reglab/statecodes huggingface dataset:
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 13. Provider Payment; General › 12-15-13-7.2. Use of Diagnostic or Procedure Codes

Sec. 7.2. (a) As used in this section, "provider" has the meaning set forth in IC 27-8-11-1.
(b) Not more than ninety (90) days after the effective date of a diagnostic or procedure code described in this subsection:
(1) the office shall for all purposes begin using the most current version of the:
(A) current procedural terminology (CPT);
(B) international classification of diseases (ICD);
(C) American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM);
(D) current dental terminology (CDT);
(E) Healthcare common procedure coding system (HCPCS); and
(F) third party administrator (TPA);
codes under which the office processes claims for services provided under the Medicaid program; and
(2) a provider shall begin using the most current version of the:
(A) current procedural terminology (CPT);
(B) international classification of diseases (ICD);
(C) American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM);
(D) current dental terminology (CDT);
(E) Healthcare common procedure coding system (HCPCS); and
(F) third party administrator (TPA);
codes under which the provider submits claims for payment for services provided under the Medicaid program.
(c) If a provider provides services that are covered under the Medicaid program:
(1) after the effective date of the most current version of a diagnostic or procedure code described in subsection (b); and
(2) before the office begins using the most current version of the diagnostic or procedure code;
the office shall reimburse the provider under the version of the diagnostic or procedure code that was in effect on the date that the services were provided.
As added by P.L.161-2001, SEC.2. Amended by P.L.66-2002, SEC.4; P.L.27-2011, SEC.3.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 13. Provider Payment; General › 12-15-13-9. Reimbursement for Providers at Federally Qualified Health Centers and Rural Health Clinics

Sec. 9. (a) Subject to subsection (b), the office shall reimburse the following providers if the providers are providing Medicaid covered services at a federally-qualified health center (as defined in 42 U.S.C. 1396d(l)(2)(B)) or a rural health clinic (as defined in 42 U.S.C. 1396d(l)(1)) within the provider's scope of practice:
(1) A clinical social worker licensed under IC 25-23.6-5.
(2) A marriage and family therapist licensed under IC 25-23.6-8.
(3) A mental health counselor licensed under IC 25-23.6-8.5.
(4) A clinical addiction counselor licensed under IC 25-23.6-10.5.
(b) By July 1, 2020, the office shall apply to the United States Department of Health and Human Services to amend the state Medicaid plan to include reimbursement described in subsection (a). The office may not implement the reimbursement under subsection (a) until the office has obtained approval for the Medicaid state plan amendment requested under this subsection.
As added by P.L.128-2019, SEC.2. Amended by P.L.103-2020, SEC.3.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 13.5. Medicaid Recovery Audits › 12-15-13.5-2. Recovery Audit; Contract; Performance

Sec. 2. (a) The office and a managed care organization that has contracted with the office under this article shall perform a recovery audit to ensure the integrity of the Medicaid program.
(b) The office shall contract with a recovery auditing entity to perform the recovery audit. A contract with a recovery auditing entity must include the following services:
(1) Review of claims submitted by providers or other individuals furnishing items and services for payment by the Medicaid program to determine whether overpayment or underpayment occurred.
(2) Recovery of identified overpayments and payment to providers of identified underpayments.
(c) A managed care organization may either perform the recovery audit internally or contract with a recovery auditing entity to perform the recovery audit. A recovery audit by a managed care organization, whether performed internally or through a contract with a recovery auditing entity, must meet the requirements of subsection (b) and section 3 of this chapter.
As added by P.L.134-2019, SEC.2.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 13.5. Medicaid Recovery Audits › 12-15-13.5-3. Audit Period

Sec. 3. A recovery audit under this chapter must include the following:
(1) Subject to subdivision (2), for audits initiated after June 30, 2019, the audit look back period must be three (3) years and one hundred-eighty (180) days.
(2) If the office or a managed care organization discovers information that may indicate a credible allegation of fraud, abusive billing practices, or a claims process error rate greater than thirty percent (30%), the office or the managed care organization may increase the audit look back period to a total of seven (7) years.
As added by P.L.134-2019, SEC.2.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 13.5. Medicaid Recovery Audits › 12-15-13.5-4. Annual Provider Education

Sec. 4. The managed care organization or the auditing entity, in conjunction with the office, shall perform educational and training programs annually for providers that include the following:
(1) A summary of the managed care organization's auditing entity's past or previous audit findings that provide guidance to Medicaid providers.
(2) The most common errors or issues and how a provider can avoid these errors and issues.
(3) Recommended practices for providers on improving claim submissions.
As added by P.L.134-2019, SEC.2.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 13.5. Medicaid Recovery Audits › 12-15-13.5-6. Recovery Audits; Development, Review, and Certification of Plans of Treatment

