IC 27-13-37
Chapter 37. Patient Protection; Choice of Health Care
Professional
IC 27-13-37-1 Enrollees allowed to choose primary care provider from list
Sec. 1. (a) A health maintenance organization shall allow each
enrollee of the health maintenance organization to choose the
enrollee's own primary care provider from a list of participating
primary care providers within the health maintenance organization.
(b) The list described in subsection (a) shall be updated
semiannually and must include a sufficient number of primary care
providers that accept new enrollees. The list must be:
(1) provided to each enrollee annually; and
(2) sent to an enrollee at the enrollee's request. As added by P.L.69-1998, SEC.15.
IC 27-13-37-2 Use of participating provider other than primary care provider
Sec. 2. (a) Each health maintenance organization shall develop a
system to allow an enrollee to use an appropriate participating
provider to manage the enrollee's medical condition when the
enrollee's primary care provider determines that the use of another
appropriate participating provider is warranted by the enrollee's
medical condition.
(b) A primary care provider who makes the required
determination under subsection (a) shall refer the enrollee to a
participating provider whom the primary care provider determines is
appropriate.
(c) A health maintenance organization shall provide coverage
under this section for treatment received by an enrollee from an
appropriate participating provider when the enrollee is referred to the
participating provider as provided in this section for as long as the
treatment is appropriate for the medical condition, subject to the
terms and conditions of the enrollee's contract with the health
maintenance organization.
(d) A contract between a health maintenance organization and a
primary care provider may not provide for a financial or other
penalty to the primary care provider for making a referral allowed
under this section. As added by P.L.69-1998, SEC.15.
IC 27-13-37-3 Continuity of care and referrals when specialty care warranted
Sec. 3. Beginning July 1, 1999, each health maintenance
organization shall provide continuity of care and referral to
appropriate participating providers when specialty care is warranted,
including the following:
(1) Enrollees have access to appropriate participating providers
on a timely basis.
(2) Enrollees have a choice of appropriate participating
providers when a referral is made. As added by P.L.69-1998, SEC.15.
IC 27-13-37-4 Point-of-service products; dental care services
Sec. 4. (a) Each health maintenance organization shall offer to
each purchaser of a group contract or individual contract a
point-of-service product to the extent permitted by IC 27-13-13-8.
(b) Beginning July 1, 2001, a limited service health maintenance
organization that provides dental care services shall offer to each
purchaser of a group contract or individual contract:
(1) a point-of-service product to the extent permitted by
IC 27-13-34-10(a)(6);
(2) a preferred provider plan (as defined in IC 27-8-11-1); or
(3) a policy of accident and sickness insurance (as defined in
IC 27-8-5-1);
that provides dental care services. As added by P.L.69-1998, SEC.15. Amended by P.L.91-2000, SEC.3.
IC 27-13-37-5 Second medical opinions
Sec. 5. Each health maintenance organization shall allow an
enrollee who has received a medical opinion from a participating
provider to obtain a second medical opinion from an appropriate
participating provider concerning the enrollee's medical condition at
the enrollee's request. As added by P.L.69-1998, SEC.15.
IC 27-13-37
Chapter 37. Patient Protection; Choice of Health Care
Professional
IC 27-13-37-1 Enrollees allowed to choose primary care provider from list
Sec. 1. (a) A health maintenance organization shall allow each
enrollee of the health maintenance organization to choose the
enrollee's own primary care provider from a list of participating
primary care providers within the health maintenance organization.
(b) The list described in subsection (a) shall be updated
semiannually and must include a sufficient number of primary care
providers that accept new enrollees. The list must be:
(1) provided to each enrollee annually; and
(2) sent to an enrollee at the enrollee's request. As added by P.L.69-1998, SEC.15.
IC 27-13-37-2 Use of participating provider other than primary care provider
Sec. 2. (a) Each health maintenance organization shall develop a
system to allow an enrollee to use an appropriate participating
provider to manage the enrollee's medical condition when the
enrollee's primary care provider determines that the use of another
appropriate participating provider is warranted by the enrollee's
medical condition.
(b) A primary care provider who makes the required
determination under subsection (a) shall refer the enrollee to a
participating provider whom the primary care provider determines is
appropriate.
(c) A health maintenance organization shall provide coverage
under this section for treatment received by an enrollee from an
appropriate participating provider when the enrollee is referred to the
participating provider as provided in this section for as long as the
treatment is appropriate for the medical condition, subject to the
terms and conditions of the enrollee's contract with the health
maintenance organization.
(d) A contract between a health maintenance organization and a
primary care provider may not provide for a financial or other
penalty to the primary care provider for making a referral allowed
under this section. As added by P.L.69-1998, SEC.15.
