Ind. Code ch. 27-13-15

in effect

Ind. Code § 27-13-15-0.1 Application of certain amendments to chapter

Sec. 0.1. The addition of section 4 of this chapter by P.L.74-2007 applies to a contract between a health maintenance organization and a participating provider that is entered into, amended, or renewed on or after April 26, 2007. As added by P.L.220-2011, SEC.460.

Ind. Code § 27-13-15-1 Contract requirements; enrollee coverage; payment of provider; rate schedule

Sec. 1. (a) A contract between a health maintenance organization and a participating provider of health care services: (1) must be in writing; (2) may not prohibit the participating provider from disclosing: (A) the terms of the contract as it relates to financial or other incentives to limit medical services by the participating provider; or (B) all treatment options available to an insured, including those not covered by the insured's policy; (3) may not provide for a financial or other penalty to a provider for making a disclosure permitted under subdivision (2); and (4) must provide that in the event the health maintenance organization fails to pay for health care services as specified by the contract, the subscriber or enrollee is not liable to the participating provider for any sums owed by the health maintenance organization. (b) An enrollee is not entitled to coverage of a health care service under a group or an individual contract unless that health care service is included in the enrollee's contract. (c) A provider is not entitled to payment under a contract for health care services provided to an enrollee unless the provider has a contract or an agreement with the carrier. (d) This subsection does not apply to a rate schedule maintained by state or federal government payers. A health maintenance organization that enters into a contract with a participating provider must provide the participating provider with a current reimbursement rate schedule: (1) every two (2) years; and (2) when three (3) or more CPT code (as defined in IC 27-1-37.5-3) rates under the contract change in a twelve (12) month period. As added by P.L.26-1994, SEC.25. Amended by P.L.195-1996, SEC.7; P.L.192-1996, SEC.3; P.L.190-2023, SEC.33.

Ind. Code § 27-13-15-2 Contract requirements not met; collection of money owed by health maintenance organization prohibited

Sec. 2. If: (1) the contract between a health maintenance organization and a participating provider has not been reduced to writing as required by this chapter; or (2) the contract fails to contain the provision required by section 1(a)(4) of this chapter; the participating provider may not collect or attempt to collect from the subscriber or enrollee any sums that are owed by the health maintenance organization. As added by P.L.26-1994, SEC.25. Amended by P.L.203-2001, SEC.25.

Ind. Code § 27-13-15-3 Actions against subscribers; costs and attorney's fees

Sec. 3. (a) A: (1) participating provider; or (2) trustee, an agent, a representative, or an assignee of a participating provider; may not bring or maintain any legal action against a subscriber or an enrollee of a health maintenance organization to collect sums owed by the health maintenance organization. (b) Except as provided in subsection (c), if a participating provider of a health maintenance organization brings or maintains a legal action against a subscriber or enrollee for an amount owed to the participating provider by the health maintenance organization, the participating provider is liable to the subscriber or enrollee for costs and attorney's fees incurred by the subscriber or enrollee in defending the legal action. (c) A participating provider shall not be liable to the subscriber or enrollee for costs and attorney's fees described in subsection (b) if the participating provider can demonstrate a reasonable basis for believing at the time the legal action was brought and while the legal action was maintained that the health maintenance organization did not owe the sums the participating provider sought to collect from the subscriber or enrollee. As added by P.L.26-1994, SEC.25. Amended by P.L.203-2001, SEC.26.

Ind. Code § 27-13-15-4 Participating provider agreement prohibitions

Sec. 4. (a) As used in this section, "health maintenance organization" includes the following: (1) A limited service health maintenance organization. (2) A person that pays or administers claims on behalf of a health maintenance organization or a limited service health maintenance organization. (b) An agreement between a health maintenance organization and a participating provider under this chapter may not contain a provision that: (1) prohibits, or grants the health maintenance organization an option to prohibit, the participating provider from contracting with another health maintenance organization to accept lower payment for health care services than the payment specified in the agreement; (2) requires, or grants the health maintenance organization an option to require, the participating provider to accept a lower payment from the health maintenance organization if the participating provider agrees with another health maintenance organization to accept lower payment for health care services; (3) requires, or grants the health maintenance organization an option of, termination or renegotiation of the agreement if the participating provider agrees with another health maintenance organization to accept lower payment for health care services; or (4) requires the participating provider to disclose the participating provider's reimbursement rates under contracts with other health maintenance organizations. (c) A contract provision that violates this section is void. As added by P.L.74-2007, SEC.2.

Ind. Code § 27-13-15-5 Coverage for dialysis treatment

Sec. 5. (a) Notwithstanding IC 27-13-1-12, as used in this section, "enrollee" refers only to an enrollee who requires dialysis treatment. (b) As used in this section, "health maintenance organization" includes the following: (1) A limited service health maintenance organization. (2) An agent of a health maintenance organization or a limited service health maintenance organization. (c) A health maintenance organization shall not require an enrollee, as a condition of coverage or reimbursement, to: (1) if the nearest dialysis facility is located within thirty (30) miles of the enrollee's home, travel more than thirty (30) miles from the enrollee's home to obtain dialysis treatment; or (2) if the nearest dialysis facility is located more than thirty (30) miles from the enrollee's home, travel a greater distance than the distance to the nearest dialysis facility to obtain dialysis treatment; regardless of whether the enrollee chooses to receive dialysis treatment at a dialysis facility that is a participating provider or a dialysis facility that is not a participating provider. As added by P.L.111-2008, SEC.6.

Ind. Code § 27-13-15-6 Right to provide prescription cost information; point of sale cost limit; pharmacist may not be required to collect higher copayment

Sec. 6. (a) As used in this section, "drug" means a prescription drug. (b) As used in this section, "health maintenance organization" refers to a health maintenance organization that provides coverage for drugs. The term includes the following: (1) A limited service health maintenance organization. (2) A person that administers drug benefits on behalf of a health maintenance organization or a limited service health maintenance organization. (c) As used in this section, "pharmacy" refers to a pharmacist or pharmacy that is a participating provider. (d) A pharmacy or pharmacist shall have the right to provide an enrollee with information concerning the amount of the enrollee's cost share for a prescription drug. Neither a pharmacy nor a pharmacist shall be proscribed by a health maintenance organization from discussing this information or from selling to the enrollee a more affordable alternative if an affordable alternative is available. (e) A health maintenance organization that covers prescription drugs may not include a provision that requires an enrollee to make payment for a prescription drug at the point of sale in an amount that exceeds the lesser of: (1) the contracted copayment amount; or (2) the amount of total approved charges by the health maintenance organization at the point of sale. This subsection does not prohibit the adjudication of claims in accordance with an individual contract or group contract issued or administered by a health maintenance organization. The enrollee is not liable for any additional charges or entitled to any credits as a result of the adjudicated claim. (f) The health maintenance organization or a pharmacy benefit manager may not require a pharmacy or pharmacist to collect a higher copayment for a prescription drug from an enrollee than the health maintenance organization or pharmacy benefit manager allows the pharmacy or pharmacist to retain. As added by P.L.209-2018, SEC.13. Amended by P.L.114-2020, SEC.21; P.L.9-2022, SEC.53.

Source: Open US Law by Vaquill AI (CC BY 4.0)URL: https://iga.in.gov/laws/2026/ic/titles/27Fetched: 10/17/2026