reglab/statecodes huggingface dataset:
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 7-8 - Preventive care services

Current through July 10, 2024
Authority: IC 12-15-44.5-9
Affected: IC 12-15-44.5
Sec. 8.
(a)
				Preventive care services as set forth in
				42 U.S.C.
				300gg-13 shall be covered, regardless of
				whether the member has met the member's deductible, and shall not be reimbursed
				using the member's POWER account.
(b) Preventive care services not set forth in
				42 U.S.C.
				300gg-13 shall be covered up to five hundred
				dollars ($500) during the member's benefit period, regardless of whether the
				member has met the member's deductible, and shall not be reimbursed using the
				member's POWER account. Any such services in excess of five hundred dollars
				($500) shall be covered but shall be subject to the member's deductible and
				shall be reimbursed using the member's POWER account.
(c) A member's failure to receive preventive
				care services applicable to the member during the benefit period may impact the
				rollover of POWER account funds as outlined in
				405
				IAC 10-10-5(c)  and
				405
				IAC 10-10-5(d).
(d) If a managed care organization determines
				that a member has not met the member's preventive care requirements during the
				benefit period, such member may submit documentation to the managed care
				organization showing that the member received the required preventive care
				services.
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 7-9 - Emergency room visits; copayments

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 subject to an eight dollar ($8) copayment for the member's
				nonemergency use of a hospital emergency department.
(b) The following members shall be exempt
				from paying the copayments described under subsection (a):
(1) Pregnant women.
(2) American Indians/Alaskan
				Natives.
(3) Individuals who meet
				the requirements of
				405 IAC
				10-10-3(f).
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 7-10 - Out-of-network services

Current through July 10, 2024
Authority: IC
				  12-15-44.5-9
Affected: IC 12-15-44.5
Sec. 10.
The following services shall be covered under the plan, even
				  if provided out-of-network:
(1) Family
				planning services.
(2) Emergency
				services.
(3) Medically necessary
				covered services if the member's managed care organization is unable to provide
				the services in network within:
(A) thirty
				(30) miles of the member's residence for primary care; and
(B) sixty (60) miles of the member's
				residence for specialty care.
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 7-11 - Self-referral services

Current through July 10, 2024
Authority: IC
				  12-15-44.5-9
Affected: IC 12-15-11; IC 12-15-44.5; IC
				  27-8-14.5-6
Sec. 11.
(a) A
				member may receive the following covered services without a referral from the
				member's primary medical provider or prior authorization or precertification
				from the member's managed care organization:
(1) Family planning services.
(2) Emergency services.
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 7-12 - Prior authorization

Current through July 10, 2024
Authority: IC 12-15-44.5-9
Affected: IC 12-15-44.5
Sec. 12.
(a) A
				managed care organization may implement utilization control procedures,
				including prior authorization or precertification of services as provided under
				42 CFR
				438.210. The following services shall be
				exempt from prior authorization:
(1) Emergency
				services, subject to the requirements of section 9 of this rule.
(2) Family planning services.
(3) Urgent care.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 10 - HEALTHY INDIANA PLAN › Rule 8 - Managed Care Organizations and Administrators › Section 8-1 - Unauthorized cost sharing

Current through July 10, 2024
Authority: IC 12-15-44.5-9
Affected: IC 12-15-44.5
Sec. 1.
(a) Managed
				care organizations and providers shall not charge, collect, or impose cost
				sharing, including premiums, copayments, or coinsurance, to plan members for
				covered services, except in the following circumstances:
(1) Deductible amounts paid for with funds
				out of a member's POWER account.
(2) Emergency room copayments, as set forth
				in
				405 IAC
				10-7-9.
(3) Copayments, as set forth in
				405 IAC
				10-10-3(c).
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 10 - HEALTHY INDIANA PLAN › Rule 8 - Managed Care Organizations and Administrators › Section 8-2 - Changing 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 member
				shall remain enrolled with the same managed care organization during the
				member's benefit period. If a member leaves the program and returns during the
				same benefit period, the member shall remain enrolled in the same MCO. A member
				may change managed care organizations upon request only in the following
				circumstances:
(1) Without cause for new
				conditional or fast track members, before making the member's fast track
				prepayment or initial POWER account contribution or within sixty (60) days of
				being assigned to a managed care organization, whichever comes first.
(2) For cause at any time. A member under
				this subsection may request to change managed care organizations at any time by
				submitting a grievance to the managed care organization and receiving the
				managed care organization's or the division's approval.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 10 - HEALTHY INDIANA PLAN › Rule 8 - Managed Care Organizations and Administrators › Section 8-3 - Network

Current through July 10, 2024
Authority: IC 12-15-44.5-9
Affected: IC 12-15-44.5
Sec. 3.
The managed care organization shall maintain and monitor an
				  adequate network of providers in accordance with
				  42 CFR
				  438.206. The managed care organization shall
				  not maintain network differentiation between its HIP Plus and HIP Basic benefit
				  plans.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 10 - HEALTHY INDIANA PLAN › Rule 9 - Providers › Section 9-1 - Provider enrollment

