CHAPTER 44.2. INDIANA CHECK-UP PLAN
IC 12-15-44.2
Chapter 44.2. Indiana Check-Up Plan
IC 12-15-44.2-1
"Plan"
Sec. 1. As used in this chapter, "plan" refers to the Indiana
check-up plan established by section 3 of this chapter.
As added by P.L.3-2008, SEC.98.
IC 12-15-44.2-2
"Preventative care services"
Sec. 2. As used in this chapter, "preventative care services" means
care that is provided to an individual to prevent disease, diagnose
disease, or promote good health.
As added by P.L.3-2008, SEC.98.
IC 12-15-44.2-3
Plan established; administration; referral of high risk individuals;
inapplicability of laws
Sec. 3. (a) The Indiana check-up plan is established.
(b) The office shall administer the plan.
(c) The department of insurance and the office of the secretary
shall provide oversight of the marketing practices of the plan.
(d) The office shall promote the plan and provide information to
potential eligible individuals who live in medically underserved rural
areas of Indiana.
(e) The office shall, to the extent possible, ensure that enrollment
in the plan is distributed throughout Indiana in proportion to the
number of individuals throughout Indiana who are eligible for
participation in the plan.
(f) The office shall establish standards for consumer protection,
including the following:
(1) Quality of care standards.
(2) A uniform process for participant grievances and appeals.
(3) Standardized reporting concerning provider performance,
consumer experience, and cost.
(g) A health care provider that provides care to an individual who
receives health insurance coverage under the plan shall participate in
the Medicaid program under IC 12-15.
(h) The office of the secretary may refer an individual who:
(1) has applied for health insurance coverage under the plan;
and
(2) is at high risk of chronic disease;
to the Indiana comprehensive health insurance association for
administration of the individual's plan benefits under IC 27-8-10.1.
(i) The following do not apply to the plan:
(1) IC 12-15-6.
(2) IC 12-15-12.
(3) IC 12-15-13.
(4) IC 12-15-14.
(5) IC 12-15-15.
(6) IC 12-15-21.
(7) IC 12-15-26.
(8) IC 12-15-31.1.
(9) IC 12-15-34.
(10) IC 12-15-35.
(11) IC 12-15-35.5.
(12) IC 16-42-22-10.
As added by P.L.3-2008, SEC.98.
IC 12-15-44.2-4
Services included in plan
Sec. 4. (a) The plan must include the following in a manner and
to the extent determined by the office:
(1) Mental health care services.
(2) Inpatient hospital services.
(3) Prescription drug coverage.
(4) Emergency room services.
(5) Physician office services.
(6) Diagnostic services.
(7) Outpatient services, including therapy services.
(8) Comprehensive disease management.
(9) Home health services, including case management.
(10) Urgent care center services.
(11) Preventative care services.
(12) Family planning services:
(A) including contraceptives and sexually transmitted
disease testing, as described in federal Medicaid law (42
U.S.C. 1396 et seq.); and
(B) not including abortion or abortifacients.
(13) Hospice services.
(14) Substance abuse services.
(b) The plan must do the following:
(1) Offer coverage for dental and vision services to an
individual who participates in the plan.
(2) Pay at least fifty percent (50%) of the premium cost of
dental and vision services coverage described in subdivision
(1).
(c) An individual who receives the dental or vision coverage
offered under subsection (b) shall pay an amount determined by the
office for the coverage. The office shall limit the payment to not
more than five percent (5%) of the individual's annual household
income. The payment required under this subsection is in addition to
the payment required under section 11(b)(2) of this chapter for
coverage under the plan.
(d) Vision services offered by the plan must include services
provided by an optometrist.
(e) The plan must comply with any coverage requirements that
apply to an accident and sickness insurance policy issued in Indiana.
(f) The plan may not permit treatment limitations or financial
requirements on the coverage of mental health care services or
substance abuse services if similar limitations or requirements are
not imposed on the coverage of services for other medical or surgical
conditions.
As added by P.L.3-2008, SEC.98.