Sec. 6. (a) Subject to subsection (b), a recovery audit shall not require documentation, at the time of service, for services provided by a community mental health center (as defined in IC 12-7-2-38) when the documentation is part of an ongoing plan of treatment or a documentation of specific treatment methods.
(b) The direct service provider shall complete documentation described in subsection (a) within a reasonable time frame, but not later than thirty (30) days from the date of service, prior to Medicaid billing.
(c) Any supervising provider in a community mental health center is eligible to review documentation in order to certify a plan of treatment or review specific treatment methods at intervals not greater than ninety (90) days.
(d) A supervising provider described in subsection (c) may review the documentation described in subsection (c) regardless of:
(1) whether the supervising provider is providing direct supervision; and
(2) the location where the service was provided.
A review described under this subsection must be documented by the signature of the supervising provider.
(e) In developing a plan of treatment, the following must be completed to demonstrate active treatment with a client:
(1) A signed client consent form.
(2) The completion of a list of requirements concerning audit compliance, as determined by the division in collaboration with community mental health centers, that verifies active participation in the development of the client's plan of treatment.
(3) Either:
(A) the signature of the client on the client's plan of treatment; or
(B) if the direct care provider, after a good faith effort, is unable to obtain the client's signature on the client's plan of treatment:
(i) the provision of documentation by the provider of the reasons the provider was unable to obtain the signature;
(ii) the continuation of attempting to obtain the client's signature on the client's plan of treatment; and
(iii) a determination by the division, based on the documentation in item (i), that the direct care provider has made a good faith effort to obtain the signature.
As added by P.L.127-2020, SEC.3.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 13.6. Audit of Prescription Drug Cost Sharing › 12-15-13.6-1. Audit of Medicaid Prescription Drug Cost Sharing; Request for Proposal

Sec. 1. (a) Once every three (3) state fiscal years:
(1) the state board of accounts; or
(2) an independent auditor with experience auditing expenses related to prescription drugs that is hired by the state board of accounts;
shall conduct an audit examining prescription drug cost sharing for the Medicaid program.
(b) The attorney general may, for an audit described under IC 27-1-3.7, issue a request for proposal under IC 27-1-3.7 to evaluate and determine whether to include the following in the request for proposal for the audit:
(1) Cost sharing.
(2) Spread pricing.
(3) Patient steering.
(4) Proper brand and generic definitions.
(5) Effective rate clawbacks.
(6) Medical loss ratio inflation.
(7) Formulary compliance.
(8) Discriminatory pricing.
(9) Specialty drug definition and categorization.
(10) Adherence to contracted pricing terms.
(11) Adherence to plan design, including:
(A) quantity limits; and
(B) prior authorization guidelines.
(12) Under market reimbursements to pharmacies.
(13) Dispensing fees.
(14) Lesser of logic pricing.
(15) Fraud, waste, and abuse.
(16) Rebates.
(17) Compliance with federal law.
(18) Review of practices of any of the following used within the Medicaid program:
(A) Managed care organizations.
(B) Pharmacies.
(C) Pharmacy services administrative organizations.
(D) Wholesalers.
(E) Drug manufacturers.
(19) Any other metric determined by the attorney general for inclusion in the audit of the Medicaid program.
This subsection expires December 31, 2025.
As added by P.L.196-2021, SEC.3. Amended by P.L.233-2023, SEC.1.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 13.6. Audit of Prescription Drug Cost Sharing › 12-15-13.6-2. Look Back Period

Sec. 2. (a) For an audit conducted under section 1(a) of this chapter, the audit look back period must be the previous three (3) state fiscal years.
(b) For an audit described in section 1(b) of this chapter, the look back period must be the previous five (5) state fiscal years. This subsection expires December 31, 2025.
As added by P.L.196-2021, SEC.3. Amended by P.L.233-2023, SEC.2.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 13.6. Audit of Prescription Drug Cost Sharing › 12-15-13.6-3. Audit Requirements

Sec. 3. An audit conducted under section 1 of this chapter must evaluate all prescription drug cost sharing for the Medicaid program for the audit look back period, including for prescription drugs paid for directly by the Medicaid program and prescription drugs paid for by managed care organizations.
As added by P.L.196-2021, SEC.3.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 13.6. Audit of Prescription Drug Cost Sharing › 12-15-13.6-4. Audit Results

Sec. 4. (a) The results of an audit conducted under section 1(a) of this chapter must be provided to the office of the secretary.
(b) Before September 1, 2024, the results of an audit conducted under IC 27-1-3.7 and section 1(b) of this chapter must be provided to the interim study committee on public health, behavioral health, and human services established by IC 2-5-1.3-4. This subsection expires December 31, 2025.
As added by P.L.196-2021, SEC.3. Amended by P.L.233-2023, SEC.3.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 14. Payment to Nursing Facilities › 12-15-14-1. Payment Criteria; Uniformity

Sec. 1. (a) Except as provided in subsection (b), payment of services for nursing facilities shall be determined under the same criteria and in a uniform manner for all facilities providing services.
(b) In addition to reimbursement under the uniform rates of payment developed for all nursing facilities under subsection (a):
(1) nursing facilities that are owned and operated by a governmental entity may receive any additional payments that are permitted under applicable federal statutes and regulations; and
(2) nursing facilities that are not owned and operated by a governmental entity may receive any additional payments that are permitted under applicable federal statutes and regulations.
(c) Each governmental transfer or other payment mechanism that the office implements under this chapter must maximize the amount of federal financial participation that the state can obtain through the intergovernmental transfer or other payment mechanism.
[Pre-1992 Revision Citation: 12-1-7-17.4.]
As added by P.L.2-1992, SEC.9. Amended by P.L.160-2001, SEC.1.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 14. Payment to Nursing Facilities › 12-15-14-2. Payment of Nursing Facility Services; Rules

