reglab/statecodes huggingface dataset:
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 8 - INDIANA PRESCRIPTION DRUG PROGRAM MEDICARE PART D ASSISTANCE BENEFIT › Rule 6 - Benefits › Section 6-3 - Assistance with Medicare prescription drug plan monthly premium only

Current through July 10, 2024
Authority: IC
				  12-10-16-5
Affected: IC 12-10-16
Sec. 3.
(a) An
				eligible member may receive assistance for the monthly premium cost of the
				Medicare prescription drug plan or Medicare-Advantage prescription drug plan in
				which the member is enrolled. Premium assistance shall be available provided
				the IPDP member enrolls in a Medicare Part D plan that has contracted with the
				state to provide such benefits.
(b)
				The amount of premium assistance provided by the IPDP shall not exceed seventy
				dollars ($70) per month premium assistance in calendar year 2007.
(c) The premium assistance benefit shall be
				paid directly to the Medicare Part D plan in which the eligible IPDP member is
				enrolled.
(d) Premium assistance
				provided by the IPDP shall be reduced by the amount of premium assistance a
				member receives from the Centers for Medicare and Medicaid Services.
(e) The IPDP member shall be responsible for
				any premium amount above the maximum dollar amount determined by the
				state.
(f) IPDP premium assistance:
(1) may only be applied to the prescription
				drug portion of a Medicare-Advantage prescription drug plan's monthly premium;
				and
(2) shall not pay for the
				medical portion of the Medicare-Advantage prescription drug plan monthly
				premium.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 8 - INDIANA PRESCRIPTION DRUG PROGRAM MEDICARE PART D ASSISTANCE BENEFIT › Rule 6 - Benefits › Section 6-4 - Benefit limitations

Current through July 10, 2024
Authority: IC
				  12-10-16-5
Affected: IC 12-10-16
Sec. 4.
(a) Benefits
				are available under sections 2 and 3 of this rule on a first come, first served
				basis.
(b) Benefits will exist
				under this program to the extent that appropriations are available for the
				program.
(c) The state budget
				director shall determine if appropriations are available to continue offering
				and paying benefits for members.
(d) Upon determination that program benefits
				will meet or exceed budget, the program will implement a waiting list for
				further benefits, beginning with the members who:
(1) do not receive any partial subsidy from
				Medicare; and
(2) are between one
				hundred thirty-five percent (135%) and one hundred fifty percent (150%)
				FPL.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 8 - INDIANA PRESCRIPTION DRUG PROGRAM MEDICARE PART D ASSISTANCE BENEFIT › Rule 9 - Member Appeals › Section 9-1 - Purpose

Current through July 10, 2024
Authority: IC
				  12-10-16-5
Affected: IC 12-10-16
Sec. 1.
(a) The
				purpose of this rule is to establish a uniform method of administrative review
				and administrative adjudication for appeals concerning applicants and enrollees
				of the program, in order to determine whether or not any action for which there
				is a complaint was done in accordance with state statutes, regulations, rules,
				and policies. As used in this rule, "policies" include:
(1) program manuals;
(2) administrative directives;
(3) transmittals; and
(4) other official written pronouncements of
				state policy.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 8 - INDIANA PRESCRIPTION DRUG PROGRAM MEDICARE PART D ASSISTANCE BENEFIT › Rule 9 - Member Appeals › Section 9-2 - Standing

Current through July 10, 2024
Authority: IC
				  12-10-16-5
Affected: IC 12-10-16
Sec. 2.
(a) In the
				event that the:
(1) rights;
(2) duties;
(3) obligations;
(4) privileges; or
(5) other legal relations; of any person or
				entity are required or authorized by law to be determined by the office, then
				such person or entity may request an administrative review by the office as
				provided for in section 3 of this rule.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 8 - INDIANA PRESCRIPTION DRUG PROGRAM MEDICARE PART D ASSISTANCE BENEFIT › Rule 9 - Member Appeals › Section 9-3 - Requests for administrative review

Current through July 10, 2024
Authority: IC
				  12-10-16-5
Affected: IC 12-10-16
Sec. 3.
(a) Any
				party complaining of an action of the office in accordance with this article
				may file a request for administrative review as provided in this
				section.
(b) The enrollee or
				applicant is required to seek administrative review before filing an
				administrative appeal under section 5 of this rule.
(c) Unless otherwise provided for by statute,
				regulation, or rule, a request for administrative review by an enrollee or
				applicant shall be filed in writing with the office not later than thirty-five
				(35) days following the date of the action being reviewed.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 8 - INDIANA PRESCRIPTION DRUG PROGRAM MEDICARE PART D ASSISTANCE BENEFIT › Rule 9 - Member Appeals › Section 9-4 - Conduct of administrative review

Current through July 10, 2024
Authority: IC
				  12-10-16-5
Affected: IC 12-10-16
Sec. 4.
(a) Upon
				receipt of a request for administrative review, the office will conduct a
				review of the action.
(b) Upon
				completion of the review, the office will issue a written decision. The
				decision will be final unless a party requests an administrative appeal in
				accordance with this rule.
(c) The
				written decision shall do the following:
(1)
				specify the reasons for the decision;
(2) identify the:
(A) statutes;
(B) regulations;
(C) rules; and
(D) policies; supporting the decision.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 8 - INDIANA PRESCRIPTION DRUG PROGRAM MEDICARE PART D ASSISTANCE BENEFIT › Rule 9 - Member Appeals › Section 9-5 - Filing an administrative appeal; scheduling appeals

