Chapter 37.6. Program to Reduce or Eliminate Prior Authorization Requirements for Health Care Providers
This entire statute falls under the category “Risk-Physicians Taking.” See the bold text below to see the language falling under the category “Payment Edits.”
Sec. 1. As used in this chapter, “bundled payments” means a reimbursement structure in which different health care providers who are treating a patient for the same or related conditions are
paid an overall sum for treating a patient’s condition rather than being paid for each individual treatment, test, or procedure.
Sec. 2. As used in this chapter, “capitated rate reimbursement arrangement” means a fixed amount of money per patient per unit of time paid in advance to the health care provider for the delivery
of health care services.
Sec. 3. As used in this chapter, “downside risk” means the risk borne by health care providers in a situation in which, if the total cost of care exceeds projected or budgeted costs, the health care
providers will be responsible for a defined percentage of the amount by which the total cost of care exceeds the projected or budgeted costs.
Sec. 4. As used in this chapter, “electronic medical record”:
(1) means a digital collection of medical information about a person that is stored on a computer, electronic platform, or cloud that is automated or permitted to be accessed; and
(2) includes information about a patient’s health history, such as:
(D) allergies; and
(E) treatment plans.
Sec. 5. As used in this chapter, “electronic medical records access agreement” means an agreement between a health plan and health care provider that:
(1) authorizes the health plan to access the provider’s electronic medical records; or
(2) allows the transfer of automated medical records information between a health care provider and health plan.
Sec. 6. As used in this chapter, “fixed fee schedule” means a total listing of fees used by a health plan to reimburse health care providers or facilities whether:
(1) the fixed fee schedule is based on or equal to Medicare reimbursement for the same health care service; or
(2) the health plan provides the fixed fee schedule to the health care provider.
Sec. 7. As used in this chapter, “health care provider” means an individual or entity that is:
(1) licensed, certified, registered, or regulated by an entity described in IC 25-0.5-11;
(2) authorized to provide health care services; and
(3) contracted to provide health care services to members of a health plan.
Sec. 8. (a) As used in this chapter, “health care service” means a medical or surgical service for the diagnosis, prevention, treatment, cure, or relief of illness, injury, or disease that is measured at the diagnosis and procedure level for an individual health care provider.
(b) The term does not include the following:
(1) Dental services.
(2) Vision services.
(3) Long term rehabilitation treatment.
(4) Pharmaceutical or pharmacist services or products.
Sec. 9. (a) As used in this chapter, “health plan” means any of the following:
(1) A policy of accident and sickness insurance (as defined in IC 27-8-5-1). However, the term does not include the coverages described in IC 27-8-5-2.5(a).
(2) A contract with a health maintenance organization (as defined in IC 27-13-1-19) that provides coverage for basic health care services (as defined in IC 27-13-1-4).
(3) A self-insurance program established under IC5-10-8-7(b) to provide health care coverage.
(b) The term includes the following:
(1) The insurer that issues a policy of accident and sickness insurance described in subsection (a)(1).
(2) The health maintenance organization referred to in subsection (a)(2).
(3) The entity with which the state contracts for the administration of the self-insurance program established under IC 5-10-8-7(b) to provide health care coverage.
(c) The term does not include a Medicaid managed care organization, as defined in IC 12-7-2-126.9.
Sec. 10. As used in this chapter, “narrow network” means a network:
(1) significantly limited to select health care providers that offer a range of health care services to health plan members; and
(2) for which any other health care provider that is not included in the network is an out of network health care provider.
Sec. 11. As used in this chapter, “pay for performance arrangement” means a reimbursement model that reimburses health care providers for meeting predefined targets as defined in the agreement for quality indicators or efficacy parameters to increase the quality or efficacy of care.
Sec. 12. As used in this chapter, “prior authorization” means a practice implemented by a health plan through which coverage of a health care service is dependent on the covered individual or
health care provider obtaining approval from the health plan before the health care service is rendered. The term includes prospective or utilization review procedures conducted before a
health care service is rendered.
Sec. 13. As used in this chapter, “provider organization” means an entity that serves beneficiaries on a risk basis through a network of employed or affiliated providers.
Sec. 14. For the purposes of this chapter, a health care service that is assigned a unique CPT code or combination of CPT codes to be used for the care of a patient with a specific diagnosis is the “same health care service” as another health care service that is assigned the same unique CPT code or combination of CPT codes to be used for the care of a patient with the same specific diagnosis.
Sec. 15. (a) As used in this chapter, “value based health care reimbursement agreement” may include the following:
(1) An accountable care organization that has a contract with a health plan in which the health plan:
(A) does not assume risk for prior authorization to a provider organization; or
(B) delegates risk to a provider organization to manage prior authorization.
(2) Bundled payments.
(3) A capitated rate reimbursement arrangement.
(4) A pay for performance arrangement.
(5) Any other health care reimbursement arrangement in which the health care provider accepts at most ten percent (10%) of the downside risk.
(b) The term does not include any of the following:
(1) Narrow networks.
(2) Fixed fee schedules.
Sec. 16. A health care provider that enters into:
(1) a value based health care reimbursement agreement; and
(2) an electronic medical records access agreement;
with a health plan may qualify to participate in a program established by the health plan to reduce or eliminate prior authorization requirements.
Sec. 17. (a) A health plan shall notify a health care provider of any requirements that a health care provider must meet to participate in a program under section 16 of this chapter.
(b) If a health plan determines that a health care provider is qualified to participate in a program established under section 16 of this chapter, the health plan shall send a notice to the healthcare
provider that contains the following information:
(1) A statement that the health care provider qualifies to participate in the program.
(2) A list of each type of health care service that is subject to the elimination or reduction of prior authorization requirements under the program.
Sec. 18. This chapter does not preclude a health plan from requiring a health care provider to provide additional information to the health plan about health care services rendered to the health
This statute became law in 2023 by the enactment of HB 1004 (2023). See https://iga.in.gov/legislative/2023/bills/house/1004/details