Sec. 2. (a) Payment of nursing facility services shall be determined in accordance with 42 U.S.C. 1396a(a)(13)(A) and any other applicable federal statutes or regulations governing such payments.
(b) The office of the secretary shall adopt rules under IC 4-22-2 to implement the reimbursement system required by this section.
[Pre-1992 Revision Citation: 12-1-7-17.6(b).]
As added by P.L.2-1992, SEC.9. Amended by P.L.152-1995, SEC.11; P.L.257-1996, SEC.10; P.L.126-1998, SEC.3; P.L.160-2001, SEC.2; P.L.241-2023, SEC.14.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 14. Payment to Nursing Facilities › 12-15-14-2.5. Prohibition on Reimbursement for Reservation of Bed for Hospitalized or Otherwise Absent Medicaid Recipient

Sec. 2.5. (a) The office may not reimburse a nursing facility provider for reserving a bed for a Medicaid recipient when the Medicaid recipient is not present in the nursing facility due to a hospital stay or leave of absence for therapeutic reasons.
(b) Not later than September 30, 2011, the office shall submit a state Medicaid plan amendment to the federal Centers for Medicare and Medicaid Services to implement this section.
As added by P.L.229-2011, SEC.127.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 14. Payment to Nursing Facilities › 12-15-14-8. Use of Rug-Iv, 48-Group Model for Payments; Public Notice if Reduction in Reimbursement

Sec. 8. (a) The office may implement an end of therapy reclassification methodology in the RUG-IV, 48-Group model or its successor for payment of nursing facility services.
(b) Before the office changes a health facility service reimbursement that results in a reduction in reimbursement, the office shall provide public notice of at least one (1) year. The public notice under this subsection:
(1) is not a rulemaking action or part of the administrative rulemaking process under IC 4-22; and
(2) must include the fiscal impact of the proposed reimbursement change.
As added by P.L.224-2017, SEC.4. Amended by P.L.165-2021, SEC.140; P.L.241-2023, SEC.15.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 15. Payment to Hospitals; General › 12-15-15-1. Services at Hospitals Licensed Under Ic 16-21; Rates Established Under Rules

Sec. 1. Payment of a service provided in a hospital licensed under IC 16-21 shall be determined in accordance with a payment rate for the service that is established under rules adopted under IC 4-22-2 by the secretary in conjunction with the office.
[Pre-1992 Revision Citation: 12-1-7-17.6(c) part.]
As added by P.L.2-1992, SEC.9. Amended by P.L.27-1992, SEC.11; P.L.2-1993, SEC.93.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 15. Payment to Hospitals; General › 12-15-15-1.2. Reimbursement for Children's Hospital Bordering Indiana; Limitations; Expiration

Sec. 1.2. (a) As used in this section, "children's hospital" means:
(1) a freestanding general acute care hospital that:
(A) is designated by the Medicare program as a children's hospital; or
(B) furnishes inpatient and outpatient health care services to patients who are predominantly individuals less than nineteen (19) years of age; or
(2) a facility located within a freestanding general acute care hospital that:
(A) is designated by the Medicare program as a children's hospital; or
(B) furnishes inpatient and outpatient health care services to patients who are predominately individuals less than nineteen (19) years of age.
(b) This section applies to reimbursement for inpatient Medicaid services and outpatient Medicaid services provided to a Medicaid recipient who is less than nineteen (19) years of age at a children's hospital that is located in a state bordering Indiana. This section does not apply to reimbursement for non-emergency medical transportation.
(c) As used in this subsection, "cost outlier case" means a Medicaid stay that exceeds a predetermined threshold, defined as the greater of twice the diagnosis-related group (DRG) rate or a fixed dollar amount that has been established by the office. The office shall reimburse a children's hospital for covered services provided to a Medicaid recipient that is described in subsection (b) at a rate set by the secretary that is based on a reimbursement formula that is:
(1) comparable to the current federal Medicare reimbursement rate for the service provided by the children's hospital; or
(2) one hundred thirty percent (130%) of the Medicaid reimbursement rate for a service that does not have a Medicare reimbursement rate.
The reimbursement methodology under this subsection must factor in any cost outlier case in a manner that results in the final reimbursement rate made to a hospital meeting the reimbursement requirements specified in this subsection. The office may, upon factoring in the cost outlier case in determining the final reimbursement rate, make retroactive reimbursements to an out of state children's hospital to the date of the initial Medicaid waiver application.
(d) Before September 1, 2021, the office shall apply to the United States Department of Health and Human Services for any state plan amendment or Medicaid waiver necessary to implement and administer this section. Before June 1, 2022, the office shall apply for an amendment to the Medicaid waiver concerning reimbursement under this section that is necessary to implement the changes required by amendments made to this section concerning factoring in any cost outlier case.
(e) The office may adopt rules under IC 4-22-2 necessary for the implementation of this section.
(f) This section expires July 1, 2025.
As added by P.L.132-2021, SEC.2. Amended by P.L.142-2022, SEC.3; P.L.76-2023, SEC.2.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 15. Payment to Hospitals; General › 12-15-15-2. Rates Adopted for Hospital Licensed Under Ic 16-21; Prospective or Retrospective Application