Current through July 10, 2024
Authority: IC
				  12-10-16-5
Affected: IC 12-10-16
Sec. 5.
(a) Any
				party who is not satisfied with the administrative review of the office as
				provided for in this rule may file a request for an administrative appeal as
				provided in this section. The person or entity requesting the administrative
				appeal shall be known as the appellant.
(b) Unless otherwise provided for by statute,
				regulation, or rule, appeal requests by an appellant shall be filed in writing
				with the hearings and appeals section of the office not later than thirty (30)
				days following the effective date of the administrative review being appealed.
				Appeal hearings shall be conducted at a reasonable time, place, and
				date.
(c) The hearings and appeals
				section of the office, upon application of any party, or in its own discretion,
				may consolidate appeals to promote administrative efficiency. Hearings may only
				be consolidated in cases in which the sole issue involved is one of state law
				or policy.
(d) Any party filing an
				appeal under this rule is not excused from exhausting all interim procedures
				that may be required by statute or rule for administrative review before the
				filing of an administrative appeal. Any issues not raised within the interim
				review procedures of the administrative review in a timely manner are waived
				and shall not be an issue during the evidentiary hearing of the administrative
				appeal.
(e) The hearings and
				appeals section of the office will schedule evidentiary hearings and issue
				notices to the parties regarding the date, time, and location of the scheduled
				hearing.
(f) A continuance of a
				hearing will be granted only for good cause shown. An objection to a request
				for a continuance shall be considered before a continuance is granted or
				denied. Requests for a continuance shall be in writing and accompanied by
				adequate documentation of the reasons for the request. Good cause includes the
				following:
(1) The inability to attend the
				hearing because of a serious physical or mental condition.
(2) An incapacitating injury.
(3) A death in the family.
(4) Severe weather conditions making it
				impossible to travel to the hearing.
(5) The unavailability of a witness and the
				evidence cannot be obtained otherwise.
(6) Other reasons similar to those listed in
				this section.
If the appellant is represented by counsel, the request for
				  continuance must also include alternative dates for the scheduling of a new
				  hearing. However, the hearings and appeals section may schedule a new hearing
				  without respect to the requested date if such date cannot be accommodated or
				  confirmed with the requesting attorney within a reasonable time of the
				  request.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 8 - INDIANA PRESCRIPTION DRUG PROGRAM MEDICARE PART D ASSISTANCE BENEFIT › Rule 9 - Member Appeals › Section 9-6 - Conduct and authority of administrative law judge

Current through July 10, 2024
Authority: IC
				  12-10-16-5
Affected: IC 12-10-16
Sec. 6.
(a) The
				conduct of an administrative law judge (ALJ) shall be in a manner that promotes
				public confidence in the integrity and impartiality of the administrative
				hearing process. The ALJ who conducts a hearing is prohibited from any of the
				following:
(1) Consulting any party or
				party's agent on any fact in issue unless upon notice and opportunity for all
				parties to participate.
(2)
				Performing any of the investigative or prosecutorial functions of the family
				and social services administration in the administrative appeal heard or to be
				heard by him or her or in a factually related administrative or judicial
				action.
(3) Being influenced by any
				of the following:
(A) Partisan
				interests.
(B) Public
				clamor.
(C) Fear of
				criticism.
(4) Conveying
				or permitting others to convey the impression that they are in a special
				position to influence the ALJ.
(5)
				Commenting publicly, except as to hearing schedules or procedures, about
				pending or impending proceedings.
(6) Engaging in financial or business
				dealings that tend to do any of the following:
(A) Reflect adversely on his or her
				impartiality.
(B) Interfere with
				the proper performance of his or her duties.
(C) Exploit the ALJ's position.
(D) Involve the ALJ in frequent financial
				business dealings with attorneys or other persons who are likely to come before
				the ALJ.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 8 - INDIANA PRESCRIPTION DRUG PROGRAM MEDICARE PART D ASSISTANCE BENEFIT › Rule 9 - Member Appeals › Section 9-7 - Conduct of hearing; hearing decisions

Current through July 10, 2024
Authority: IC
				  12-10-16-5
Affected: IC 12-10-16
Sec. 7.
(a) The
				administrative law judge (ALJ) shall conduct the hearing in an informal manner
				and without recourse to the technical common law rules of evidence.
(b) The ALJ shall exclude from consideration
				irrelevant, immaterial, or unduly repetitious evidence.
(c) Every party shall have the right to
				submit evidence. In the event that an objection to evidence is sustained, the
				party proffering the evidence may make an offer of proof. Each party shall have
				the right to cross-examine the witnesses and offer rebutting
				evidence.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 8 - INDIANA PRESCRIPTION DRUG PROGRAM MEDICARE PART D ASSISTANCE BENEFIT › Rule 9 - Member Appeals › Section 9-8 - Hearing decision