Current through July 10, 2024
Authority: IC 12-15-44.5-9
Affected: IC 12-15-44.5
Sec. 1.
(a) With the
				exception of emergency services providers, a provider rendering covered
				services to a member shall be enrolled in the Indiana Medicaid program at the
				time of service in order to receive reimbursement. An emergency services
				provider who is not enrolled in the Indiana Medicaid program at the time of
				service shall enroll in the Indiana Medicaid program retroactive to the date of
				service in order to receive reimbursement.
(b) In order to enroll as a provider as
				required under subsection (a), the provider shall comply with the procedures
				set forth in
				405 IAC
				5-4-1.
(c)
				A provider providing covered services to members shall provide the services
				under a contract with a managed care organization except in the following
				circumstances:
(1) If the service provided is
				listed in
				405 IAC
				10-7-10.
(2) If the managed care organization:
(A) has designed an out-of-network benefit
				for its members; or
(B) otherwise
				approves the out-of-network service.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 10 - HEALTHY INDIANA PLAN › Rule 9 - Providers › Section 9-2 - Provider grievances and 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) The
				right of providers contracting with managed care organizations to dispute any
				actions taken by the managed care organization shall be governed by the
				provider's contract with the managed care organization.
(b) The reimbursement dispute resolution
				procedure set forth at 405 IAC 1-1.6 shall apply to providers who do not have a
				contract with a managed care organization for services provided under the
				plan.
(c) Any provider disputes
				involving prior authorization determinations made by the managed care
				organizations shall be governed by the managed care organization's procedures
				for provider grievances and appeals.
(d) A contracted or noncontracted provider
				shall have no right to appeal a managed care organization's action to the
				state.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 10 - HEALTHY INDIANA PLAN › Rule 9 - Providers › Section 9-3 - Provision of covered services; verification of enrollment

Current through July 10, 2024
Authority: IC 12-15-44.5-9
Affected: IC 12-15-44.5
Sec. 3.
(a) Except
				as provided in subsection (b), before providing any nonemergency service
				covered under the plan, a provider shall verify all of the following:
(1) The individual is eligible for the
				plan.
(2) The individual is
				enrolled with a managed care organization.
(3) The individual is enrolled in the plan at
				the time the service is being provided.
(4) The individual whose name appears on the
				card is the same individual for whom the service is being performed.
(5) The service is covered under the member's
				benefit plan.
Failure to do so may result in denial of the provider's claim
				  if the individual is not enrolled in the plan or the service is not
				  authorized.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 10 - HEALTHY INDIANA PLAN › Rule 9 - Providers › Section 9-4 - Provider reimbursement; managed care organizations

Current through July 10, 2024
Authority: IC
				  12-15-44.5-9
Affected: IC
				  12-15-44.5-5
Sec. 4.
(a)
				Reimbursement matters including:
(1) the time
				limit for filing claims; and
(2)
				rates paid to providers contracting with managed care organizations;
shall be governed by the contract between the provider and
				  the managed care organization.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 10 - HEALTHY INDIANA PLAN › Rule 9 - Providers › Section 9-5 - Reimbursement process; provider reimbursement rates; POWER account

Current through July 10, 2024
Authority: IC 12-15-44.5-9
Affected: IC 12-15-44.5
Sec. 5.
(a) A
				provider shall be reimbursed for covered services as follows:
(1) Until the member's deductible is met,
				with POWER account funds accessed through the member's POWER account and paid
				by the managed care organization. If the member lacks sufficient POWER account
				funds at the time of service, the managed care organization shall pay for any
				portion of the plan reimbursement rate that cannot be paid with POWER account
				funds but shall reconcile these prepaid amounts as additional POWER account
				funds are received from the member.
(2) For all covered preventive care services,
				which are not subject to the member's deductible, by the managed care
				organization.
(3) For covered
				services under the member's health plan after the deductible has been met, by
				the managed care organization. The provider shall be reimbursed at the plan
				reimbursement rate.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 10 - HEALTHY INDIANA PLAN › Rule 9 - Providers › Section 9-6 - Member payment liability

Current through July 10, 2024
Authority: IC 12-15-44.5-9
Affected: IC 12-15-44.5
Sec. 6.
A provider shall accept plan reimbursement as payment in
				  full. A provider cannot collect from a member any portion of the provider's
				  charge for a covered service that is not reimbursed by the managed care
				  organization, with the exception of the following:
(1) Emergency room copayments authorized
				under this article.
(2) Payments
				made with POWER account funds before the deductible of the member's health plan
				is met.
(3) Copayments authorized
				under
				405 IAC
				10-10-3(c).
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 10 - HEALTHY INDIANA PLAN › Rule 10 - POWER Accounts and Copayments › Section 10-1 - Establishment of POWER account; noninterest bearing account

Current through July 10, 2024
Authority: IC
				  12-15-44.5-9
Affected: IC 12-15-44.5
Sec. 1.
(a) The
				managed care organizations shall establish and administer a POWER account in
				the name of each individual enrolled in the plan. The maximum amount that may
				be contributed to the POWER account is two thousand five hundred dollars
				($2,500) per year, contributed as specified under section 4 of this
				rule.
(b) POWER account funds shall
				be used to pay the member's deductible for health care services covered under
				the plan.
(c) A member shall not
				keep interest earned on 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 10 - POWER Accounts and Copayments › Section 10-2 - Uses of POWER account funds