Sec. 2. The rates adopted under this chapter for a hospital licensed under IC 16-21 may be the following:
(1) Prospective.
(2) Retroactive.
(3) A combination of prospective and retroactive.
[Pre-1992 Revision Citation: 12-1-7-17.6(c) part.]
As added by P.L.2-1992, SEC.9. Amended by P.L.2-1993, SEC.94.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 15. Payment to Hospitals; General › 12-15-15-2.5. Payment for Physician Services in Emergency Department

Sec. 2.5. (a) Payment for physician services provided in the emergency department of a hospital licensed under IC 16-21 must be at a rate of one hundred percent (100%) of rates payable under the Medicaid fee structure.
(b) The payment under subsection (a) must be calculated using the same methodology used for all other physicians participating in the Medicaid program.
(c) For services rendered and documented in an individual's medical record, physicians must be reimbursed for federally required medical screening exams that are necessary to determine the presence of an emergency using the appropriate Current Procedural Terminology (CPT) codes 99281, 99282, or 99283 described in the Current Procedural Terminology Manual published annually by the American Medical Association, without authorization by the enrollee's primary medical provider.
(d) This section does not apply to a person enrolled in a Medicaid risk based managed care program.
As added by P.L.153-1995, SEC.10. Amended by P.L.119-1997, SEC.5; P.L.245-1999, SEC.1; P.L.223-2001, SEC.10; P.L.152-2017, SEC.23.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 15. Payment to Hospitals; General › 12-15-15-3. Services Provided at Hospitals Operating Under Ic 16-24-1; Prospective Payment Rate

Sec. 3. Payment of a service provided in a hospital operating under IC 16-24-1 shall be determined in accordance with a prospective payment rate for the service.
[Pre-1992 Revision Citation: 12-1-7-17.6(c) part.]
As added by P.L.2-1992, SEC.9. Amended by P.L.2-1993, SEC.95.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 15. Payment to Hospitals; General › 12-15-15-4. Per Diem Rate for Services Provided in Hospitals Operating Under Ic 16-24-1

Sec. 4. The office shall establish a per diem rate for the service provided in a hospital operating under IC 16-24-1 under rules adopted under IC 4-22-2 by the secretary.
[Pre-1992 Revision Citation: 12-1-7-17.6(c) part.]
As added by P.L.2-1992, SEC.9. Amended by P.L.2-1993, SEC.96.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 15. Payment to Hospitals; General › 12-15-15-4.5. Payment for HIV Test; Limitation

Sec. 4.5. Payment to a hospital for a test required under IC 16-41-6-4 must be in an amount equal to the hospital's actual cost of performing the test and may not reduce or replace the reimbursement of other services that are provided to the patient under the state Medicaid program. The total cost to the state may not be more than twenty-four thousand dollars ($24,000) in a state fiscal year.
As added by P.L.237-2003, SEC.2.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 15. Payment to Hospitals; General › 12-15-15-5. Repealed

[Pre-1992 Revision Citation: 12-1-7-17.6(c) part.]
As added by P.L.2-1992, SEC.9. Repealed by P.L.126-1998, SEC.22.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 15. Payment to Hospitals; General › 12-15-15-6. Fees in Addition to Infant Delivery Fees

Sec. 6. (a) In addition to a payment due to a hospital for the delivery of a newborn infant, the office shall tender a payment to the hospital for the hospital's collection, handling, and delivery of a specimen for testing under IC 16-41-17-2(a)(10).
(b) Payment to a hospital required under subsection (a) must be in an amount equal to the total of the following costs:
(1) The cost incurred by the hospital to collect, handle, and deliver the specimen obtained for testing under IC 16-41-17-2(a)(10).
(2) Any fee assessed against the hospital for a laboratory's testing of the specimen under IC 16-41-17-2(a)(10).
(3) Any newborn screening fee or other fee assessed against the hospital by the Indiana department of health in connection with the testing of the specimen under IC 16-41-17-2(a)(10).
As added by P.L.149-2001, SEC.2. Amended by P.L.56-2023, SEC.100.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 15. Payment to Hospitals; General › 12-15-15-9.6. Limitation on Total Amount of Payments

Sec. 9.6. For state fiscal years beginning after June 30, 2007, the total amount of payments to hospitals under sections 9 and 9.5 of this chapter may not exceed the amount paid to hospitals under sections 9 and 9.5 of this chapter for the state fiscal year ending June 30, 2007.
As added by P.L.255-2003, SEC.21. Amended by P.L.212-2007, SEC.6; P.L.218-2007, SEC.16.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 15. Payment to Hospitals; General › 12-15-15-10. Payments to Providers Under Medicaid Disproportionate Share Provider Program

