HB 1004

Bill Subjects

Abstract

Establishes: (1) a state directed payment program (program) for hospitals; and (2) a managed care assessment fee. Changes disproportionate share payments when a state directed payment program is in effect. Allows the incremental hospital fee fund to be used to fund the Medicaid program. Changes the name of the managed care assessment fund to the managed care assessment fee holding fund and states that the funds revert to the state general fund. Requires a nonprofit hospital system to submit audited financial statements. Provides for the revocation of a hospital's license for failure to submit the hospital's financial statements. Limits what may constitute community benefits for certain nonprofit hospitals. Before June 30, 2026, requires the office of management and budget (office) to conduct a study of commercial inpatient hospital prices and outpatient hospital prices by using specified data to determine Indiana's statewide average inpatient and outpatient hospital prices. Requires the office to submit a report of the study to the governor and general assembly. Requires an annual adjustment calculation by the office. Before June 30, 2029, requires an Indiana nonprofit hospital system's aggregate average inpatient and outpatient hospital prices to at least be equal to or less than the statewide average. States that a violation by the Indiana nonprofit hospital system results in a forfeiture of its nonprofit status. Requires, before November 1 of each year, every nonprofit hospital to provide the health care cost oversight task force with specified federally filed forms. Provides an exemption from health care billing requirements for a facility located in a specified populated municipality. Requires a third party administrator to disclose commissions and fees to policyholders in a separate notification. Requires an insurer and a health maintenance organization to submit specified data information to the all payer claims data base. Requires an insurance producer or third party administrator to, before or at the time of sale, provide the plan sponsor with a statement from the insurer or health maintenance organization, disclosing commissions and fees that the insurance producer or third party administrator will receive. Changes the time frame in which certain information and claims data must be submitted to a contract holder as part of an audit or claims data request. Sets requirements for certain hospitals concerning a direct to employer health care arrangement. Beginning January 1, 2026, requires a state employee health plan, a policy of accident and sickness insurance, and a health maintenance organization contract to provide to a covered individual the national average drug acquisition cost of a generic drug on the written materials provided at the point of sale. Provides that if an agreement between a health plan and a pharmacy benefit manager that is entered into or renewed after December 31, 2025, provides that less than 85% of the estimated rebates will be deducted from the cost of prescription drugs before a covered individual's cost sharing requirement is determined, the pharmacy benefit manager must provide the policyholder with a notice on an annual basis that includes: (1) an explanation of what a rebate is; (2) an explanation of how rebates accrue to the health plan from the manufacturer; and (3) the aggregate amount of rebates that accrued to the health plan for prescription drugs dispensed under the policyholder's health plan for the previous year. Places limitations on hospital health provider contracts linking reimbursement or terms for a Medicare Advantage plan unless the reimbursement rate offered meets a specified percentage of Medicare reimbursement. Requires the office to study the effect, including fiscal impact, of requiring the primary care physician reimbursement rates under a commercial policy to be set at a minimum reimbursement rate and report its findings under the study. Requires certain health carriers to provide claims data to a contract holder not more than four times per year (current law allows for the provision of the data twice annually). Requires the department of insurance to perform an examination for a violation of these provisions. Requires certain insurers and health maintenance organization to file specified information concerning changes in hospital reimbursement to the department of insurance.