2023 Indiana Code › Title 27. Insurance › Article 1. Department of Insurance › Chapter 45. Health Facility Compensation › 27-1-45-8. Out of Network Practitioner Providing Services at in Network Facility; Conditions for Reimbursement of Out of Network Practitioner at Higher Rate; Explanation of Charge Exceeding Estimate; Rules

Sec. 8. (a) 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 as described in subsection (b) unless all of the following conditions are met:
(1) At least five (5) business days before the health care service is scheduled to be provided to the covered individual, the facility or practitioner provides to the covered individual, on a form separate from any other form provided to the covered individual by the facility or practitioner, a statement in conspicuous type that meets the following requirements:
(A) Includes a notice reading substantially as follows: "[Name of facility or 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 facility or practitioner] will not be allowed to bill you the difference between the price charged for the services 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 facility's or practitioner's good faith estimate of the established fee 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 the 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.
(b) If an out of network practitioner does not meet the requirements of subsection (a), 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.
(c) If a covered individual's network plan remits reimbursement to the covered individual for health care services that did not meet the requirements of subsection (a), 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.
(d) If the charge of a facility or practitioner for health care services provided to a covered individual exceeds the estimate provided to the covered individual under subsection (a)(1)(B) by an amount greater than:
(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.
(e) The department shall adopt emergency rules under IC 4-22-2-37.1 to specify the requirements of the notifications set forth in:
(1) subsections (b) and (c); and
(2) IC 25-1-9-23(j) and IC 25-1-9-23(k).
As added by P.L.93-2020, SEC.11. Amended by P.L.202-2021, SEC.10; P.L.165-2022, SEC.8.