CHIP Legislation
Chapter One- Definition
IC 12-17.6
ARTICLE 17.6. CHILDREN'S HEALTH INSURANCE PROGRAM
IC 12-17.6-1
Chapter 1. Definitions
IC 12-17.6-1-1
Sec. 1. The definitions in this chapter apply throughout this article.
As added by P.L.273-1999, SEC.177.
IC 12-17.6-1-2
Sec. 2. "Crowd out" means the extent to which:
(1) families substitute coverage offered under the program for employer sponsored health insurance coverage for children; or
(2) employers:
(A) reduce or eliminate health insurance benefits for children under an employer based health insurance plan; or
(B) increase the employee's share of the cost of benefits for children under an employer based health insurance plan relative to the total cost of the plan;
as a result of the program.
As added by P.L.273-1999, SEC.177.
IC 12-17.6-1-2.6
Sec. 2.6. "Emergency" means 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 lay person 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.95-2000, SEC.2.
IC 12-17.6-1-3
Sec. 3. "Fund" refers to the children's health insurance program fund established by IC 12-17.6-7-1.
As added by P.L.273-1999, SEC.177.
IC 12-17.6-1-4
YAMD.1999
Sec. 4. "Office" refers to the office of the children's health insurance program established by IC 12-17.6-2-1.
As added by P.L.273-1999, SEC.177.
IC 12-17.6-1-5
Sec. 5. "Program" refers to the children's health insurance program
established by IC 12-17.6-2.
As added by P.L.273-1999, SEC.177.
IC 12-17.6-1-6
Sec. 6. "Provider" has the meaning set forth in IC 12-7-2-149(2).
As added by P.L.273-1999, SEC.177.
Chapter 2- Program Administration
IC 12-17.6-2
Chapter 2. Program Administration
IC 12-17.6-2-1
Sec. 1. The office of the children's health insurance program is established within the office of the secretary.
As added by P.L.273-1999, SEC.177.
IC 12-17.6-2-2
Sec. 2. The office shall design and administer a system to provide health benefits coverage for children eligible for the program.
As added by P.L.273-1999, SEC.177.
IC 12-17.6-2-3
Sec. 3. To the greatest extent possible, the office shall use the same:
(1) eligibility determination;
(2) enrollment;
(3) provider networks; and
(4) claims payment systems;
as are used by the Medicaid managed care program for children.
As added by P.L.273-1999, SEC.177.
IC 12-17.6-2-4
Sec. 4. The office shall evaluate the feasibility of the following:
(1) Establishing a program to subsidize employer sponsored coverage under the program.
(2) Expanding health insurance coverage under the program to other populations as provided under section 2105(c)(3) of the federal Social Security Act.
As added by P.L.273-1999, SEC.177.
IC 12-17.6-2-5
Sec. 5. Reviews of the program shall:
(1) be conducted in compliance with federal requirements; and
(2) include an analysis of the extent to which crowd out is occurring.
As added by P.L.273-1999, SEC.177.
IC 12-17.6-2-6
Sec. 6. The office shall do the following:
(1) Establish performance criteria and evaluation measures.
(2) Monitor program performance.
(3) Adopt a formula that:
(A) specifies the premiums, if any, to be paid by the parent or guardian of a child enrolled in the program; and
(B) is based on the child's family income.
As added by P.L.273-1999, SEC.177.
IC 12-17.6-2-7
Sec. 7. (a) The office shall contract with an independent organization to evaluate the program.
(b) The office shall report the results of each evaluation to the:
(1) children's health policy board established by IC 4-23-27-2; and
(2) select joint committee on Medicaid oversight established by P.L.130-1998.
(c) This section does not modify the requirements of other statutes relating to the confidentiality of medical records.
As added by P.L.273-1999, SEC.177.
IC 12-17.6-2-8
Sec. 8. The office may, in administering the program, contract with community entities, including private entities, for the following:
(1) Outreach for and enrollment in the managed care program.
(2) Provision of services.
(3) Consumer education and public health education.
As added by P.L.273-1999, SEC.177.
IC 12-17.6-2-9
Sec. 9. (a) The office shall incorporate creative methods, reflective of community level objectives and input, to do the following:
(1) Encourage beneficial and appropriate use of health care services.
(2) Pursue efforts to enhance provider availability.
(b) In determining the best approach for each area, the office shall do the following:
(1) Evaluate distinct market areas.
(2) Weigh the advantages and disadvantages of alternative delivery models, including the following:
(A) Risk based managed care only.
(B) Primary care gatekeeper model only.
(C) A combination of clauses (A) and (B).
As added by P.L.273-1999, SEC.177.
IC 12-17.6-2-10
Sec. 10. (a) The office may establish a program to subsidize employer sponsored coverage for:
(1) eligible individuals; and
(2) the families of eligible individuals;
consistent with federal law.