Current through July 10, 2024
Authority: IC 12-15-44.5-9
Affected: IC 12-15-44.5
Sec. 2.
(a) Each
				member shall be responsible for the member's use of funds in the member's POWER
				account until the deductible is met. A member's POWER account funds shall only
				be used to pay for covered services and shall not be used to pay the following:
(1) The emergency room services copayment
				described in
				405 IAC
				10-7-9.
(2) HIP Basic copayments as set forth in
				section 3(b) of this rule.
(3) Any
				other cost not covered in the member's specific benefit package as listed in
				405
				IAC 10-7-2,
				405
				IAC 10-7-3, or
				405 IAC
				10-7-4.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 10 - HEALTHY INDIANA PLAN › Rule 10 - POWER Accounts and Copayments › Section 10-3 - POWER account contributions; copayments

Current through July 10, 2024
Authority: IC
				  12-15-44.5-9
Affected: IC 12-15-44.5
Sec. 3.
(a) A member
				enrolled in either HIP Plus or HIP State Plan Plus shall be required to
				contribute a monthly amount to the member's POWER account. Except as provided
				in subsection (h), a member's monthly POWER account contribution (PAC) shall be
				determined in accordance with the following criteria:
Percent of FPL
Monthly PAC Single Individual
Monthly PAC Spouses
[LESS THAN] 22%
$1.00
$1.00
23-50%
$5.00
$2.50
51-75%
$10.00
$5.00
76-100%
$15.00
$7.50
101-138%
$20.00
$10.00
In no event shall the member's monthly POWER account payment
				  exceed one hundred dollars ($100) per month or be less than one dollar ($1) per
				  month or one dollar and fifty cents ($1.50) per month for a tobacco user as set
				  forth in section 15 of this rule.
(b) All tobacco users shall be subject to a
				fifty percent (50%) surcharge for each monthly POWER account payment.
(c) Except as provided under subsection (d),
				a member enrolled in HIP Basic or HIP State Plan Basic shall not be required to
				make monthly contributions to the member's POWER account but shall be charged a
				copayment at the time services are rendered, as follows:
(1) Four dollars ($4) for outpatient
				services.
(2) Seventy-five dollars
				($75) for inpatient services.
(3)
				Four dollars ($4) for preferred drugs.
(4) Eight dollars ($8) for nonpreferred
				drugs.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 10 - HEALTHY INDIANA PLAN › Rule 10 - POWER Accounts and Copayments › Section 10-4 - POWER account contributions; state contributions; employer contributions

Current through July 10, 2024
Authority: IC
				  12-15-44.5-9
Affected: IC 12-15-44.5
Sec. 4.
(a) The
				state shall contribute the difference between:
(1) the member's annual contribution;
				and
(2) two thousand five hundred
				dollars ($2,500).
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 10 - HEALTHY INDIANA PLAN › Rule 10 - POWER Accounts and Copayments › Section 10-5 - Annual recalculation of POWER account contribution; rollover; copayment

Current through July 10, 2024
Authority: IC 12-15-44.5-9
Affected: IC 12-15-44.5
Sec. 5.
(a) A member
				enrolled in the Healthy Indiana Plan by December 31 may be eligible to rollover
				part of the member's POWER account to the new benefit period beginning January
				1 of each year.
(b) A member
				enrolled in HIP Plus or HIP State Plan Plus with a balance remaining in the
				member's POWER account at the end of the benefit period may be eligible to roll
				over a portion of the account balance to reduce such member's POWER account
				contributions for the new benefit period in accordance with subsection (c) or
				(d), as applicable.
(c) If a member
				enrolled in HIP Plus or HIP State Plan Plus has met the member's preventive
				care services goals as set by the office for the expiring benefit period as set
				forth in
				405 IAC
				10-7-8, the member's final rollover amount shall be
				calculated as follows:
(1) The member's
				pro-rata share is determined by adding the member's required monthly
				contributions owed for all enrolled months in the expiring benefit period
				dividing that sum by two thousand five hundred dollars ($2,500).
(2) The member's portion is determined by
				multiplying the member's pro-rata share as determined in subdivision (1) by the
				amount spent from the POWER account.
(3) The base rollover amount is determined by
				subtracting the member's portion determined under subdivision (2) by the sum of
				the member's paid contributions for the benefit period.
(4) The final rollover amount is determined
				by multiplying the base rollover amount as determined in subdivision (2) by two
				(2).
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 10 - HEALTHY INDIANA PLAN › Rule 10 - POWER Accounts and Copayments › Section 10-6 - POWER account balance; termination and disenrollment