Sec. 10. (a) This section applies to a hospital that:
(1) is licensed under IC 16-21; and
(2) qualifies as a provider under IC 12-15-16, IC 12-15-17, or IC 12-15-19 of the Medicaid disproportionate share provider program.
(b) The office may, after consulting with affected providers, do one (1) or more of the following:
(1) Establish a nominal charge hospital payment program.
(2) Establish any other permissible payment program.
(c) A program expanded or established under this section is subject to the availability of:
(1) intergovernmental transfers;
(2) funds certified as being eligible for federal financial participation; or
(3) other permissible sources of non-federal share dollars.
(d) The office may not implement a program under this section until the federal Centers for Medicare and Medicaid Services approves the provisions regarding the program in the amended state plan for medical assistance.
(e) The office may determine not to continue to implement a program established under this section if federal financial participation is not available.
As added by P.L.113-2000, SEC.4. Amended by P.L.66-2002, SEC.6; P.L.212-2007, SEC.7; P.L.218-2007, SEC.17.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 15. Payment to Hospitals; General › 12-15-15-11. Nominal Charge Hospitals

Sec. 11. Hospitals licensed under IC 16-21 that are established and operated under IC 16-22, IC 16-22-8, or IC 16-23 are nominal charge hospitals for purposes of the Medicaid program.
As added by P.L.283-2001, SEC.21.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 15. Payment to Hospitals; General › 12-15-15-12. Budget Committee Review of Medicaid Reimbursement to Children's Hospitals Bordering Indiana; Provision of Information; Expiration

Sec. 12. (a) By November 1, 2022, and by November 1, 2023, the budget committee shall review the Medicaid reimbursements provided under section 1.2 of this chapter for children's hospitals that are located in a state bordering Indiana. The budget committee's review shall include the following for patients who are less than nineteen (19) years of age:
(1) For the state fiscal year most recently ended:
(A) the total number of inpatients served;
(B) the total number of outpatients served;
(C) the total amount of state funding expended for inpatient services; and
(D) the total amount of state funding expended for outpatient services.
(2) In the case of the first review by November 1, 2022, for the current state fiscal year:
(A) an estimate of the total number of inpatients expected to be served;
(B) an estimate of the total number of outpatients expected to be served;
(C) an estimate of the total amount of state funding expected to be expended for inpatient services; and
(D) an estimate of the total amount of state funding expected to be expended for outpatient services.
(b) Each children's hospital located in a state bordering Indiana that receives state funding under section 1.2 of this chapter shall provide the information required by subsection (a) to the family and social services administration not later than August 1, 2022, and August 1, 2023.
(c) This section expires January 1, 2024.
As added by P.L.132-2021, SEC.3.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 16. Disproportionate Share Providers; Eligibility › 12-15-16-1. Disproportionate Share Provider Status

Sec. 1. (a) A provider that is an acute care hospital licensed under IC 16-21, a state mental health institution under IC 12-24-1-3, or a private psychiatric institution licensed under IC 12-25 is a disproportionate share provider if the provider meets either of the following conditions:
(1) The provider's Medicaid inpatient utilization rate is at least one (1) standard deviation above the mean Medicaid inpatient utilization rate for providers receiving Medicaid payments in Indiana. However, the Medicaid inpatient utilization rate of providers whose low income utilization rate exceeds twenty-five percent (25%) must be excluded in calculating the statewide mean Medicaid inpatient utilization rate.
(2) The provider's low income utilization rate exceeds twenty-five percent (25%).
(b) An acute care hospital licensed under IC 16-21 is a municipal disproportionate share provider if the hospital:
(1) has a Medicaid utilization rate greater than one percent (1%); and
(2) is established and operated under IC 16-22-2 or IC 16-23.
(c) A community mental health center:
(1) that is identified in IC 12-29-2-1;
(2) for which a county provides funds under:
(A) IC 12-29-1-7(b) before January 1, 2004; or
(B) IC 12-29-2 after December 31, 2018;
or from other county sources; and
(3) that provides inpatient services to Medicaid patients;
is a community mental health center disproportionate share provider if the community mental health center's Medicaid inpatient utilization rate is greater than one percent (1%).
(d) A disproportionate share provider under IC 12-15-17 must have at least two (2) obstetricians who have staff privileges and who have agreed to provide obstetric services under the Medicaid program. For a hospital located in a rural area (as defined in Section 1886 of the Social Security Act), an obstetrician includes a physician with staff privileges at the hospital who has agreed to perform nonemergency obstetric procedures. However, this obstetric service requirement does not apply to a provider whose inpatients are predominantly individuals less than eighteen (18) years of age or that did not offer nonemergency obstetric services as of December 21, 1987.
(e) The determination of a provider's status as a disproportionate share provider under this section shall be based on utilization and revenue data from the most recent year for which an audited cost report from the provider is on file with the office.
[Pre-1992 Revision Citation: 12-1-7-60(a).]
As added by P.L.2-1992, SEC.9. Amended by P.L.27-1992, SEC.12; P.L.277-1993(ss), SEC.71; P.L.126-1998, SEC.6; P.L.113-2000, SEC.5; P.L.78-2004, SEC.8; P.L.123-2008, SEC.1; P.L.76-2018, SEC.2.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 16. Disproportionate Share Providers; Eligibility › 12-15-16-2. Inpatient Utilization Rate