Current through July 10, 2024
Authority: IC
				  12-10-16-5
Affected: IC 12-10-16
Sec. 8.
(a)
				Following completion of the hearing, or after submission of briefs by the
				parties (if briefing is permitted by the administrative law judge (ALJ), the
				ALJ shall issue his or her decision in the matter concurrently to the parties.
				The decision shall be final unless a party requests agency review of the
				decision in accordance with this rule.
(b) The ALJ's decision shall do the
				following:
(1) Include findings of
				fact.
(2) Specify the reasons for
				the decision.
(3) Identify the
				evidence and statutes, regulations, rules and policies supporting the
				decision.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 8 - INDIANA PRESCRIPTION DRUG PROGRAM MEDICARE PART D ASSISTANCE BENEFIT › Rule 9 - Member Appeals › Section 9-9 - Agency review

Current through July 10, 2024
Authority: IC
				  12-10-16-5
Affected: IC 12-10-16
Sec. 9.
(a) Any
				party who is not satisfied with the decision of the administrative law judge
				(ALJ) may request agency review of the decision within ten (10) days of receipt
				thereof in accordance with instructions issued with the decision.
(b) After receiving a request for agency
				review of a hearing decision, the hearings and appeals section of the family
				and social services administration shall notify the parties when the decision
				will be reviewed. The agency review shall be completed by the secretary of the
				family and social services administration or the secretary's designee. All such
				reviews shall be conducted upon the record, as defined in section 7 of this
				rule, except that a transcript of the oral testimony shall not be necessary for
				review unless the party requests that one be transcribed at the party's
				expense.
(c) No new evidence will
				be considered during the agency review; however, any party wishing to submit a
				memorandum of law, citing evidence in the record, may do so pursuant to
				instructions issued by the hearings and appeals section of the family and
				social services administration.
(d)
				The secretary of family and social services administration or the secretary's
				designee shall review the ALJ's decision to determine if the decision is
				supported by the evidence in the record and is in accordance with statutes,
				regulations, rules, and policies applicable to the issues under
				appeal.
(e) Following the review of
				the secretary or designee, the secretary or designee shall issue a written
				decision doing one (1) of the following:
(1)
				Affirming the decision of the ALJ.
(2) Amending or modifying the decision of the
				ALJ.
(3) Reversing the decision of
				the ALJ.
(4) Remanding the matter
				to the ALJ for further specified action.
(5) Making such other order or determination
				as is proper on the record.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 8 - INDIANA PRESCRIPTION DRUG PROGRAM MEDICARE PART D ASSISTANCE BENEFIT › Rule 9 - Member Appeals › Section 9-10 - Agency record; judicial review

Current through July 10, 2024
Authority: IC
				  12-10-16-5
Affected: IC
				  4-21.5-3-33; IC 4-21.5-5;
				  IC 12-10-16
Sec. 10.
(a) The
				record of the administrative proceedings shall be that as defined in IC
				4-21.5-3-33.
(b) If the appellant is not satisfied with
				the secretary's final action after agency review, he or she may file for
				judicial review in accordance with IC 4-21.5-5.
(c) The appellant is required to seek agency
				review before filing a petition for judicial review.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 8 - INDIANA PRESCRIPTION DRUG PROGRAM MEDICARE PART D ASSISTANCE BENEFIT › Rule 10 - Contracts with Part D Plans › Section 10-1 - General provisions for contracting for assistance with Medicare prescription drug plan monthly premium and other Medicare Part D plan costs

Current through July 10, 2024
Authority: IC
				  12-10-16-5
Affected: IC 12-10-16
Sec. 1.
(a) The IPDP
				may contract with Medicare Part D plans to administer state assistance with
				Medicare prescription drug plan monthly premium.
(b) Medicare Part D plans contracting with
				the IPDP to administer state Medicare Part D assistance may place an IPDP logo
				on joint IPDP and PDP member prescription drug cards, if approved by the
				program, and shall do the following:
(1)
				Accept electronic auto-enrollment records in a standard defined by the
				IPDP.
(2) Only invoice the state
				for premium expenses up to the state maximum limit.
(3) Provide IPDP with claims data on IPDP
				members:
(A) in order for the IPDP to
				understand the utilization underlying its costs; and
(B) for reconciliation of incurred and paid
				amounts.
(4) Comply with
				all federal regulations pertaining to Medicare Part D plans as outlined in the
				Medicare Prescription Drug, Improvement, and Modernization Act of
				2003.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 8 - INDIANA PRESCRIPTION DRUG PROGRAM MEDICARE PART D ASSISTANCE BENEFIT › Rule 10 - Contracts with Part D Plans › Section 10-2 - General provisions for contracting for assistance with Medicare prescription drug plan monthly premium only

Current through July 10, 2024
Authority: IC
				  12-10-16-5
Affected: IC 12-10-16
Sec. 2.
(a) The IPDP
				may contract with Medicare Part D plans to administer state Medicare Part D
				premium-only assistance. Medicare Part D plans offering coverage in the state
				of Indiana may contract with the IPDP to administer the state's Medicare Part D
				premium assistance programs.
(b)
				Medicare Part D plans contracting with the IPDP to administer the state's
				Medicare Part D premium assistance program may place a IPDP logo on joint IPDP
				and PDP member prescription drug cards, if approved by the program, and shall
				do the following:
(1) Only invoice the state
				for premium expenses up to the maximum dollar amount as determined by the
				state.
(2) Provide IPDP with data
				on IPDP members in order for the IPDP to understand the utilization underlying
				its costs and for reconciliation of incurred and paid amounts.
(3) Comply with all federal regulations
				pertaining to Medicare Part D plans as outlined in the Medicare Prescription
				Drug, Improvement, and Modernization Act of 2003.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 10 - HEALTHY INDIANA PLAN › Rule 1 - General Provisions › Section 1-1 - Intent and purpose