(b) If the office establishes a program under subsection (a), the employer sponsored benefit package must comply with federal law.
As added by P.L.273-1999, SEC.177.
IC 12-17.6-2-11
Sec. 11. (a) The office shall adopt rules under IC 4-22-2 to implement the program.
(b) The office may adopt emergency rules under IC 4-22-2-37.1 to implement the program on an emergency basis.
As added by P.L.273-1999, SEC.177.
IC 12-17.6-2-12
Sec. 12. Not later than April 1, the office shall provide a report describing the program's activities during the preceding calendar year to the:
(1) budget committee;
(2) legislative council;
(3) children's health policy board established by IC 4-23-27-2; and
(4) select joint committee on Medicaid oversight established by P.L.130-1998.
As added by P.L.273-1999, SEC.177.
Chapter 3- Eligibility, Outreach, and Enrollment
IC 12-17.6-3
Chapter 3. Eligibility, Outreach, and Enrollment
IC 12-17.6-3-1
Sec. 1. This chapter does not apply until January 1, 2000.
As added by P.L.273-1999, SEC.177.
IC 12-17.6-3-2
Sec. 2. (a) To be eligible to enroll in the program, a child must meet the following requirements:
(1) The child is less than nineteen (19) years of age.
(2) The child is a member of a family with an annual income of:
(A) more than one hundred fifty percent (150%); and
(B) not more than two hundred percent (200%);
of the federal income poverty level.
(3) The child is a resident of Indiana.
(4) The child meets all eligibility requirements under Title XXI of the federal Social Security Act.
(5) The child's family agrees to pay any cost sharing amounts required by the office.
(b) The office may adjust eligibility requirements based on available program resources under rules adopted under IC 4-22-2.
As added by P.L.273-1999, SEC.177.
IC 12-17.6-3-3
Sec. 3. (a) Subject to subsection (b), a child who is eligible for the program shall receive services from the program until the earlier of the following:
(1) The end of a period of twelve (12) consecutive months following the determination of the child's eligibility for the program.
(2) The child becomes nineteen (19) years of age.
(b) Subsection (a) applies only if the child and the child's family comply with enrollment requirements.
As added by P.L.273-1999, SEC.177.
IC 12-17.6-3-4
Sec. 4. The office shall implement outreach strategies that build on community resources.
As added by P.L.273-1999, SEC.177.
IC 12-17.6-3-5
Sec. 5. A child may apply at an enrollment center as provided in IC 12-15-4-1 to receive health care services from the program if the child meets the eligibility requirements of section 2 of this chapter.
As added by P.L.273-1999, SEC.177.
Chapter 4- Benefits, Crowd Out and Cost Sharing
IC 12-17.6-4
Chapter 4. Benefits, Crowd Out, and Cost Sharing
IC 12-17.6-4-1
Sec. 1. This chapter does not apply until January 1, 2000.
As added by P.L.273-1999, SEC.177.
IC 12-17.6-4-2
Sec. 2. (a) The benefit package provided under the program shall focus on age appropriate preventive, primary, and acute care services.
(b) The office shall offer health insurance coverage for the following basic services:
(1) Inpatient and outpatient hospital services.
(2) Physicians' services provided by a physician (as defined in 42 U.S.C. 1395x(r)).
(3) Laboratory and x-ray services.
(4) Well-baby and well-child care, including:
(A) age appropriate immunizations; and
(B) periodic screening, diagnosis, and treatment services according to a schedule developed by the office.
The office may offer services in addition to those listed in this subsection if appropriations to the program exist to pay for the additional services.
(c) The office shall offer health insurance coverage for the following additional services if the coverage for the services has an actuarial value equal to or greater than the actuarial value of the services provided by the benchmark program determined by the children's health policy board established by IC 4-23-27-2:
(1) Prescription drugs.
(2) Mental health services.
(3) Vision services.
(4) Hearing services.
(5) Dental services.
(d) Notwithstanding subsections (b) and (c), the office may not impose treatment limitations or financial requirements on the coverage of services for a mental illness if similar treatment limitations or financial requirements are not imposed on coverage for services for other illnesses.
As added by P.L.273-1999, SEC.177.
IC 12-17.6-4-3
Sec. 3. Premium and cost sharing amounts established by the office are limited by the following:
(1) Deductibles, coinsurance, or other cost sharing is not permitted with respect to benefits for:
(A) well-baby and well-child care, including age appropriate immunizations; and
(B) services provided for treatment of an emergency in an emergency department of a hospital licensed under IC 16-21.
(2) Premiums and other cost sharing may be imposed based on family income. However, the total annual aggregate cost sharing
with respect to all children in a family under this article may not exceed five percent (5%) of the family's income for the year.