Sec. 2. (a) For purposes of disproportionate share eligibility, a provider's Medicaid inpatient utilization rate is a fraction (expressed as a percentage) where:
(1) the numerator is the provider's total number of Medicaid inpatient days in the most recent year for which an audited cost report is on file with the office; and
(2) the denominator is the total number of the provider's inpatient days in the most recent year for which an audited cost report is on file with the office.
(b) For purposes of this section, "Medicaid inpatient days" includes all acute care days attributable to individuals eligible for Medicaid benefits under a state plan approved under 42 U.S.C. 1396a on the days of service:
(1) whether attributable to individuals eligible for Medicaid in Indiana or any other state;
(2) even if the office did not make payment for any services, including inpatient days that are determined to be medically necessary but for which payment is denied by the office for other reasons; and
(3) including days attributable to Medicaid beneficiaries receiving services through a managed care organization or health maintenance organization.
[Pre-1992 Revision Citation: 12-1-7-60(b).]
As added by P.L.2-1992, SEC.9. Amended by P.L.277-1993(ss), SEC.72; P.L.156-1995, SEC.2; P.L.126-1998, SEC.7; P.L.113-2000, SEC.6; P.L.283-2001, SEC.22; P.L.153-2011, SEC.18.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 16. Disproportionate Share Providers; Eligibility › 12-15-16-3. Low Income Utilization Rate; Contractual Allowances and Discounts

Sec. 3. (a) For purposes of disproportionate share eligibility, a provider's low income utilization rate is the sum of the following, based on the most recent year for which an audited cost report is on file with the office:
(1) A fraction (expressed as a percentage) for which:
(A) the numerator is the sum of:
(i) the total Medicaid patient revenues paid to the provider; plus
(ii) the amount of the cash subsidies received directly from state and local governments, including payments made under the hospital care for the indigent program (IC 12-16-2) (before its repeal) and IC 12-16-2.5; and
(B) the denominator is the total amount of the provider's patient revenues paid to the provider, including cash subsidies; and
(2) A fraction (expressed as a percentage) for which:
(A) the numerator is the total amount of the provider's charges for inpatient services that are attributable to care provided to individuals who have no source of payment; and
(B) the denominator is the total amount of charges for inpatient services.
(b) The numerator in subsection (a)(1)(A) does not include contractual allowances and discounts other than for indigent patients not eligible for Medicaid.
[Pre-1992 Revision Citation: 12-1-7-60(c).]
As added by P.L.2-1992, SEC.9. Amended by P.L.277-1993(ss), SEC.73; P.L.113-2000, SEC.7; P.L.283-2001, SEC.23; P.L.120-2002, SEC.16.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 16. Disproportionate Share Providers; Eligibility › 12-15-16-4. Repealed

[Pre-1992 Revision Citation: 12-1-7-60(d).]
As added by P.L.2-1992, SEC.9. Repealed by P.L.156-1995, SEC.9.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 16. Disproportionate Share Providers; Eligibility › 12-15-16-5. Implementation; Federal Health Care Financing Administration Approval; Percentage Reduction of Payments to Medicaid Indigent Care Trust Fund

Sec. 5. (a) The office may not implement this chapter, IC 12-15-17, IC 12-15-18, IC 12-15-19, or IC 12-15-20 until the federal Centers for Medicare and Medicaid Services has issued its approval of the amended state plan for medical assistance.
(b) The office may determine not to continue to implement this chapter, IC 12-15-17, IC 12-15-18, IC 12-15-19, and IC 12-15-20 if federal financial participation is not available.
(c) If federal financial participation is approved for less than all of the amounts paid into the Medicaid indigent care trust fund with respect to a fiscal year, the office may reduce payments attributable to that fiscal year under IC 12-15-19-1 by a percentage sufficient to compensate for the aggregate reduction in federal financial participation. If additional federal financial participation is subsequently approved with respect to payments into the Medicaid indigent care trust fund for the same fiscal year, the office shall distribute such amounts using the percentage that was used to compensate for the prior reduction in federal financial participation.
[Pre-1992 Revision Citation: P.L.112-1991, SEC.7(b), (c), (d).]
As added by P.L.2-1992, SEC.9. Amended by P.L.277-1993(ss), SEC.74; P.L.156-1995, SEC.3; P.L.126-1998, SEC.8; P.L.66-2002, SEC.7.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 17. Disproportionate Share Providers; Disproportionate Share Payments › 12-15-17-1. Providers Servicing Disproportionate Share of Medicaid Recipients and Low Income Patients; Basic Rate; Minimum Medicaid Inpatient Utilization Rate Required