Current through July 10, 2024
Authority: IC
				  12-15-44.5-9
Affected: IC 12-15-44.5
Sec. 1.
(a) Under IC
				12-15-44.2, the office hereby adopts and promulgates this article to:
(1) ensure the:
(A) efficient;
(B) economical;
(C) medically reasonable; and
(D) quality; operations of the plan;
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 10 - HEALTHY INDIANA PLAN › Rule 1 - General Provisions › Section 1-2 - Approval of waiver; federal financial participation; hospital assessment fee

Current through July 10, 2024
Authority: IC 12-15-44.5-9
Affected: IC 12-15-44.5; IC 16-21-10
Sec. 2.
The plan shall be conditioned upon the following:
(1) The continued approval of the Healthy
				Indiana Plan Section 1115 waiver application by the Centers for Medicare and
				Medicaid Services.
(2) The
				increased federal medical assistance percentage available to individuals
				defined in
				42
				CFR 435.119, as provided in
				42
				U.S.C. 1396d(y).
(3) The hospital assessment fee funds as set
				forth in IC 16-21-10, to support the plan beginning in calendar year 2017.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 10 - HEALTHY INDIANA PLAN › Rule 1 - General Provisions › Section 1-3 - References to the United States Code

Current through July 10, 2024
Authority: IC
				  12-15-44.5-9
Affected: IC 12-15-44.5
Sec. 3.
Any reference to a provision of the United States Code
				  (U.S.C.) shall mean that which was effective on February 20, 2015.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 10 - HEALTHY INDIANA PLAN › Rule 1 - General Provisions › Section 1-4 - References to the Code of Federal Regulations

Current through July 10, 2024
Authority: IC
				  12-15-44.5-9
Affected: IC 12-15-44.5
Sec. 4.
Any reference to a provision of the Code of Federal
				  Regulations (CFR) shall mean the October 1, 2017, edition. The provisions are
				  incorporated by reference. Copies may be obtained from the Government Printing
				  Office, 732 North Capitol Street NW, Washington, D.C. 20401 or are available
				  for review and copying at the Indiana Family and Social Services
				  Administration, Office of General Counsel, Indiana Government Center South,
				  Room W451, 402 West Washington Street, Indianapolis, Indiana 46204.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 10 - HEALTHY INDIANA PLAN › Rule 2 - Definitions › Section 2-1 - Definitions

Current through July 10, 2024
Authority: IC 12-15-44.5-9
Affected: IC 12-15-44.2; IC 12-15-44.5
Sec. 1.
The following definitions in this rule apply throughout this
				  article:
(1) "Alternative benefit
				plan" means an alternative benefit plan approved by the Centers for Medicare
				and Medicaid Services.
(2)
				"American Indian/Alaskan Native" means any individual defined in
				25
				U.S.C. 1603(13) or
				25
				U.S.C. 1603(28) or whom the division has determined eligible as an American
				Indian/Alaskan Native under
				42 CFR
				136.12.
(3) "Applicant" means an individual for whom
				coverage under the plan is requested.
(4) "Benefit period" means the annual period,
				from January 1 through December 31, in which an individual is enrolled with the
				same managed care organization, unless the individual meets the for cause
				standard defined in
				405 IAC
				10-8-2. Member benefits with limitations are subject
				to those limitations on a per benefit period basis. Member POWER accounts are
				also active for one (1) benefit period.
(5) "Conditionally eligible" or
				"conditionally eligible individual" means a plan applicant who:
(A) has been determined eligible for the plan
				by the division; and
(B) is not yet
				able to receive coverage under HIP Basic, HIP Plus, HIP State Plan Basic, or
				HIP State Plan Plus.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 10 - HEALTHY INDIANA PLAN › Rule 3 - Applicants and Members › Section 3-1 - Application process

Current through July 10, 2024
Authority: IC 12-15-44.5-9
Affected: IC 12-15-44.5
Sec. 1.
(a) An
				applicant seeking coverage under the plan shall submit an application on the
				form approved or accepted by the office.
(b) An application may be submitted through:
(1) the division;
(2) a designated enrollment center;
(3) an online method determined by the
				division; or
(4) the federal
				marketplace.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 10 - HEALTHY INDIANA PLAN › Rule 3 - Applicants and Members › Section 3-2 - Standard enrollment

Current through July 10, 2024
Authority: IC 12-15-44.5-9
Affected: IC 12-15-44.5
Sec. 2.
(a) This
				section does not apply to a:
(1) pending
				applicant; or
(2) pregnant woman
				eligible for HIP Maternity.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 10 - HEALTHY INDIANA PLAN › Rule 3 - Applicants and Members › Section 3-3 - Fast track enrollment

