Section 25-1-9-23 - In network practitioner charge limited to network plan rate; conditions for reimbursement of out of network practitioner at higher rate(a) This section does not apply to emergency services.(b) As used in this section, "covered individual" means an individual who is entitled to be provided health care services at a cost established according to a network plan.(c) As used in this section, "emergency services" means services that are: (1) furnished by a provider qualified to furnish emergency services; and(2) needed to evaluate or stabilize an emergency medical condition.(d) As used in this section, "in network practitioner" means a practitioner who is required under a network plan to provide health care services to covered individuals at not more than a preestablished rate or amount of compensation.(e) As used in this section, "network plan" means a plan under which facilities and practitioners are required by contract to provide health care services to covered individuals at not more than a preestablished rate or amount of compensation.(f) As used in this section, "out of network" means that the health care services provided by the practitioner to a covered individual are not subject to the covered individual's health carrier network plan.(g) As used in this section, "practitioner" means the following:(1) An individual who holds:(A) an unlimited license, certificate, or registration;(B) a limited or probationary license, certificate, or registration;(C) a temporary license, certificate, registration, or permit;(E) a provisional license; issued by the board (as defined in IC 25-0.5-11-1) regulating the profession in question.
(2) An entity that: (A) is owned by, or employs; or(B) performs billing for professional health care services rendered by; an individual described in subdivision (1).
The term does not include a dentist licensed under IC 25-14, an optometrist licensed under IC 25-24, or a provider facility (as defined in IC 25-1-9.8-10).
(h) An in network practitioner who provides covered health care services to a covered individual may not charge more for the covered health care services than allowed according to the rate or amount of compensation established by the individual's network plan.(i) An out of network practitioner who provides health care services at an in network facility to a covered individual may not be reimbursed more for the health care services than allowed according to the rate or amount of compensation established by the covered individual's network plan unless all of the following conditions are met: (1) At least five (5) business days before the health care services are scheduled to be provided to the covered individual, the practitioner provides to the covered individual, on a form separate from any other form provided to the covered individual by the practitioner, a statement in conspicuous type that meets the following requirements:(A) Includes a notice reading substantially as follows: "[Name of practitioner] is an out of network practitioner providing [type of care] with [name of in network facility], which is an in network provider facility within your health carrier's plan. [Name of practitioner] will not be allowed to bill you the difference between the price charged by the practitioner and the rate your health carrier will reimburse for the services during your care at [name of in network facility] unless you give your written consent to the charge.".(B) Sets forth the practitioner's good faith estimate of the amount that the practitioner intends to charge for the health care services provided to the covered individual.(C) Includes a notice reading substantially as follows concerning the good faith estimate set forth under clause (B): "The estimate of our intended charge for [name or description of health care services] set forth in this statement is provided in good faith and is our best estimate of the amount we will charge. If our actual charge for [name or description of health care services] exceeds our estimate by the greater of: (i) one hundred dollars ($100); or(ii) five percent (5%); we will explain to you why the charge exceeds the estimate.".
(2) The covered individual signs the statement provided under subdivision (1), signifying the covered individual's consent to the charge for the health care services being greater than allowed according to the rate or amount of compensation established by the network plan.(j) If an out of network practitioner does not meet the requirements of subsection (i), the out of network practitioner shall include on any bill remitted to a covered individual a written statement in conspicuous type stating that the covered individual is not responsible for more than the rate or amount of compensation established by the covered individual's network plan plus any required copayment, deductible, or coinsurance.(k) If a covered individual's network plan remits reimbursement to the covered individual for health care services subject to the reimbursement limitation of subsection (i), the network plan shall provide with the reimbursement a written statement in conspicuous type that states that the covered individual is not responsible for more than the rate or amount of compensation established by the covered individual's network plan and that is included in the reimbursement plus any required copayment, deductible, or coinsurance.(l) If the charge of a practitioner for health care services provided to a covered individual exceeds the estimate provided to the covered individual under subsection (i)(1)(B) by the greater of:(1) one hundred dollars ($100); or(2) five percent (5%); the facility or practitioner shall explain in a writing provided to the covered individual why the charge exceeds the estimate.
(m) An in network practitioner is not required to provide a covered individual with the good faith estimate if the nonemergency health care service is scheduled to be performed by the practitioner within five (5) business days after the health care service is ordered.(n) The department of insurance shall adopt rules under IC 4-22-2 to specify the requirements of the notifications set forth in subsections (j) and (k).(o) The requirements of this section do not apply to a practitioner who: (1) is required to comply with; and(2) is in compliance with; 45 CFR Part 149, Subparts E and G, as may be enforced and amended by the federal Department of Health and Human Services.
Amended by P.L. 93-2024,SEC. 180, eff. 7/1/2024.Amended by P.L. 190-2023,SEC. 8, eff. 7/1/2023.Amended by P.L. 165-2022,SEC. 1, eff. 7/1/2022.Amended by P.L. 32-2021,SEC. 68, eff. 7/1/2021.Amended by P.L. 202-2021,SEC. 1, eff. 6/30/2021.Added by P.L. 93-2020,SEC. 6, eff. 7/1/2020.