Current through July 10, 2024
Authority: IC
				  12-15-44.5-9
Affected: IC 12-15-44.5; IC 32-34-1
Sec. 6.
(a) If a
				member loses plan eligibility due to nonpayment of POWER account contributions
				as specified in section 12 of this rule, the member shall be paid only a
				portion of the balance remaining in the member's POWER account as calculated in
				subsection (b).
(b) If a member
				loses plan eligibility for reasons set forth in subsection (a), the member
				refund shall be calculated as follows:
(1)
				Divide the sum of total contributions owed by the member for enrolled months
				during the benefit period by two thousand five hundred dollars
				($2,500).
(2) Multiply the ratio
				calculated in subdivision (1) by the total amount spent from the individual's
				POWER account.
(3) Sum total
				contributions made towards the member's required monthly contributions and
				subtract the member share calculated in subdivision (2). Where the result is
				positive the member shall be due a refund. Where the result is negative the
				member may have debt as calculated under section 7 of this rule.
(4) Multiply the amount calculated in
				subdivision (3) by seventy-five hundredths (.75) to determine the amount to be
				returned to the individual.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 10 - HEALTHY INDIANA PLAN › Rule 10 - POWER Accounts and Copayments › Section 10-7 - Member debt

Current through July 10, 2024
Authority: IC 12-15-44.5-9
Affected: IC 12-15-44.5
Sec. 7.
(a) For
				purposes of this section, "debt" means amounts that accrue as a result of:
(1) a managed care organization's advance
				payment of the member's portion of the deductible as provided under
				405
				IAC 10-9-5(a)(1)  that has not been
				repaid through the member's POWER account contributions; or
(2) any nonsufficient funds check charges
				resulting from a member's payments to a managed care organization as a result
				of payment processing.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 10 - HEALTHY INDIANA PLAN › Rule 10 - POWER Accounts and Copayments › Section 10-8 - Reporting changes

Current through July 10, 2024
Authority: IC
				  12-15-44.5-9
Affected: IC 12-15-44.5
Sec. 8.
A member shall promptly report any change that may affect
				  the member's continued eligibility in the plan, including any of the following
				  qualifying events:
(1) A change in
				family status that results in an increase or decrease in the number of
				individuals in the member's household.
(2) Any change in employment status or
				household income.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 10 - HEALTHY INDIANA PLAN › Rule 10 - POWER Accounts and Copayments › Section 10-9 - POWER account contributions; billing; payment options

Current through July 10, 2024
Authority: IC
				  12-15-44.5-9
Affected: IC 12-15-44.5
Sec. 9.
A member shall, at a minimum, make the required POWER
				  account contribution within sixty (60) days from the first day of the coverage
				  month for which the POWER account contribution is owed each month to remain
				  eligible. Any excess payments a member pays in a given month shall offset the
				  following months' payments.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 10 - HEALTHY INDIANA PLAN › Rule 10 - POWER Accounts and Copayments › Section 10-10 - Third party contributions

Current through July 10, 2024
Authority: IC
				  12-15-44.5-9
Affected: IC 12-15-44.5
Sec. 10.
(a) An
				employer or other third party defined in section 4(b)(3) of this rule may
				contribute up to one hundred percent (100%) of a member's annual POWER account
				obligation. If such an entity contributes less than a member's annual POWER
				account obligation, such amount shall be applied to the member's next due POWER
				account payment. Any excess amount shall be carried over from month to month
				until it is exhausted. A member shall be responsible for paying any balance in
				a given month.
(b) Any contribution
				received from an employer or other third party defined in section 4(b)(3) of
				this rule shall be used to offset the member's required POWER account
				contribution only, and shall not be used to offset the state's contribution to
				the POWER account set forth in section 4(a) of this rule.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 10 - HEALTHY INDIANA PLAN › Rule 10 - POWER Accounts and Copayments › Section 10-11 - Billing; prior year contribution amount

Current through July 10, 2024
Authority: IC
				  12-15-44.5-9
Affected: IC 12-15-44.5
Sec. 11.
(a) If a
				member's first POWER account contribution for a new benefit period becomes due
				before the division calculates the member's new POWER account contribution, the
				managed care organization may bill the member in the amount of the POWER
				account contribution for the previous benefit period.
(b) Any overpayments or underpayments a
				member makes as a result of subsection (a) shall be reconciled within thirty
				(30) days of notification by the state of the member's recalculated POWER
				account contribution amount for the new benefit period. An overpayment or
				underpayment may impact a member's future POWER account obligations as a result
				of subsection (a).
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 10 - HEALTHY INDIANA PLAN › Rule 10 - POWER Accounts and Copayments › Section 10-12 - Nonpayment of monthly POWER account contribution; termination

Current through July 10, 2024
Authority: IC
				  12-15-44.5-9
Affected: IC 12-15-44.5
Sec. 12.
(a) A HIP
				Plus or HIP State Plan Plus member who does not make a required monthly POWER
				account contribution within the time frame established in section 9 of this
				rule shall receive a notice of nonpayment. Upon receiving a notice of
				nonpayment:
(1) except as provided in section
				13 of this rule, a member with household income above one hundred percent
				(100%) of the FPL shall:
(A) be terminated
				from participation in the plan; and
(B) not be allowed to reapply for a period of
				six (6) months from the notice of nonpayment; or
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 10 - HEALTHY INDIANA PLAN › Rule 10 - POWER Accounts and Copayments › Section 10-13 - Exceptions to nonpayment penalties and plan lockout periods