Current through July 10, 2024
Authority: IC 12-15-44.5-9
Affected: IC 12-15-44.5
Sec. 3.
(a) This
				section applies to a pending applicant.
(b) Upon receipt of an application but prior
				to determining eligibility, the office shall assign the pending applicant to
				either:
(1) the managed care organization
				selected on the application; or
(2)
				a managed care organization assigned to an individual in accordance with
				section 1(f) of this rule.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 10 - HEALTHY INDIANA PLAN › Rule 3 - Applicants and Members › Section 3-4 - Enrollment for pregnant women

Current through July 10, 2024
Authority: IC 12-15-44.5-9
Affected: IC 12-15-44.5
Sec. 4.
(a) This
				section applies to a pending applicant who is also a pregnant woman.
(b) An applicant once determined eligible
				shall be considered conditionally eligible for HIP Plus unless such individual
				is eligible for HIP State Plan benefits.
(c) Pregnant members shall begin coverage in
				HIP Maternity benefits on the first day of the month following the eligibility
				determination on the application.
(d) Pregnant members shall be evaluated for
				coverage under traditional Medicaid for a period of up to ninety (90) days
				prior to the application submission in the following manner:
(1) The coverage shall be provided under the
				fee for service model.
(2) Members
				in HIP Maternity shall have no cost sharing obligations as provided for in
				405 IAC
				10-4-6.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 10 - HEALTHY INDIANA PLAN › Rule 4 - Eligibility › Section 4-1 - Eligibility requirements

Current through July 10, 2024
Authority: IC 12-15-44.5-9
Affected: IC 12-15-44.5; IC 12-17.6; IC 27-8-14.1-1
Sec. 1.
(a) The
				following individual shall be eligible for participation in the plan if the
				individual:
(1) Is at least nineteen (19)
				years of age and less than sixty-five (65) years of age, except as set forth in
				section 4(d) of this rule.
(2) Is
				an Indiana resident.
(3) Is not
				enrolled in or eligible for enrollment in the federal Medicare
				program.
(4) Is not eligible for
				another Medicaid assistance category, except for the following:
(A) Section 1931 parents and caretaker
				relatives.
(B) Transitional medical
				assistance.
(C) Members eligible
				for the HIP Maternity category in accordance with section 6 of this
				rule.
(5) Has household
				income at or below one hundred thirty-three percent (133%) of the FPL for the
				applicable family size.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 10 - HEALTHY INDIANA PLAN › Rule 4 - Eligibility › Section 4-2 - HIP Plus; HIP Basic

Current through July 10, 2024
Authority: IC 12-15-44.5-9
Affected: IC 12-15-44.5
Sec. 2.
(a) Except as
				otherwise provided in this article, a member in HIP Plus or HIP State Plan Plus
				shall make regular monthly POWER account contributions in the amount set forth
				in
				405 IAC
				10-10-3(a). A member who fails to
				make the member's POWER account contributions shall be subject to the actions
				set forth in
				405
				IAC 10-10-12, unless the individual is excepted under
				405
				IAC 10-10-13.
(b) A member who is either:
(1) enrolled in HIP Basic or HIP State Plan
				Basic in accordance with
				405 IAC
				10-3-2 or
				405 IAC
				10-3-3; or
(2) transferred to HIP Basic or HIP State
				Plan Basic in accordance with
				405
				IAC 10-10-12; shall not be required to make POWER
				account contributions but may be required to pay copayments at the time of
				service delivery in accordance with
				405 IAC
				10-10-3(b).
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 10 - HEALTHY INDIANA PLAN › Rule 4 - Eligibility › Section 4-3 - Medically frail

Current through July 10, 2024
Authority: IC 12-15-44.5-9
Affected: IC 12-15-44.5
Sec. 3.
(a) Subject
				to the eligibility requirements under subsection (b), a member who is
				determined to have one (1) or more of the conditions outlined under
				405 IAC 10-2-1(30)
				 shall be eligible to receive HIP State Plan
				services.
(b) An applicant who self
				identifies as medically frail under
				405 IAC 10-6-1(b)
				 shall be eligible for HIP State Plan Plus
				benefits and shall be enrolled in either HIP State Plan Plus or HIP State Plan
				Basic in accordance with
				405 IAC
				10-3-2 or
				405 IAC
				10-3-3, as applicable, effective the first of the
				month following the confirmation of his or her medically frail status by the
				managed care organization.
(c) A
				medically frail member who is enrolled in HIP State Plan Plus shall continue
				making the member's monthly POWER account contributions while the member's
				medically frail status is verified and, if confirmed as medically frail, during
				the benefit period. A member who does not continue making monthly POWER account
				contributions shall be subject to the nonpayment penalties set forth in
				405
				IAC 10-10-12, unless the individual is excepted under
				405
				IAC 10-10-13.
(d) A medically frail member in HIP State
				Plan Basic may choose to enroll in HIP State Plan Plus at annual renewal or
				prior to the rollover determination as provided in section 2(c) of this rule by
				making POWER account contributions in accordance with
				405 IAC
				10-10-3(a).
(e) A member's medically frail status shall
				be redetermined in accordance with
				405 IAC
				10-6-1. If the member is determined not to be
				medically frail, but still eligible under the plan, such member shall no longer
				receive HIP State Plan benefits and shall be transferred to:
(1) HIP Plus if the member is currently
				enrolled in HIP State Plan Plus; or
(2) HIP Basic if the member is currently
				enrolled in HIP State Plan Basic.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 10 - HEALTHY INDIANA PLAN › Rule 4 - Eligibility › Section 4-4 - Section 1931 parents and caretaker relatives