As added by P.L.273-1999, SEC.177. Amended by P.L.95-2000, SEC.3.
IC 12-17.6-4-4
Sec. 4. The office may do the following:
(1) Determine cost sharing amounts.
(2) Determine waiting periods that may not exceed three (3) months and exceptions to the requirement of waiting periods for potential enrollees in the program.
(3) Adopt additional methods for complying with federal requirements relating to crowd out.
As added by P.L.273-1999, SEC.177.
IC 12-17.6-4-5
Sec. 5. (a) It is a violation of IC 27-4-1-4 if an insurer, or an insurance agent or insurance broker compensated by the insurer, knowingly or intentionally refers an insured or the dependent of an insured to the program for health insurance coverage when the insured already receives health insurance coverage through an employer's health care plan that is underwritten by the insurer.
(b) The office shall coordinate with the children's health policy board under IC 4-23-27 to evaluate the need for mechanisms that minimize the incentive for an employer to eliminate or reduce health care coverage for an employee's dependents.
As added by P.L.273-1999, SEC.177.
IC 12-17.6-4-6
Sec. 6. Community health centers shall be used to provide health care services.
As added by P.L.273-1999, SEC.177.
Chapter 5- Provider Contracts
IC 12-17.6-5
Chapter 5. Provider Contracts
IC 12-17.6-5-1
Sec. 1. This chapter does not apply until January 1, 2000.
As added by P.L.273-1999, SEC.177.
IC 12-17.6-5-2
Sec. 2. A provider agreement must include information that the office finds necessary to facilitate carrying out this article.
As added by P.L.273-1999, SEC.177.
IC 12-17.6-5-3
Sec. 3. A provider who participates in the program, including a provider who is a member of a managed care organization, must comply with the enrollment requirements that are established under IC 12-15.
As added by P.L.273-1999, SEC.177.
IC 12-17.6-5-4
Sec. 4. (a) A provider that participates in the Medicaid program is considered a provider for both the Medicaid program and the program under this article.
(b) If an enrollee in the Medicaid managed care program for children has direct access to a provider who has entered into a provider agreement under IC 12-15-11, an enrollee in the program has direct access to the same provider.
As added by P.L.273-1999, SEC.177.
Chapter 6- Provider Sanctions, Theft, Kickbacks and Bribes
IC 12-17.6-6
Chapter 6. Provider Sanctions, Theft, Kickbacks, and Bribes
IC 12-17.6-6-1
Sec. 1. This chapter does not apply until January 1, 2000.
As added by P.L.273-1999, SEC.177.
IC 12-17.6-6-2
Sec. 2. If after investigation the office finds that a provider has violated this article or rule adopted under this article, the office may impose at least one (1) of the following sanctions:
(1) Deny payment to the provider for program services provided during a specified time.
(2) Reject a prospective provider's application for participation in the program.
(3) Terminate a provider agreement allowing a provider's participation in the program.
(4) Assess a civil penalty against the provider in an amount not to exceed three (3) times the amount paid to the provider that exceeds the amount that was legally due.
(5) Assess an interest charge, at a rate not to exceed the rate established by IC 24-4.6-1-101(2) for judgments on money, on the amount paid to the provider that exceeds the amount that was legally due. The interest charge accrues from the date of the overpayment to the provider.
As added by P.L.273-1999, SEC.177.
IC 12-17.6-6-3
Sec. 3. In addition to any sanction imposed on a provider under section 2 of this chapter, a provider convicted of an offense under IC 35-43-5-7.2 is ineligible to participate in the program for ten (10) years after the conviction.
As added by P.L.273-1999, SEC.177.
IC 12-17.6-6-4
Sec. 4. A provider may appeal a sanction imposed under section 2 of this chapter under rules concerning Medicaid provider appeals that are adopted by the secretary under IC 4-22-2.
As added by P.L.273-1999, SEC.177.
IC 12-17.6-6-5
Sec. 5. After exhausting all administrative remedies, a provider may obtain judicial review of a sanction under IC 4-21.5-5.
As added by P.L.273-1999, SEC.177.
IC 12-17.6-6-6
Sec. 6. A final directive made by the office that:
(1) denies payment to a provider for medical services provided during a specified period; or
(2) terminates a provider agreement permitting a provider's participation in the program;
must direct the provider to inform each eligible recipient of services, before services are provided, that the office will not pay for those services if provided.
As added by P.L.273-1999, SEC.177.
IC 12-17.6-6-7
Sec. 7. Subject to section 8 of this chapter, a final directive:
(1) denying payment to a provider;
(2) rejecting a prospective provider's application for participation in the program; or
(3) terminating a provider agreement allowing a provider's participation in the program;
must be for a sufficient time, in the opinion of the office, to allow for the correction of all deficiencies or to prevent further abuses.