IC 12-15-44.2-5
Preventative care
Sec. 5. (a) The office shall provide to an individual who
participates in the plan a list of health care services that qualify as
preventative care services for the age, gender, and preexisting
conditions of the individual. The office shall consult with the federal
Centers for Disease Control and Prevention for a list of
recommended preventative care services.
(b) The plan shall, at no cost to the individual, provide payment
for not more than five hundred dollars ($500) of qualifying
preventative care services per year for an individual who participates
in the plan. Any additional preventative care services covered under
the plan and received by the individual during the year are subject to
the deductible and payment requirements of the plan.
As added by P.L.3-2008, SEC.98.
IC 12-15-44.2-6
Coverage limitations
Sec. 6. The plan has the following per participant coverage
limitations:
(1) An annual individual maximum coverage limitation of three
hundred thousand dollars ($300,000).
(2) A lifetime individual maximum coverage limitation of one
million dollars ($1,000,000).
As added by P.L.3-2008, SEC.98.
IC 12-15-44.2-7
Use of appropriated funds
Sec. 7. The following requirements apply to funds appropriated
by the general assembly to the plan:
(1) At least eighty-five percent (85%) of the funds must be used
to fund payment for health care services.
(2) An amount determined by the office of the secretary to fund:
(A) administrative costs of; and
(B) any profit made by;
an insurer or a health maintenance organization under a contract
with the office to provide health insurance coverage under the
plan. The amount determined under this subdivision may not
exceed fifteen percent (15%) of the funds.
As added by P.L.3-2008, SEC.98.
IC 12-15-44.2-8
Not an entitlement; maximum enrollment
Sec. 8. The plan is not an entitlement program. The maximum
enrollment of individuals who may participate in the plan is
dependent on funding appropriated for the plan.
As added by P.L.3-2008, SEC.98.
IC 12-15-44.2-9
Eligibility requirements
Sec. 9. (a) An individual is eligible for participation in the plan if
the individual meets the following requirements:
(1) The individual is at least eighteen (18) years of age and less
than sixty-five (65) years of age.
(2) The individual is a United States citizen and has been a
resident of Indiana for at least twelve (12) months.
(3) The individual has an annual household income of not more
than two hundred percent (200%) of the federal income poverty
level.
(4) The individual is not eligible for health insurance coverage
through the individual's employer.
(5) The individual has not had health insurance coverage for at
least six (6) months.
(b) The following individuals are not eligible for the plan:
(1) An individual who participates in the federal Medicare
program (42 U.S.C. 1395 et seq.).
(2) A pregnant woman for purposes of pregnancy related
services.
(3) An individual who is eligible for the Medicaid program as
a disabled person.
(c) The eligibility requirements specified in subsection (a) are
subject to approval for federal financial participation by the United
States Department of Health and Human Services.
As added by P.L.3-2008, SEC.98.
IC 12-15-44.2-10
Health care account; funding
Sec. 10. (a) An individual who participates in the plan must have
a health care account to which payments may be made for the
individual's participation in the plan only by the following:
(1) The individual.
(2) An employer.
(3) The state.
(b) The minimum funding amount for a health care account is the
amount required under section 11 of this chapter.
(c) An individual's health care account must be used to pay the
individual's deductible for health care services under the plan.
(d) An individual may make payments to the individual's health
care account as follows:
(1) An employer withholding or causing to be withheld from an
employee's wages or salary, after taxes are deducted from the
wages or salary, the individual's contribution under this chapter
and distributed equally throughout the calendar year.
(2) Submission of the individual's contribution under this
chapter to the office to deposit in the individual's health care
account in a manner prescribed by the office.
(3) Another method determined by the office.
(e) An employer may make, from funds not payable by the
employer to the employee, not more than fifty percent (50%) of an
individual's required payment to the individual's health care account.
As added by P.L.3-2008, SEC.98.