Current through July 10, 2024
Authority: IC 12-15-44.5-9
Affected: IC 10-14-3-12; IC 12-15-44.5
Sec. 13.
(a) A
				member exempt from cost sharing pursuant to section 3(d) of this rule shall not
				be subject to any of the nonpayment penalties set forth in section 12(a) of
				this rule.
(b) A medically frail
				individual with household income over one hundred percent (100%) of the FPL
				shall not be subject to disenrollment for nonpayment under section 12(a)(1) of
				this rule, but shall:
(1) remain in HIP State
				Plan Plus;
(2) be required to pay
				copayments as set forth in section 3(c) of this rule; and
(3) continue to be billed for monthly POWER
				account contributions and accrue debt to the managed care organization. Such
				member shall no longer be subject to the copayment requirement under subsection
				(b)(2) if, at the member's annual renewal, the member pays the first month
				POWER account contribution in the new benefit period.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 10 - HEALTHY INDIANA PLAN › Rule 10 - POWER Accounts and Copayments › Section 10-14 - Member identification cards

Current through July 10, 2024
Authority: IC
				  12-15-44.5-9
Affected: IC 12-15-44.5
Sec. 14.
Each member shall receive a membership identification card
				  upon enrollment in the plan.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 10 - HEALTHY INDIANA PLAN › Rule 10 - POWER Accounts and Copayments › Section 10-15 - Tobacco surcharge

Current through July 10, 2024
Authority: IC
				  12-15-44.5-9
Affected: IC 12-15-44.5
Sec. 15.
HIP Plus members who are tobacco users shall be required to
				  pay a surcharge to the member's monthly contributions. The surcharge shall be
				  waived for the first year of enrollment in order to provide the individual the
				  opportunity to take advantage of the smoking cessation programs offered through
				  the Healthy Indiana Plan. If after a year the member continues to be a tobacco
				  user, the member's monthly contributions shall increase beginning in the first
				  month of the member's renewed benefit period. The tobacco surcharge is not
				  applicable to the excluded groups listed in section 3(d) of this
				  rule.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 10 - HEALTHY INDIANA PLAN › Rule 12 - Gateway to Work › Section 12-1 - Definitions

Current through July 10, 2024
Authority: IC 12-15-44.5-9
Affected: IC 12-15-44.5; IC 20-18-2-18; IC 20-33-2; IC
				  21-7-13-6; IC 21-17-1-15
Sec. 1.
The following definitions apply throughout this rule:
(1) "Certified temporary illness or
				incapacity" means either of the following:
(A)
				An inpatient or observation hospital stay covered under the plan.
(B) An illness or injury certified by a
				provider, via a face-to-face interaction, within the first seven (7) days of
				incapacity, that leaves a member incapacitated for more than three (3)
				consecutive, full calendar days, and any subsequent treatment or period of
				incapacity relating to the same condition that also involves either:
(i) treatment by a health care provider two
				(2) or more times within thirty (30) days of the first day of incapacity,
				unless extenuating circumstances exist (i.e., the health care provider does not
				have any available appointments during that timeframe); or
(ii) treatment by a health care provider on
				at least one (1) occasion that results in a regimen of continuing treatment
				under the supervision of the healthcare provider.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 10 - HEALTHY INDIANA PLAN › Rule 12 - Gateway to Work › Section 12-2 - Eligibility

Current through July 10, 2024
Authority: IC 12-15-44.5-9
Affected: IC 12-15-44.5
Sec. 2.
(a)
				Participation in the Gateway to Work community engagement program shall be a
				condition of eligibility for all HIP members who are between the ages of
				nineteen (19) and fifty-nine (59) years of age.
(b) HIP members shall be reviewed on January
				1, 2019, to determine if the member meets a GTW exemption, based on the
				member's eligibility information, in order to be declared exempt from
				participating in GTW.
(c) HIP
				applicants shall be reviewed at the time of the application to determine if the
				applicant meets a GTW exemption, based on the applicant's eligibility
				information, in order to be declared exempt from participating in
				GTW.
(d) All HIP members without an
				exemption shall be considered Gateway to Work required. Gateway to Work
				required members shall complete and report activities in at least one (1) of
				fifteen (15) qualifying activities for twenty (20) hours per week, or eighty
				(80) hours per month, for eight (8) out of twelve (12) months in a calendar
				year, subject to the phase-in period of section 5 of this rule.
(e) If a member meets one (1) of the
				exemptions in section 3 of this rule but is not determined exempt at the time
				of enrollment, the member may claim an exemption by contacting the member's
				MCO.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 10 - HEALTHY INDIANA PLAN › Rule 12 - Gateway to Work › Section 12-3 - Exemptions to Gateway to Work requirements

