27-13-36-9
Coverage and reimbursement for expenses for care obtained in anemergency
    Sec. 9. (a) As used in this section, "care obtained in anemergency" means, with respect to an enrollee, covered services that

are:
        (1) furnished by a provider within the scope of the provider'slicense and as otherwise authorized under law; and
        (2) needed to evaluate or stabilize an individual in anemergency.
    (b) As used in this section, "stabilize" means to provide medicaltreatment to an individual in an emergency as may be necessary toassure, within reasonable medical probability, that materialdeterioration of the individual's condition is not likely to result fromor during any of the following:
        (1) The discharge of the individual from an emergencydepartment or other care setting where emergency services areprovided to the individual.
        (2) The transfer of the individual from an emergencydepartment or other care setting where emergency services areprovided to the individual to another health care facility.
        (3) The transfer of the individual from a hospital emergencydepartment or other hospital care setting where emergencyservices are provided to the individual to the hospital's inpatientsetting.
    (c) As described in subsection (d), each health maintenanceorganization shall cover and reimburse expenses for care obtained inan emergency by an enrollee without:
        (1) prior authorization; or
        (2) regard to the contractual relationship between:
            (A) the provider who provided health care services to theenrollee in an emergency; and
            (B) the health maintenance organization;
in a situation where a prudent lay person could reasonably believethat the enrollee's condition required immediate medical attention.The emergency care obtained by an enrollee under this sectionincludes care for the alleviation of severe pain, which is a symptomof an emergency as provided in IC 27-13-1-11.7.
    (d) Each health maintenance organization shall cover andreimburse expenses for emergency services at a rate equal to thelesser of the following:
        (1) The usual, customary, and reasonable charge in the healthmaintenance organization's service area for health care servicesprovided during the emergency.
        (2) An amount agreed to between the health maintenanceorganization and the out of network provider.
A provider that provides emergency services to an enrollee under thissection may not charge the enrollee except for an applicablecopayment or deductible. Care and treatment provided to an enrolleeonce the enrollee is stabilized is not care obtained in an emergency.
As added by P.L.69-1998, SEC.14.

IC 27-13-36-10
Access plan to meet needs of vulnerable, underserved, andnon-English speaking enrollees    Sec. 10. Each health maintenance organization shall demonstrateto the commissioner that the health maintenance organization hasdeveloped an access plan to meet the needs of the health maintenanceorganization's enrollees, including vulnerable and underservedenrollees and enrollees from major population groups who speak aprimary language other than English.
As added by P.L.69-1998, SEC.14.

IC 27-13-36-11
Standards for continuity of care
    Sec. 11. The health maintenance organization shall developstandards for continuity of care following enrollment, includingsufficient information on how to access care within the healthmaintenance organization.
As added by P.L.69-1998, SEC.14.

IC 27-13-36-12
Payment to enrollee for service rendered by nonparticipatingprovider; requirements
    Sec. 12. (a) As used in this section, "nonparticipating provider"means a provider that has not entered into an agreement with a healthmaintenance organization to serve as a participating provider.
    (b) After September 30, 2009, if a health maintenanceorganization makes a payment to an enrollee for a health care servicerendered by a nonparticipating provider, the health maintenanceorganization shall include with the payment instrument written noticeto the enrollee that includes the following:
        (1) A statement specifying the claims covered by the paymentinstrument.
        (2) The name and address of the provider submitting eachclaim.
        (3) The amount paid by the health maintenance organization foreach claim.
        (4) Any amount of a claim that is the enrollee's responsibility.
        (5) A statement in at least 24 point bold type that:
            (A) instructs the enrollee to use the payment to pay thenonparticipating provider if the enrollee has not paid thenonparticipating provider in full;
            (B) specifies that paying the nonparticipating provider is theenrollee's responsibility; and
            (C) states that the failure to make the payment violates thelaw and may result in collection proceedings or criminalpenalties.
As added by P.L.144-2009, SEC.3.