IC 12-15-44.2-11
Participation requirements; contributions to health care account;
nonpayment
Sec. 11. (a) An individual's participation in the plan does not
begin until an initial payment is made for the individual's
participation in the plan. A required payment to the plan for the
individual's participation may not exceed one-twelfth (1/12) of the
annual payment required under subsection (b).
(b) To participate in the plan, an individual shall do the following:
(1) Apply for the plan on a form prescribed by the office. The
office may develop and allow a joint application for a
household.
(2) If the individual is approved by the office to participate in
the plan, contribute to the individual's health care account the
lesser of the following:
(A) One thousand one hundred dollars ($1,100) per year,
less any amounts paid by the individual under the:
(i) Medicaid program under IC 12-15;
(ii) children's health insurance program under IC 12-17.6;
and
(iii) Medicare program (42 U.S.C. 1395 et seq.);
as determined by the office.
(B) Not more than the following applicable percentage of the
individual's annual household income per year, less any
amounts paid by the individual under the Medicaid program
under IC 12-15, the children's health insurance program
under IC 12-17.6, and the Medicare program (42 U.S.C.
1395 et seq.) as determined by the office:
(i) Two percent (2%) of the individual's annual household
income per year if the individual has an annual household
income of not more than one hundred percent (100%) of
the federal income poverty level.
(ii) Three percent (3%) of the individual's annual
household income per year if the individual has an annual
household income of more than one hundred percent
(100%) and not more than one hundred twenty-five
percent (125%) of the federal income poverty level.
(iii) Four percent (4%) of the individual's annual
household income per year if the individual has an annual
household income of more than one hundred twenty-five
percent (125%) and not more than one hundred fifty
percent (150%) of the federal income poverty level.
(iv) Five percent (5%) of the individual's annual household
income per year if the individual has an annual household
income of more than one hundred fifty percent (150%) and
not more than two hundred percent (200%) of the federal
income poverty level.
(c) The state shall contribute the difference to the individual's
account if the individual's payment required under subsection (b)(2)
is less than one thousand one hundred dollars ($1,100).
(d) If an individual's required payment to the plan is not made
within sixty (60) days after the required payment date, the individual
may be terminated from participation in the plan. The individual
must receive written notice before the individual is terminated from
the plan.
(e) After termination from the plan under subsection (d), the
individual may not reapply to participate in the plan for twelve (12)
months.
As added by P.L.3-2008, SEC.98.
IC 12-15-44.2-12
Plan period; renewal; termination; refund of payments to health
care account
Sec. 12. (a) An individual who is approved to participate in the
plan is eligible for a twelve (12) month plan period. An individual
who participates in the plan may not be refused renewal of
participation in the plan for the sole reason that the plan has reached
the plan's maximum enrollment.
(b) If the individual chooses to renew participation in the plan, the
individual shall complete a renewal application and any necessary
documentation, and submit to the office the documentation and
application on a form prescribed by the office.
(c) If the individual chooses not to renew participation in the plan,
the individual may not reapply to participate in the plan for at least
twelve (12) months.
(d) Any funds remaining in the health care account of an
individual who renews participation in the plan at the end of the
individual's twelve (12) month plan period must be used to reduce
the individual's payments for the subsequent plan period. However,
if the individual did not, during the plan period, receive all qualified
preventative services recommended as provided in section 5 of this
chapter, the state's contribution to the health care account may not be
used to reduce the individual's payments for the subsequent plan
period.
(e) If an individual is no longer eligible for the plan, does not
renew participation in the plan at the end of the plan period, or is
terminated from the plan for nonpayment of a required payment, the
office shall, not more than sixty (60) days after the last date of
participation in the plan, refund to the individual the amount
determined under subsection (f) of any funds remaining in the
individual's health care account as follows:
(1) An individual who is no longer eligible for the plan or does
not renew participation in the plan at the end of the plan period
shall receive the amount determined under STEP FOUR of
subsection (f).
(2) An individual who is terminated from the plan due to
nonpayment of a required payment shall receive the amount
determined under STEP FIVE of subsection (f).