Current through July 10, 2024
Authority: IC 12-15-44.5-9
Affected: IC 12-15-44.5; IC 20-33-2-6
Sec. 3.
(a) HIP
				members meeting one (1) or more of the following exemptions shall not be
				required to complete GTW community engagement related activities in order to
				maintain continued coverage during the month or months the exemption applies:
(1) Pregnant women.
(2) Students enrolled at least half-time as
				defined in section 1 of this rule.
(3) Primary caregiver of:
(A) a dependent child below the compulsory
				education age, as set forth in IC 20-33-2-6;
(B) a dependent that has been designated by
				the department of child services as children in need of services (CHINS) cases;
				or
(C) a disabled
				dependent.
(4) Members
				determined to be medically frail pursuant to 405 IAC 10-6.
(5) Those members with a certified temporary
				illness or incapacity (includes individuals on FMLA) as defined in section 1 of
				this rule.
(6) Members actively
				participating in substance use disorder treatment as defined in section 1 of
				this rule.
(7) Anyone sixty (60)
				years of age or above.
(8) Homeless
				or institutionalized members as defined in section 1 of this rule.
(9) Members who have been recently
				incarcerated, as defined in section 1 of this rule, within the previous six (6)
				months.
(10) Current Temporary
				Assistance for Needy Families (TANF) recipients or Supplemental Nutrition
				Assistance Program (SNAP) recipients.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 10 - HEALTHY INDIANA PLAN › Rule 12 - Gateway to Work › Section 12-4 - Qualifying activities

Current through July 10, 2024
Authority: IC 12-15-44.5-9
Affected: IC 12-15-44.5
Sec. 4.
(a) HIP
				members may satisfy their GTW community engagement requirements through a
				variety of activities, including:
(1)
				employment;
(2) educational
				activities as a student enrolled in less than half-time;
(3) MCO employment initiatives;
(4) job skills training;
(5) job search activities;
(6) education related to
				employment;
(7) general education
				(i.e., high school equivalency);
(8) attending English as a second language
				education program taught by a licensed or certified professional;
(9) vocational education or
				training;
(10) community work
				experience;
(11) community service
				or public service;
(12) caregiving
				services for a nondependent relative or other person with a chronic, disabling
				health condition, including individuals receiving FMLA to provide
				caregiving;
(13)
				homeschooling;
(14) volunteer work;
				or
(15) members of the Pokagon Band
				of Potawatomi who participate in the tribe's comprehensive Pathways program.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 10 - HEALTHY INDIANA PLAN › Rule 12 - Gateway to Work › Section 12-5 - Community engagement minimum requirements

Current through July 10, 2024
Authority: IC 12-15-44.5-9
Affected: IC 12-15-44.5
Sec. 5.
(a) All
				members not meeting an exemption in section 3 of this rule shall be required to
				meet the GTW community engagement hours as outlined in subsection
				(b).
(b) HIP members entering the
				program any time during the phase-in period shall be required to meet the
				minimum hours per week using the following criteria:
Gateway to Work Phase-in Period
							 Requirements
Gateway to Work Phase-in Period
Required Community Engagement Hours Per Week
January 1, 2019 - June 30, 2019
0
July 1, 2019 - September 30, 2019
5
October 1, 2019 - December 31, 2019
10
January 1, 2020 - June 30, 2020
15
July 1, 2020, and beyond
20
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 10 - HEALTHY INDIANA PLAN › Rule 12 - Gateway to Work › Section 12-6 - Compliance

Current through July 10, 2024
Authority: IC 12-15-44.5-9
Affected: IC 12-15-44.5
Sec. 6.
(a) Members
				required to participate in Gateway to Work shall be required to engage in
				qualifying activities pursuant to section 4 of this rule or provide
				documentation of an exemption pursuant to section 3 of this rule.
(b) Compliance shall be assessed annually in
				December for all members by reviewing the Gateway to Work eligibility period
				for that year.
(c) A member with
				Gateway to Work required status shall engage in any combination of the Gateway
				to Work qualifying activities to meet all weekly hour requirements for eight
				(8) of the twelve (12) months during the Gateway to Work eligibility
				period.
(d) Members shall report
				their qualifying activities and may be required to provide further verification
				to document the member's community engagement.
(e) Any member who is employed and working
				more than the minimum required hours in section 5 of this rule shall not be
				required to report their activities if the member's employment status has been
				reported to the office as required in
				405 IAC
				10-10-8.
(f) Reported activities may be subject to
				auditing to verify compliance.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 10 - HEALTHY INDIANA PLAN › Rule 12 - Gateway to Work › Section 12-7 - Noncompliance

Current through July 10, 2024
Authority: IC 12-15-44.5-9
Affected: IC 12-15-44.5
Sec. 7.
(a) Subject
				to subsection (b), coverage shall be suspended effective the first day of the
				new benefit period for HIP members who fail to meet required community
				engagement hours for eight (8) out of the twelve (12) months in the previous
				Gateway to Work eligibility period.
(b) A member shall not be suspended in
				January of the following benefit period if the member:
(1) has an exemption in place during the
				month of December; or
(2) appeals
				the suspension prior to its effective date pursuant to section 10 of this rule,
				and the appeal is still pending.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 10 - HEALTHY INDIANA PLAN › Rule 12 - Gateway to Work › Section 12-8 - Reactivation following noncompliance