IC 27-13-37-3 Continuity of care and referrals when specialty care warranted
Sec. 3. Beginning July 1, 1999, each health maintenance
organization shall provide continuity of care and referral to
appropriate participating providers when specialty care is warranted,
including the following:
(1) Enrollees have access to appropriate participating providers
on a timely basis.
(2) Enrollees have a choice of appropriate participating
providers when a referral is made. As added by P.L.69-1998, SEC.15.
IC 27-13-37-4 Point-of-service products; dental care services
Sec. 4. (a) Each health maintenance organization shall offer to
each purchaser of a group contract or individual contract a
point-of-service product to the extent permitted by IC 27-13-13-8.
(b) Beginning July 1, 2001, a limited service health maintenance
organization that provides dental care services shall offer to each
purchaser of a group contract or individual contract:
(1) a point-of-service product to the extent permitted by
IC 27-13-34-10(a)(6);
(2) a preferred provider plan (as defined in IC 27-8-11-1); or
(3) a policy of accident and sickness insurance (as defined in
IC 27-8-5-1);
that provides dental care services. As added by P.L.69-1998, SEC.15. Amended by P.L.91-2000, SEC.3.
IC 27-13-37-5 Second medical opinions
Sec. 5. Each health maintenance organization shall allow an
enrollee who has received a medical opinion from a participating
provider to obtain a second medical opinion from an appropriate
participating provider concerning the enrollee's medical condition at
the enrollee's request. As added by P.L.69-1998, SEC.15.
IC 27-13-37
Chapter 37. Patient Protection; Choice of Health Care
Professional
IC 27-13-37-1 Enrollees allowed to choose primary care provider from list
Sec. 1. (a) A health maintenance organization shall allow each
enrollee of the health maintenance organization to choose the
enrollee's own primary care provider from a list of participating
primary care providers within the health maintenance organization.
(b) The list described in subsection (a) shall be updated
semiannually and must include a sufficient number of primary care
providers that accept new enrollees. The list must be:
(1) provided to each enrollee annually; and
(2) sent to an enrollee at the enrollee's request. As added by P.L.69-1998, SEC.15.
IC 27-13-37-2 Use of participating provider other than primary care provider
Sec. 2. (a) Each health maintenance organization shall develop a
system to allow an enrollee to use an appropriate participating
provider to manage the enrollee's medical condition when the
enrollee's primary care provider determines that the use of another
appropriate participating provider is warranted by the enrollee's
medical condition.
(b) A primary care provider who makes the required
determination under subsection (a) shall refer the enrollee to a
participating provider whom the primary care provider determines is
appropriate.
(c) A health maintenance organization shall provide coverage
under this section for treatment received by an enrollee from an
appropriate participating provider when the enrollee is referred to the
participating provider as provided in this section for as long as the
treatment is appropriate for the medical condition, subject to the
terms and conditions of the enrollee's contract with the health
maintenance organization.
(d) A contract between a health maintenance organization and a
primary care provider may not provide for a financial or other
penalty to the primary care provider for making a referral allowed
under this section. As added by P.L.69-1998, SEC.15.
IC 27-13-37-3 Continuity of care and referrals when specialty care warranted
Sec. 3. Beginning July 1, 1999, each health maintenance
organization shall provide continuity of care and referral to
appropriate participating providers when specialty care is warranted,
including the following:
(1) Enrollees have access to appropriate participating providers
on a timely basis.
(2) Enrollees have a choice of appropriate participating
providers when a referral is made. As added by P.L.69-1998, SEC.15.
IC 27-13-37-4 Point-of-service products; dental care services
Sec. 4. (a) Each health maintenance organization shall offer to
each purchaser of a group contract or individual contract a
point-of-service product to the extent permitted by IC 27-13-13-8.
(b) Beginning July 1, 2001, a limited service health maintenance
organization that provides dental care services shall offer to each
purchaser of a group contract or individual contract:
(1) a point-of-service product to the extent permitted by
IC 27-13-34-10(a)(6);
(2) a preferred provider plan (as defined in IC 27-8-11-1); or
(3) a policy of accident and sickness insurance (as defined in
IC 27-8-5-1);
that provides dental care services. As added by P.L.69-1998, SEC.15. Amended by P.L.91-2000, SEC.3.
IC 27-13-37-5 Second medical opinions
Sec. 5. Each health maintenance organization shall allow an
enrollee who has received a medical opinion from a participating
provider to obtain a second medical opinion from an appropriate
participating provider concerning the enrollee's medical condition at
the enrollee's request. As added by P.L.69-1998, SEC.15.