(f) The office shall determine the amount payable to an individual
described in subsection (e) as follows:
STEP ONE: Determine the total amount paid into the
individual's health care account under section 10(d) of this
chapter.
STEP TWO: Determine the total amount paid into the
individual's health care account from all sources.
STEP THREE: Divide STEP ONE by STEP TWO.
STEP FOUR: Multiply the ratio determined in STEP THREE
by the total amount remaining in the individual's health care
account.
STEP FIVE: Multiply the amount determined under STEP
FOUR by seventy-five hundredths (0.75).
As added by P.L.3-2008, SEC.98.
IC 12-15-44.2-13
Payment for nonemergency services in emergency room
Sec. 13. Subject to appeal to the office, an individual may be held
responsible under the plan for receiving nonemergency services in an
emergency room setting, including prohibiting the individual from
using funds in the individual's health care account to pay for the
nonemergency services. However, an individual may not be
prohibited from using funds in the individual's health care account to
pay for nonemergency services provided in an emergency room
setting for a medical condition that arises suddenly and unexpectedly
and manifests itself by acute symptoms of such severity, including
severe pain, that the absence of immediate medical attention could
reasonably be expected by a prudent layperson who possesses an
average knowledge of health and medicine to:
(1) place an individual's health in serious jeopardy;
(2) result in serious impairment to the individual's bodily
functions; or
(3) result in serious dysfunction of a bodily organ or part of the
individual.
As added by P.L.3-2008, SEC.98.
IC 12-15-44.2-14
Claim processing; provider reimbursement; cultural competency
Sec. 14. (a) An insurer or health maintenance organization that
contracts with the office to provide health insurance coverage, dental
coverage, or vision coverage to an individual that participates in the
plan:
(1) is responsible for the claim processing for the coverage;
(2) shall reimburse providers at a reimbursement rate of:
(A) not less than the federal Medicare reimbursement rate
for the service provided; or
(B) at a rate of one hundred thirty percent (130%) of the
Medicaid reimbursement rate for a service that does not have
a Medicare reimbursement rate; and
(3) may not deny coverage to an eligible individual who has
been approved by the office to participate in the plan, unless the
individual has met the coverage limitations described in section
6 of this chapter.
(b) An insurer or a health maintenance organization that contracts
with the office to provide health insurance coverage under the plan
must incorporate cultural competency standards established by the
office. The standards must include standards for nonEnglish
speaking, minority, and disabled populations.
As added by P.L.3-2008, SEC.98.
IC 12-15-44.2-15
Offer of coverage to eligible individuals when maximum
enrollment reached
Sec. 15. (a) An insurer or a health maintenance organization that
contracts with the office to provide health insurance coverage under
the plan or an affiliate of an insurer or a health maintenance
organization that contracts with the office to provide health insurance
coverage under the plan shall offer to provide the same health
insurance coverage to an individual who:
(1) has not had health insurance coverage during the previous
six (6) months; and
(2) meets the eligibility requirements specified in section 9 of
this chapter for participation in the plan but is not enrolled
because the plan has reached maximum enrollment.
(b) The insurance underwriting and rating practices applied to
health insurance coverage offered under subsection (a) must not be
different from underwriting and rating practices used for the health
insurance coverage provided under the plan.
(c) The state does not provide funding for health insurance
coverage received under this section.
As added by P.L.3-2008, SEC.98.
IC 12-15-44.2-16
Offer of coverage to ineligible individuals
Sec. 16. (a) An insurer or a health maintenance organization that
contracts with the office to provide health insurance coverage under
the plan or an affiliate of an insurer or a health maintenance
organization that contracts with the office to provide health insurance
coverage under the plan shall offer to provide the same health
insurance coverage to an individual who:
(1) has not had health insurance coverage during the previous
six (6) months; and
(2) does not meet the eligibility requirements specified in
section 9 of this chapter for participation in the plan.
(b) An insurer, a health maintenance organization, or an affiliate
described in subsection (a) may apply to health insurance coverage
offered under subsection (a) the insurer's, health maintenance
organization's, or affiliate's standard individual or small group
insurance underwriting and rating practices.