Sec. 1. A disproportionate share payment shall be made to:
(1) a hospital licensed under IC 16-21;
(2) a state mental health institution under IC 12-24-1-3; and
(3) a private psychiatric institution licensed under IC 12-25;
that serves a disproportionate share of Medicaid recipients and other low income patients as determined under IC 12-15-16-1. However, a provider may not be defined as a disproportionate share provider under IC 12-15-16-1 unless the provider has a Medicaid inpatient utilization rate (as defined in 42 U.S.C. 1396r-4(b)(2)) of at least one percent (1%). Subdivisions (2) and (3) do not apply during the period that the office is assessing a hospital fee authorized by IC 16-21-10.
[Pre-1992 Revision Citation: 12-1-7-17.6(d).]
As added by P.L.2-1992, SEC.9. Amended by P.L.27-1992, SEC.13; P.L.2-1993, SEC.97; P.L.277-1993(ss), SEC.76; P.L.1-1994, SEC.60; P.L.156-1995, SEC.5; P.L.113-2000, SEC.9; P.L.229-2011, SEC.135; P.L.205-2013, SEC.198.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 17. Disproportionate Share Providers; Disproportionate Share Payments › 12-15-17-2. Repealed

[Pre-1992 Revision Citation: 12-1-7-17.6(e).]
As added by P.L.2-1992, SEC.9. Amended by P.L.27-1992, SEC.14. Repealed by P.L.277-1993(ss), SEC.83.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 17. Disproportionate Share Providers; Disproportionate Share Payments › 12-15-17-3. Repealed

[Pre-1992 Revision Citation: 12-1-7-17.6(f).]
As added by P.L.2-1992, SEC.9. Repealed by P.L.27-1992, SEC.30.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 18. Disproportionate Share Providers; Assessments › 12-15-18-1. Repealed

[Pre-1992 Revision Citation: 12-1-7-17.7(a)(1).]
As added by P.L.2-1992, SEC.9. Repealed by P.L.27-1992, SEC.30.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 18. Disproportionate Share Providers; Assessments › 12-15-18-2. "Hospital" Defined

Sec. 2. (a) As used in this chapter, "hospital" has the meaning set forth in IC 16-18-2-179(b).
(b) The term does not include a state institution or a private psychiatric institution.
[Pre-1992 Revision Citation: 12-1-7-17.7(a)(2).]
As added by P.L.2-1992, SEC.9. Amended by P.L.2-1993, SEC.98.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 18. Disproportionate Share Providers; Assessments › 12-15-18-3. "Private Psychiatric Institution" Defined

Sec. 3. As used in this chapter, "private psychiatric institution" means an acute care inpatient facility licensed under IC 12-25, for the treatment of individuals with mental illness.
[Pre-1992 Revision Citation: 12-1-7-17.7(a)(4).]
As added by P.L.2-1992, SEC.9.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 18. Disproportionate Share Providers; Assessments › 12-15-18-4. Repealed

[Pre-1992 Revision Citation: 12-1-7-17.7(b).]
As added by P.L.2-1992, SEC.9. Amended by P.L.27-1992, SEC.16; P.L.2-1993, SEC.99; P.L.277-1993(ss), SEC.77; P.L.1-1994, SEC.61. Repealed by P.L.156-1995, SEC.9.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 18. Disproportionate Share Providers; Assessments › 12-15-18-5. Repealed

[Pre-1992 Revision Citation: 12-1-7-17.7(c).]
As added by P.L.2-1992, SEC.9. Amended by P.L.27-1992, SEC.17; P.L.2-1993, SEC.100; P.L.277-1993(ss), SEC.78; P.L.1-1994, SEC.62; P.L.156-1995, SEC.6; P.L.115-1996, SEC.1; P.L.24-1997, SEC.51. Repealed by P.L.126-1998, SEC.21.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 18. Disproportionate Share Providers; Assessments › 12-15-18-5.1. Intergovernmental Transfers for State Fiscal Years Ending on or After June 30, 1998; Coordination of Transfers; Transfers by Municipal Disproportionate Share Providers; Certification by County

Sec. 5.1. (a) For state fiscal years ending on or after June 30, 1998, the trustees and each municipal health and hospital corporation established under IC 16-22-8-6 are authorized to make intergovernmental transfers to the Medicaid indigent care trust fund in amounts to be determined jointly by the office and the trustees, and the office and each municipal health and hospital corporation.
(b) The treasurer of state shall annually transfer from appropriations made for the division of mental health and addiction sufficient money to provide the state's share of payments under IC 12-15-16-6(c)(2).
(c) The office shall coordinate the transfers from the trustees and each municipal health and hospital corporation established under IC 16-22-8-6 so that the aggregate intergovernmental transfers, when combined with federal matching funds:
(1) produce payments to each hospital licensed under IC 16-21 that qualifies as a disproportionate share provider under IC 12-15-16-1(a); and
(2) both individually and in the aggregate do not exceed limits prescribed by the federal Centers for Medicare and Medicaid Services.
The trustees and a municipal health and hospital corporation are not required to make intergovernmental transfers under this section. The trustees and a municipal health and hospital corporation may make additional transfers to the Medicaid indigent care trust fund to the extent necessary to make additional payments from the Medicaid indigent care trust fund apply to a prior federal fiscal year as provided in IC 12-15-19-1(b).
(d) A municipal disproportionate share provider (as defined in IC 12-15-16-1) shall transfer to the Medicaid indigent care trust fund an amount determined jointly by the office and the municipal disproportionate share provider. A municipal disproportionate share provider is not required to make intergovernmental transfers under this section. A municipal disproportionate share provider may make additional transfers to the Medicaid indigent care trust fund to the extent necessary to make additional payments from the Medicaid indigent care trust fund apply to a prior federal fiscal year as provided in IC 12-15-19-1(b).
(e) A county making a payment under:
(1) IC 12-29-1-7(b) before January 1, 2004; or
(2) IC 12-29-2 after December 31, 2018;
or from other county sources to a community mental health center qualifying as a community mental health center disproportionate share provider shall certify that the payment represents expenditures that are eligible for federal financial participation under 42 U.S.C. 1396b(w)(6)(A) and 42 CFR 433.51. The office shall assist a county in making this certification.
As added by P.L.126-1998, SEC.10. Amended by P.L.113-2000, SEC.10; P.L.215-2001, SEC.44; P.L.66-2002, SEC.8; P.L.78-2004, SEC.9; P.L.123-2008, SEC.2; P.L.76-2018, SEC.3.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 18. Disproportionate Share Providers; Assessments › 12-15-18-6. Repealed