Current through July 10, 2024
Authority: IC 12-15-44.5-9
Affected: IC 12-15-44.5
Sec. 4.
(a) An
				eligible applicant or member who meets the definition for Section 1931 parent
				and caretaker relative shall be enrolled in either HIP State Plan Plus or HIP
				State Plan Basic in accordance with
				405 IAC
				10-3-2 or
				405 IAC
				10-3-3, as applicable.
(b) If a member under this section is
				determined to no longer meet the Section 1931 parent and caretaker relative
				definition but is still eligible under the plan, the member shall be
				transferred to:
(1) HIP Plus if the member is
				currently enrolled in HIP State Plan Plus; or
(2) HIP Basic if the member is currently
				enrolled in HIP State Plan Basic.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 10 - HEALTHY INDIANA PLAN › Rule 4 - Eligibility › Section 4-6 - HIP Maternity

Current through July 10, 2024
Authority: IC 12-15-44.5-9
Affected: IC 12-15-44.5
Sec. 6.
(a) A member
				who becomes pregnant during the member's benefit period shall remain enrolled
				in the plan.
(b) A pregnant member
				shall be exempt from cost sharing, including, but not limited to, the
				following:
(1) HIP Plus monthly contributions
				set forth in
				405 IAC
				10-10-3(a).
(2) HIP Basic copayments set forth in
				405 IAC
				10-10-3(c).
(3) Copayments for nonemergent use of a
				hospital emergency department set forth in
				405 IAC 10-7-9.
(4) Deductible amounts funded through the
				member's POWER account.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 10 - HEALTHY INDIANA PLAN › Rule 4 - Eligibility › Section 4-7 - American Indian/Alaskan Native

Current through July 10, 2024
Authority: IC 12-15-44.5-9
Affected: IC 12-15-44.5
Sec. 7.
(a) An
				American Indian/Alaskan Native who meets the eligibility requirements for the
				plan shall not be subject to any cost sharing requirements under this
				article.
(b) An American
				Indian/Alaskan Native applicant who applies for benefits and who has been
				determined eligible for the plan shall be enrolled in HIP Plus or HIP State
				Plan Plus benefits in accordance with
				405 IAC
				10-3-2(f). Such an individual may
				either:
(1) elect to enroll or remain enrolled
				with a managed care organization; or
(2) elect to opt-out of the plan to receive
				fee-for-service coverage by submitting a form provided by the office at any
				time following the date of application.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 10 - HEALTHY INDIANA PLAN › Rule 4 - Eligibility › Section 4-8 - Household; household income; as applied

Current through July 10, 2024
Authority: IC 12-15-44.2-19
Affected: IC 12-15-44.2
Sec. 8.
The division shall determine the applicant's or member's:
(1) eligibility under the plan;
				and
(2) POWER account contribution
				requirements;
by considering the applicant's or member's household and
				  household income as defined in
				  405 IAC 10-2-1(25)
				   and
				  405 IAC
				  10-2-1(26).
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 10 - HEALTHY INDIANA PLAN › Rule 4 - Eligibility › Section 4-9 - Eligibility period; renewal

Current through July 10, 2024
Authority: IC 12-15-44.5-9
Affected: IC 12-15-44.5
Sec. 9.
(a) A member
				shall be eligible for a twelve (12) month period from the date such individual
				becomes a member unless the member:
(1) is
				terminated from the plan in accordance with
				405
				IAC 10-10-12; or
(2) becomes ineligible under the rules
				established under section 10 of this rule.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 10 - HEALTHY INDIANA PLAN › Rule 4 - Eligibility › Section 4-10 - Loss of eligibility

Current through July 10, 2024
Authority: IC 12-15-44.5-9
Affected: IC 12-15-44.5
Sec. 10.
(a) During
				the twelve (12) month eligibility period, an individual shall become ineligible
				to participate in the plan under the following circumstances:
(1) The member is no longer an Indiana
				resident.
(2) The member is
				enrolled or is otherwise eligible for enrollment in the federal Medicare
				program.
(3) The member becomes
				eligible for another Medicaid assistance category, except for:
(A) Section 1931 parents and caretaker
				relatives;
(B) transitional medical
				assistance; or
(C) HIP
				Maternity.
(4) The
				member has household income above one hundred percent (100%) of the FPL and is
				terminated under
				405
				IAC 10-10-12 for failure to make the required POWER
				account contributions, unless the member is excepted under
				405
				IAC 10-10-13.
(5) The member or the member's duly
				authorized representative requests in writing that coverage be
				terminated.
(6) The member
				falsifies information on the application.
(7) The member is at least sixty-five (65)
				years of age unless the member is:
(A) a
				Section 1931 parent and caretaker relative; or
(B) eligible for transitional medical
				assistance.
(8) Except
				for a member eligible for transitional medical assistance, the member's
				household income exceeds one hundred thirty-three percent (133%) of the
				FPL.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 10 - HEALTHY INDIANA PLAN › Rule 4 - Eligibility › Section 4-11 - Presumptive eligibility

