HB 1003

Bill Subjects

Agencies; Department Of Health (Idoh) Agencies; Family And Social Services Administration (Fssa) Civil Law And Procedure; Contracts And Legal Documents Health Care Facilities; Generally Health Care Professionals; Generally Health; Billing And Costs Health; Generally Health; Medicaid Health; Medical Records Insurance; Health Insurance Insurance; Medicare State Elected Officials; Attorney General

Abstract

Specifies that the Medicaid fraud control unit's (MFCU) investigation of Medicaid fraud may include the investigation of provider fraud, insurer fraud, duplicate billing, and other instances of fraud. Permits the attorney general to enter into a data sharing agreement with specified state agencies and authorizes the MFCU to analyze this data to carry out its investigative duties. Provides that all complaints made to the state Medicaid fraud control unit are confidential until an action is filed concerning the complaint. Provides that the attorney general may designate investigators employed within the MFCU to be law enforcement officers of the state. Requires a state employee health plan, the office of the secretary of family and social services (office), an insurer, and a health maintenance organization to provide reimbursement for a health care service that is provided in an outpatient setting at the same reimbursement rate that is provided at a physician's office. Requires the office to establish: (1) metrics to assess the quality of care and patient outcomes; and (2) transparency and accountability safeguards; for a long term care risk based managed care program. Allows the Indiana department of health (state department) to enter into partnerships and joint ventures to encourage best practices in the appropriate and effective use of prior authorization in health care. Requires the state department, in consultation with the office of technology, to: (1) develop certain standards regarding medical records and data; and (2) mandate compliance with the standards by any medical provider that contracts with the state. Requires, not later than December 31, 2025, a clinical laboratory and diagnostic imaging facility to post pricing information. Requires providers to submit a claim for health care services with the appropriate place of service code for the setting. Allows: (1) a manufacturer to provide; and (2) a patient to receive; individualized investigational treatment if certain conditions are met. Prohibits a 340B covered entity from charging an individual for a prescription drug under the program at a greater price than the prescription drug was obtained for under the program. Allows the state department to enforce the 340B drug requirements and assess a civil penalty. Provides exemptions from provisions regarding health care billing. Sets forth requirements regarding the submission of a bill for health care services. Requires an Indiana nonprofit hospital system to report a list of facilities that may submit a bill on an institutional provider form. Prohibits an out-of-network practitioner providing nonemergency health care services at an in network facility from being reimbursed more for the health care services than the 2019 median in network rate with the specified adjustment. Requires a provider to provide the patient with a written list of services that the: (1) patient received; and (2) provider intends to bill the patient; upon a patient's discharge from receiving certain services. Requires good faith estimates for health care services, issued before July 1, 2026, to be provided at least two business days (rather than five business days) before the health care services are scheduled to be provided. Requires good faith estimates, issued after June 30, 2026, to be provided immediately. Removes language concerning the disclosure of a trade secret from provisions that allow for a health plan sponsor to access and audit claims data. Provides that when a health carrier is in the process of negotiating a health provider contract with a health provider facility or provider, the health carrier must provide certain information to the health provider facility or provider. Specifies certain provisions that may not be included in a health provider contract. Prohibits a health plan from rescinding a prior authorization that the health plan has previously approved within one year after the prior authorization is approved. Provides that a health plan shall ensure that any adverse determination on a request for prior authorization is made by a clinical peer of the provider who requested the prior authorization. Allows the department of insurance to receive information regarding prior authorization disputes and requires the department of insurance to prepare a report with findings and recommendations related to the information. Requires, not later than September 1, 2025, the department of insurance to issue a request for information concerning ways to better enable medical consumers to compare and shop for medical and health care services. Adds the secretary of health and human services as a nonvoting advisory member of the all payer claims data base advisory board. Provides that an insurer or a health maintenance organization may not deny a claim for reimbursement on the basis that the referring provider is an out of network direct primary care provider or independent physician. Requires, if a fully credentialed physician becomes employed with another employer or establishes or relocates a medical practice in Indiana, an insurer and health maintenance organization to provisionally credential the physician for 60 days or until the physician is fully credentialed, whichever is earlier.