(c) The state does not provide funding for health insurance
coverage received under this section.
As added by P.L.3-2008, SEC.98.
IC 12-15-44.2-17
Indiana check-up fund
Sec. 17. (a) The Indiana check-up plan trust fund is established for
the following purposes:
(1) Administering a plan created by the general assembly to
provide health insurance coverage for low income residents of
Indiana under this chapter.
(2) Providing copayments, preventative care services, and
premiums for individuals enrolled in the plan.
(3) Funding tobacco use prevention and cessation programs,
childhood immunization programs, and other health care
initiatives designed to promote the general health and well
being of Indiana residents.
The fund is separate from the state general fund.
(b) The fund shall be administered by the office of the secretary
of family and social services.
(c) The expenses of administering the fund shall be paid from
money in the fund.
(d) The fund shall consist of the following:
(1) Cigarette tax revenues designated by the general assembly
to be part of the fund.
(2) Other funds designated by the general assembly to be part
of the fund.
(3) Federal funds available for the purposes of the fund.
(4) Gifts or donations to the fund.
(e) The treasurer of state shall invest the money in the fund not
currently needed to meet the obligations of the fund in the same
manner as other public money may be invested.
(f) Money must be appropriated before funds are available for use.
(g) Money in the fund does not revert to the state general fund at
the end of any fiscal year.
(h) The fund is considered a trust fund for purposes of
IC 4-9.1-1-7. Money may not be transferred, assigned, or otherwise
removed from the fund by the state board of finance, the budget
agency, or any other state agency.
As added by P.L.3-2008, SEC.98.
IC 12-15-44.2-18
Requirements for implementation
Sec. 18. (a) The office may not:
(1) enroll applicants;
(2) approve any contracts with vendors to provide services or
administer the plan;
(3) incur costs other than costs necessary to study and plan for
the implementation of the plan; or
(4) create financial obligations for the state;
unless both of the conditions of subsection (b) are satisfied.
(b) The office may not take any action described in subsection (a)
unless:
(1) there is a specific appropriation from the general assembly
to implement the plan; and
(2) after review by the budget committee, the budget agency
approves an actuarial analysis that reflects a determination that
sufficient funding is reasonably estimated to be available to
operate the plan for at least the following five (5) years.
The actuarial analysis approved under subdivision (2) must clearly
indicate the cost and revenue assumptions used in reaching the
determination.
(c) The office may not operate the plan in a manner that would
obligate the state to financial participation beyond the level of state
appropriations authorized for the plan.
As added by P.L.3-2008, SEC.98.
IC 12-15-44.2-19
Rules
Sec. 19. (a) The office may adopt rules under IC 4-22-2 necessary
to implement this chapter.
(b) The office may adopt emergency rules under IC 4-22-2-37.1
to implement the plan on an emergency basis.
As added by P.L.3-2008, SEC.98. Amended by P.L.1-2010, SEC.59.
IC 12-15-44.2-20
Premium assistance program
Sec. 20. (a) The office may establish a health insurance coverage
premium assistance program for individuals who:
(1) have an annual household income of not more than two
hundred percent (200%) of the federal income poverty level;
and
(2) are eligible for health insurance coverage through an
employer but cannot afford the health insurance coverage
premiums.
(b) A program established under this section must:
(1) contain eligibility requirements that are similar to the
eligibility requirements of the plan;
(2) include a health care account as a component; and
(3) provide that an individual's payment:
(A) to a health care account; or
(B) for a health insurance coverage premium;
may not exceed five percent (5%) of the individual's annual
income.
As added by P.L.3-2008, SEC.98.
IC 12-15-44.2-21
Federal approval; severability
Sec. 21. A denial of federal approval and federal financial
participation that applies to any part of this chapter does not prohibit
the office from implementing any other part of this chapter that:
(1) is federally approved for federal financial participation; or
(2) does not require federal approval or federal financial
participation.
As added by P.L.3-2008, SEC.98.