Current through July 10, 2024
Authority: IC
				  12-15-44.5-9
Affected: IC 12-15-44.5
Sec. 11.
(a) An
				individual may apply for presumptive eligibility under the plan. A qualified
				presumptive eligibility provider shall determine whether an individual is
				eligible for a presumptive eligibility period.
(b) An individual who is determined
				presumptively eligible for the plan shall receive coverage under the
				fee-for-service model comparable to HIP Basic, including applicable
				copayments.
(c) A presumptively
				eligible individual who does not file an Indiana application for health
				coverage shall receive the presumptive eligibility benefits described in
				subsection (b) until the last day of the month following the month in which the
				determination of presumptive eligibility was made.
(d) A presumptively eligible individual whose
				application for health coverage has been filed and approved by the division
				shall receive the presumptive eligibility benefits described in subsection (b),
				until one (1) of the following occurs, as applicable:
(1) Presumptively eligible adult members are
				enrolled in HIP Basic effective the first day of the month following approval
				of the members full Indiana health coverage program application. These members
				continue to have the potential to buy in to HIP Plus benefits by making a POWER
				account contribution within sixty (60) days of HIP enrollment.
(2) Presumptively eligible adult members who
				make a POWER account payment within sixty (60) days from the date of
				determination shall be enrolled in HIP Plus effective the first day of the
				month after payment is received.
(3) Presumptively eligible adult members who
				do not make a POWER account payment within sixty (60) days and have household
				income equal to or less than one hundred percent (100%) of the FPL, shall be
				enrolled in HIP Basic effective the first day of the month following approval
				of the members full Indiana health coverage program application. These members
				are not eligible to buy in to HIP Plus until eligibility
				redetermination.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 10 - HEALTHY INDIANA PLAN › Rule 5 - Member Appeals › Section 5-1 - Appeals of determinations by the office or division

Current through July 10, 2024
Authority: IC
				  12-15-44.5-9
Affected: IC 12-15-44.5
Sec. 1.
(a) For
				purposes of this rule, the term action means any of the following:
(1) A termination of benefits.
(2) A suspension of benefits.
(3) A change in benefits.
(4) A denial of covered services.
(5) A reduction of covered
				services.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 10 - HEALTHY INDIANA PLAN › Rule 5 - Member Appeals › Section 5-2 - Member appeals; managed care organizations

Current through July 10, 2024
Authority: IC
				  12-15-44.5-9
Affected: IC 12-15-44.5
Sec. 2.
(a) A
				pending applicant, conditionally eligible individual, or plan member
				dissatisfied with the action of a managed care organization must first exhaust
				the managed care organization's internal appeals procedure prior to requesting
				a hearing with the state.
(b) After
				exhausting the managed care organization's internal appeals procedures, a
				pending applicant, conditionally eligible individual, or member may request an
				administrative hearing with the state no later than thirty-three (33) days from
				the date of the managed care organization's resolution of appeal.
(c) The state's hearing process shall be
				governed by the procedures and time limits set forth in 405 IAC 1.1.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 10 - HEALTHY INDIANA PLAN › Rule 5 - Member Appeals › Section 5-3 - Maintaining services

Current through July 10, 2024
Authority: IC 12-15-44.5-9
Affected: IC 12-15-44.5
Sec. 3.
(a) This
				subsection applies to an aggrieved member requesting an administrative appeal
				under section 1 or 2 of this rule as follows:
(1) If an aggrieved member requests an
				administrative hearing as provided in the notice of adverse action, prior to
				the effective date of the adverse action, plan coverage shall continue without
				change until an administrative law judge issues a decision after the hearing
				under
				405 IAC 1.1-1-6.
				If POWER account contributions were required for that member to receive
				services, the member shall continue to make contributions to the member's POWER
				account during the appeal in order to continue coverage.
(2) If the administrative law judge sustains
				the action, the member shall be responsible for repaying the cost of any
				services furnished by reason of this section, minus any POWER account
				contributions made for coverage during the pendency of the appeal.
(3) If the action under appeal is overturned,
				the state or the managed care organization shall make coverage available
				effective to the date the overturned action was taken. However, unless the
				member is not required to make POWER account payments to maintain coverage, the
				individual shall make any POWER account payments that became due during the
				appeal within sixty (60) days of the managed care organization's date of
				invoice in order to continue participating in the plan.
(4) A member shall not receive continued
				benefits pending the outcome of an administrative hearing if:
(A) the action is the result of the member's
				nonpayment of POWER account contributions; or
(B) the member requests in writing that plan
				benefits not be maintained pending the administrative appeal.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 10 - HEALTHY INDIANA PLAN › Rule 6 - Medically Frail › Section 6-1 - Medically frail screening

Current through July 10, 2024
Authority: IC 12-15-44.5-9
Affected: IC 12-15-44.5
Sec. 1.
(a) An
				applicant or member shall be reviewed for medically frail status at any of the
				following times:
(1) During the verification
				period if such member's responses on the initial health screening indicate the
				potential existence of a medically frail condition.
(2) At any time during the benefit period if
				documentation, such as claims data or provider identification, demonstrates
				that the member may have a medically frail condition.
(3) At any time if documentation demonstrates
				that the member may no longer have a medically frail condition.
(4) At any time upon member
				request.
(5) For a medically frail
				member, at least annually by the managed care organization for continued
				medically frail eligibility.
(6)
				For an applicant that has been locked out pursuant to
				405
				IAC 10-10-12, a request for a lockout exemption based
				on a medically frail condition.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 10 - HEALTHY INDIANA PLAN › Rule 7 - Benefits and Medical Policy › Section 7-1 - Coverage requirements; medically necessary service