Current through July 10, 2024
Authority: IC 12-15-44.5-9
Affected: IC 12-15-44.5
Sec. 8.
(a)
				Reactivation shall occur based on the following specific member eligibility
				criteria:
(1) If a member becomes eligible
				under another eligibility category in Medicaid, the member's coverage shall be
				reactivated based on established policy for that group.
(2) If a member meets an exemption, the
				member's coverage shall reactivate in the concurrent month of notification of
				exemption.
(3) If a member becomes
				pregnant, the member's coverage may be retroactive to a prior month pursuant to
				405 IAC
				10-3-4.
(4) If a member completes one (1) month of
				required community engagement hours, the member's coverage shall reactivate in
				the month following notification to the office that the member has come into
				compliance.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 10 - HEALTHY INDIANA PLAN › Rule 12 - Gateway to Work › Section 12-9 - Good cause exemptions

Current through July 10, 2024
Authority: IC 12-15-44.5-9
Affected: IC 12-15-44.5
Sec. 9.
(a) A member
				may present evidence of a good cause exemption at any point to either the
				office or the member's MCO.
(b) A
				good cause exemption may apply to a member's eligibility in section 2 of this
				rule, a member's exemption in section 3 of this rule, or a member's qualifying
				activity in section 4 of this rule.
(c) A good cause exemption may be first
				presented during the member's appeal process as set forth in section 10 of this
				rule.
(d) Recognized good cause
				exemptions include the following verified circumstances:
(1) The member has a disability as defined by
				the Americans with Disabilities Act (ADA), Section 504 of the Rehabilitation
				Act, or Section 1557 of the Patient Protection and Affordable Care Act and was
				unable to meet the requirement for reasons related to that
				disability.
(2) The member is a
				recent victim, within the previous six (6) months, of domestic
				violence.
(3) Severe inclement
				weather or other natural disaster.
(4) Other circumstances that would impose a
				severe burden on participating in community engagement activities.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 10 - HEALTHY INDIANA PLAN › Rule 12 - Gateway to Work › Section 12-10 - Appeals

Current through July 10, 2024
Authority: IC 12-15-44.5-9
Affected: IC 12-15-44.5
Sec. 10.
Appeals for the Gateway to Work community engagement program
				  shall follow the appeals process as set forth in 405 IAC 10-5.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 10 - HEALTHY INDIANA PLAN › Rule 13 - HIP Workforce Bridge Account › Section 13-1 - HIP Workforce Bridge Account program definitions

Current through July 10, 2024
Authority: IC 12-15-44.5-9
Affected: IC 12-15-30.5-3; IC 12-15-44.5; IC 25-10-1-1
Sec. 1.
The following definitions apply to this rule:
(1) "Covered service" has the meaning set
				forth in
				405 IAC 10-2-1, but
				shall exclude the following services:
(A)
				Noncovered services, which has the meaning set forth in
				405 IAC
				5-29-1.
(B) Services provided in a long term care
				facility, which has the meaning set forth in
				405 IAC 1-20-1.
(C) Hospice, which has the meaning set forth
				in
				405 IAC
				5-2-10.1.
(D) Medicaid rehabilitation option services,
				which has the meaning set forth in
				405 IAC
				5-21.5-1.
(E) Nonemergency medical transportation,
				which has the meaning set forth in IC 12-15-30.5-3.
(F) Foot orthotics.
(G) Chiropractic specialty, which means those
				services rendered within the scope of chiropractic, which has the meaning set
				forth in IC 25-10-1-1.
(H) Case
				management billed as Healthcare Common Procedure Coding System (HCPCS) code
				T1016.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 10 - HEALTHY INDIANA PLAN › Rule 13 - HIP Workforce Bridge Account › Section 13-2 - HIP Workforce Bridge Account program

Current through July 10, 2024
Authority: IC 12-15-44.5-9
Affected: IC 12-15-44.5
Sec. 2.
(a) Coverage
				under the program is not minimum essential coverage, as defined in
				26 U.S.C.
				5000A(f).
(b) Individuals participating in the program
				are not members of HIP, as defined in
				405 IAC 10-2-1. The
				provisions of
				405 IAC
				10-10-3 do not apply to participants in the
				program.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 10 - HEALTHY INDIANA PLAN › Rule 13 - HIP Workforce Bridge Account › Section 13-3 - HIP Workforce Bridge Account program eligibility and participation

Current through July 10, 2024
Authority: IC 12-15-44.5-9
Affected: IC 12-15-44.5
Sec. 3.
(a) To be
				eligible for the program:
(1) an individual
				must have become ineligible for HIP coverage solely due to an increase in
				verified income under
				405 IAC
				10-4-10(a)(8);
(2) an individual or the individual's next of
				kin or authorized representative must notify the office of their election to
				participate in the program within thirty (30) days of the determination by the
				office of the individual's HIP ineligibility; and
(3) the office must not have ceased to enroll
				new individuals in the program, under the program limitations specified in
				section 7 of this rule.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 10 - HEALTHY INDIANA PLAN › Rule 13 - HIP Workforce Bridge Account › Section 13-4 - HIP Workforce Bridge Account benefits