[Pre-1992 Revision Citation: 12-1-7-17.7(d).]
As added by P.L.2-1992, SEC.9. Repealed by P.L.27-1992, SEC.30.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 19. Disproportionate Share Providers; Enhanced Disproportionate Share Payments › 12-15-19-2. Repealed

[Pre-1992 Revision Citation: 12-1-7-17.8(b).]
As added by P.L.2-1992, SEC.9. Amended by P.L.27-1992, SEC.19; P.L.277-1993(ss), SEC.80; P.L.156-1995, SEC.8. Repealed by P.L.126-1998, SEC.21.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 19. Disproportionate Share Providers; Enhanced Disproportionate Share Payments › 12-15-19-2.1. Disproportionate Share Payment Methodology for State Fiscal Years Ending on or After June 30, 2000; Limits on Total Disproportionate Share Payments to Hospitals

Sec. 2.1. (a) This section does not apply during the period that the office is assessing a hospital fee authorized by IC 16-21-10. For each state fiscal year ending on or after June 30, 2000, the office shall develop a disproportionate share payment methodology that ensures that each hospital qualifying for disproportionate share payments under IC 12-15-16-1(a) timely receives total disproportionate share payments that do not exceed the hospital's hospital specific limit provided under 42 U.S.C. 1396r-4(g). The payment methodology as developed by the office must:
(1) maximize disproportionate share hospital payments to qualifying hospitals to the extent practicable;
(2) take into account the situation of those qualifying hospitals that have historically qualified for Medicaid disproportionate share payments; and
(3) ensure that payments for qualifying hospitals are equitable.
(b) Total disproportionate share payments to a hospital under this chapter shall not exceed the hospital specific limit provided under 42 U.S.C. 1396r-4(g). The hospital specific limit for a state fiscal year shall be determined by the office taking into account data provided by each hospital that is considered reliable by the office based on a system of periodic audits, the use of trending factors, and an appropriate base year determined by the office. The office may require independent certification of data provided by a hospital to determine the hospital's hospital specific limit.
(c) The office shall include a provision in each amendment to the state plan regarding Medicaid disproportionate share payments that the office submits to the federal Centers for Medicare and Medicaid Services that, as provided in 42 CFR 447.297(d)(3), allows the state to make additional disproportionate share expenditures after the end of each federal fiscal year that relate back to a prior federal fiscal year. However, the total disproportionate share payments to:
(1) each individual hospital; and
(2) all qualifying hospitals in the aggregate;
may not exceed the limits provided by federal law and regulation.
As added by P.L.113-2000, SEC.12. Amended by P.L.283-2001, SEC.24; P.L.66-2002, SEC.10; P.L.212-2007, SEC.8; P.L.218-2007, SEC.18; P.L.229-2011, SEC.136; P.L.205-2013, SEC.199.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 19. Disproportionate Share Providers; Enhanced Disproportionate Share Payments › 12-15-19-3. Repealed

[Pre-1992 Revision Citation: 12-1-7-17.8(c) part.]
As added by P.L.2-1992, SEC.9. Repealed by P.L.27-1992, SEC.30.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 19. Disproportionate Share Providers; Enhanced Disproportionate Share Payments › 12-15-19-4. Repealed

[Pre-1992 Revision Citation: 12-1-7-17.8(c) part.]
As added by P.L.2-1992, SEC.9. Amended by P.L.27-1992, SEC.20; P.L.277-1993(ss), SEC.81. Repealed by P.L.156-1995, SEC.9.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 19. Disproportionate Share Providers; Enhanced Disproportionate Share Payments › 12-15-19-5. Federal Financial Participation Unavailable; Withholding Disproportionate Share Payment Adjustments

Sec. 5. Except as provided in section 6 of this chapter, disproportionate share payment adjustments under this chapter may not be withheld by the office unless federal financial participation becomes unavailable to match state money for the purpose of providing disproportionate share payment adjustments.
[Pre-1992 Revision Citation: 12-1-7-17.8(d).]
As added by P.L.2-1992, SEC.9. Amended by P.L.27-1992, SEC.21; P.L.113-2000, SEC.13.