Current through July 10, 2024
Authority: IC 12-15-44.2-19
Affected: IC 12-15-44.2
Sec. 1.
For a service to be covered under the plan, it shall be
				  medically necessary as defined in
				  405 IAC
				  10-2-1(30).
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 10 - HEALTHY INDIANA PLAN › Rule 7 - Benefits and Medical Policy › Section 7-2 - HIP Basic covered benefits and services; noncovered services

Current through July 10, 2024
Authority: IC 12-15-44.5
Affected: IC 12-15-44.5
Sec. 2.
(a) This
				section outlines the services available to an individual enrolled in HIP Basic.
				The covered services provided under HIP Basic are in accordance with the
				essential health benefit requirements under
				42 CFR
				440.347 for alternative benefit
				plans.
(b) HIP Basic shall include
				covered services in each of the following categories:
(1) Ambulatory patient services.
(2) Emergency services.
(3) Hospitalization.
(4) Maternity services.
(5) Mental health and substance abuse
				services.
(6) Prescription
				drugs.
(7) Rehabilitative and
				habilitative services and devices.
(8) Laboratory services.
(9) Preventive care services.
(10) Early and periodic screening,
				diagnostic, and treatment services for members nineteen (19) and twenty (20)
				years of age.
(11) Any other
				services approved by the Centers for Medicare and Medicaid Services in the HIP
				Basic alternative benefit plan.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 10 - HEALTHY INDIANA PLAN › Rule 7 - Benefits and Medical Policy › Section 7-3 - HIP Plus covered benefits and services; noncovered services

Current through July 10, 2024
Authority: IC 12-15-44.5
Affected: IC 12-15-44.5
Sec. 3.
(a) This
				section outlines the services available to an individual enrolled in HIP Plus.
				The covered services provided under HIP Plus are in accordance with the
				essential health benefit requirements under
				42 CFR
				440.347 for alternative benefit
				plans.
(b) HIP Plus shall include
				covered services in each of the following categories:
(1) Ambulatory patient services.
(2) Emergency services.
(3) Hospitalization.
(4) Maternity services.
(5) Mental health and substance abuse
				services.
(6) Prescription
				drugs.
(7) Rehabilitative and
				habilitative services and devices.
(8) Laboratory services.
(9) Preventive care services.
(10) Vision services.
(11) Dental services.
(12) Early and periodic screening,
				diagnostic, and treatment services for members nineteen (19) and twenty (20)
				years of age.
(13) Any other
				services approved by the Centers for Medicare and Medicaid Services in the HIP
				Plus alternative benefit plan.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 10 - HEALTHY INDIANA PLAN › Rule 7 - Benefits and Medical Policy › Section 7-4 - HIP State Plan

Current through July 10, 2024
Authority: IC 12-15-44.5
Affected: IC 12-15-44.5
Sec. 4.
(a) This
				section outlines services available to a member enrolled in HIP State Plan. All
				covered services under HIP State Plan are subject to the coverage criteria,
				limitations, and procedures specified in this article as well as those services
				specified in the Centers for Medicare and Medicaid Services approved Medicaid
				State Plan.
(b) HIP State Plan
				shall include covered services in the following categories that are equivalent
				to the Medicaid State Plan:
(1) Ambulatory
				patient services.
(2) Emergency
				services.
(3)
				Hospitalization.
(4) Maternity
				services.
(5) Mental health and
				substance abuse services.
(6)
				Prescription drugs.
(7)
				Rehabilitative and habilitative services and devices.
(8) Laboratory services.
(9) Preventive care services.
(10) Vision services.
(11) Dental services.
(12) Early and periodic screening,
				diagnostic, and treatment services for members nineteen (19) and twenty (20)
				years of age.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 10 - HEALTHY INDIANA PLAN › Rule 7 - Benefits and Medical Policy › Section 7-5 - Mental health parity

Current through July 10, 2024
Authority: IC
				  12-15-44.5-9
Affected: IC 12-15-44.5
Sec. 5.
Coverage of mental health care services shall be subject to
				  the same treatment limitations or financial requirements as coverage of
				  services for physical illness.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 10 - HEALTHY INDIANA PLAN › Rule 7 - Benefits and Medical Policy › Section 7-6 - Prescription drug benefits

Current through July 10, 2024
Authority: IC 12-15-44.5-9
Affected: IC 12-15-44.5
Sec. 6.
(a) For
				purposes of prescription drug benefits, HIP Basic and HIP Plus shall cover, at
				a minimum:
(1) one (1) drug in every United
				States Pharmacopeia category and class; or
(2) the same number of prescription drugs in
				each category and class of the essential health benefits benchmark
				plan.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 10 - HEALTHY INDIANA PLAN › Rule 7 - Benefits and Medical Policy › Section 7-7 - Laboratory services

Current through July 10, 2024
Authority: IC
				  12-15-44.5-9
Affected: IC 12-15-44.5
Sec. 7.
Covered laboratory services include only laboratory services
				  provided by laboratories or providers certified by Clinical Laboratory
				  Improvement Amendments.