Current through July 10, 2024
Authority: IC 12-15-44.5-9
Affected: IC 12-15-5; IC 12-15-44.5
Sec. 4.
(a) The
				program shall provide up to one thousand dollars ($1,000) in funds to pay for
				eligible health care expenses incurred by a participant during the twelve (12)
				month eligibility period, as specified in section 3(c) of this rule.
(b) Covered services paid by the program must
				be expenses covered in the Indiana Medicaid State Plan, as defined in
				405 IAC
				5-2-6.
(c)
				Program funds may be used only for the following health care expenses:
(1) A premium for a health insurance plan
				that covers the participant.
(2)
				The following costs for covered services incurred by the participant with a
				provider, as defined in
				405 IAC 10-2-1:
(A) Health insurance deductible
				costs.
(B) Copayments.
(C) Co-insurance.
(3) Direct payment to a provider, as defined
				in
				405 IAC 10-2-1, if
				the participant is not covered by a plan specified in subdivision
				(1).
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 10 - HEALTHY INDIANA PLAN › Rule 13 - HIP Workforce Bridge Account › Section 13-5 - HIP Workforce Bridge Account payment and reimbursement procedure

Current through July 10, 2024
Authority: IC 12-15-44.5-9
Affected: IC 12-15-2-20; IC 12-15-2.5-2; IC 12-15-44.5
Sec. 5.
(a) To
				receive reimbursement for a private or employer-based health insurance plan
				premium, the participant shall, within ninety (90) days of the date the premium
				was incurred by the participant:
(1) complete
				the applicable form prescribed by the office providing the name of the
				participant, the amount of the premium, the date the premium was incurred, and
				the amount claimed;
(2) include
				with the form documentation to support the cost of the premium incurred by the
				participant; and
(3) submit the
				form and supporting documentation to the office via email or U.S.
				mail.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 10 - HEALTHY INDIANA PLAN › Rule 13 - HIP Workforce Bridge Account › Section 13-6 - HIP Workforce Bridge Account termination or withdrawal

Current through July 10, 2024
Authority: IC 12-15-44.5-9
Affected: IC 12-15-2-20; IC 12-15-2.5-2; IC 12-15-44.5
Sec. 6.
(a) A
				participant shall become ineligible to participate in the program under the
				following circumstances:
(1) Circumstances
				listed in
				405 IAC 10-4-10(a)(1)
				 through
				405 IAC
				10-4-10(a)(7).
(2) If the participant becomes an inmate of a
				public institution and is no longer eligible for Medicaid under section
				1905(a)(30)(A) of the Social Security Act.
(3) If the participant is eligible for
				Medicaid, HIP, or HIP Maternity, or becomes presumptively eligible under 405
				IAC 10-411.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 10 - HEALTHY INDIANA PLAN › Rule 13 - HIP Workforce Bridge Account › Section 13-7 - HIP Workforce Bridge Account limitations

Current through July 10, 2024
Authority: IC 12-15-44.5-9
Affected: IC 12-15-44.5
Sec. 7.
(a) If:
(1) the office determines there are
				insufficient funds available to award new accounts;
(2) the office has awarded the maximum number
				of accounts allowed for the program as part of the U.S. Department of Health
				and Human Services approved Section 1115 demonstration waiver; or
(3) federal approval of the program is
				withdrawn or otherwise ceases; the office shall not enroll any new individuals
				in the program and there shall be no new participants. Existing program
				accounts shall remain active until the termination date described in section
				3(c) of this rule.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 10 - HEALTHY INDIANA PLAN › Rule 13 - HIP Workforce Bridge Account › Section 13-8 - HIP Workforce Bridge Account participant appeals

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-44.5-9
Affected: IC 12-15-28
Sec. 8.
Appeals regarding the program shall be governed by the
				  procedures and time limits set out in 405 IAC 1.1.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 11 - CHILDREN'S HEALTH INSURANCE PROGRAM GENERAL PROVISIONS; PROVIDERS › Rule 1 - Definitions › Section 1-1 - Use of Medicaid definitions

Current through July 10, 2024
Authority: IC 12-17.6-2-11
Affected: IC 12-17.6
Sec. 1.
Unless otherwise specifically defined in this title,
				  definitions for terminology used are the same as those used in the Medicaid
				  program and defined in 405 IAC 5-2.
Transferred from the Office of the Children's Health
					 Insurance Program (
					 407 IAC
					 1-1-1 ) to the Office of the Secretary of Family and
					 Social Services ( 405 IAC 11-1-1 ) by P.L. 35-2016, SECTION 53, effective March
					 21, 2016.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 11 - CHILDREN'S HEALTH INSURANCE PROGRAM GENERAL PROVISIONS; PROVIDERS › Rule 1 - Definitions › Section 1-2 - Applicability

Current through July 10, 2024
Authority: IC 12-17.6-2-11
Affected: IC 12-17.6
Sec. 2.
The definitions in this rule apply throughout this title
				  unless the context clearly indicates another meaning.
Transferred from the Office of the Children's Health
					 Insurance Program (
					 407 IAC 1-1-2 ) to
					 the Office of the Secretary of Family and Social Services ( 405 IAC 11-1-2 ) by
					 P.L. 35-2016, SECTION 53, effective March 21,
					 2016.