As added by P.L.273-1999, SEC.177.
IC 12-17.6-6-8
Sec. 8. Except as provided in section 10 of this chapter, a provider sanctioned under section 2 of this chapter may not be declared reinstated as a provider under this article until the office has received the following:
(1) Full repayment of the amount paid to the provider in excess of the proper and legal amount due, including any interest charge assessed by the office.
(2) Full payment of a civil penalty assessed under section 2(4) of this chapter.
As added by P.L.273-1999, SEC.177.
IC 12-17.6-6-9
Sec. 9. Except as provided in section 10 of this chapter, a provider sanctioned under section 2 of this chapter may file an agreement as provided in IC 12-17.6-5.
As added by P.L.273-1999, SEC.177.
IC 12-17.6-6-10
Sec. 10. A provider who has been:
(1) convicted of a crime relating to the provision of services under this chapter; or
(2) subjected to a sanction under section 2 of this chapter on three (3) separate occasions by directive of the office;
is ineligible to submit claims for the program.
As added by P.L.273-1999, SEC.177.
IC 12-17.6-6-11
Sec. 11. Evidence that a person or provider received money or other benefits as a result of a violation of:
(1) a provision of this article; or
(2) a rule established by the office under this article;
constitutes prima facie evidence, for purposes of IC 35-43-4-2, that the person or provider intended to deprive the state of a part of the value of the money or benefits.
As added by P.L.273-1999, SEC.177.
IC 12-17.6-6-12
Sec. 12. A person who furnishes items or services to an individual for which payment is or may be made under this chapter and who knowingly or intentionally solicits, offers, or receives a:
(1) kickback or bribe in connection with the furnishing of the items or services or the making or receipt of the payment; or
(2) rebate of a fee or charge for referring the individual to another person for the furnishing of items or services;
commits a Class A misdemeanor.
As added by P.L.273-1999, SEC.177.
Chapter 7- Funding
IC 12-17.6-7
Chapter 7. Funding
IC 12-17.6-7-1
Sec. 1. The children's health insurance program fund is established for the purpose of paying expenses relating to:
(1) the program;
(2) services offered through the program for children enrolled in the program; and
(3) services and administration eligible for reimbursement under Title XXI of the federal Social Security Act for children enrolled in Medicaid under IC 12-15-2-14.
As added by P.L.273-1999, SEC.177.
IC 12-17.6-7-2
Sec. 2. The office shall administer the fund.
As added by P.L.273-1999, SEC.177.
IC 12-17.6-7-3
Sec. 3. The fund consists of the following:
(1) Amounts appropriated by the general assembly.
(2) Amounts appropriated by the federal government.
(3) Fees, charges, gifts, grants, donations, money received from any other source, and other income funds as may become available.
As added by P.L.273-1999, SEC.177.
IC 12-17.6-7-4
Sec. 4. 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 funds may be invested.
As added by P.L.273-1999, SEC.177.
IC 12-17.6-7-5
Sec. 5. Money in the fund at the end of a state fiscal year does not revert to the state general fund.
As added by P.L.273-1999, SEC.177.
Chapter 8- Appeals and Hearings
IC 12-17.6-8
Chapter 8. Appeals and Hearings
IC 12-17.6-8-1
Sec. 1. This chapter does not apply until January 1, 2000.
As added by P.L.273-1999, SEC.177.
IC 12-17.6-8-2
Sec. 2. An applicant for or a recipient of services under the program may appeal to the office if at least one (1) of the following occurs:
(1) An application or a request is not acted upon by the office within a reasonable time after the application or request is filed.
(2) The application is denied.
(3) The applicant or recipient is dissatisfied with the action of the office.
As added by P.L.273-1999, SEC.177.
IC 12-17.6-8-3
Sec. 3. The secretary shall conduct hearings and appeals concerning the program under IC 4-21.5.
As added by P.L.273-1999, SEC.177.
IC 12-17.6-8-4
Sec. 4. The office shall, upon receipt of notice of appeal under section 2 of this chapter, set the matter for hearing and give the applicant or recipient an opportunity for a fair hearing in the county in which the applicant or recipient resides.
As added by P.L.273-1999, SEC.177.
IC 12-17.6-8-5
Sec. 5. (a) At a hearing held under section 4 of this chapter, the applicant or recipient and the office may introduce additional evidence.
(b) A hearing held under section 4 of this chapter shall be conducted under rules adopted by the secretary for applicants and recipients of Medicaid that are not inconsistent with IC 4-21.5 and the program.
As added by P.L.273-1999, SEC.177.
IC 12-17.6-8-6
Sec. 6. The office:
(1) may make necessary additional investigations; and
(2) shall make decisions concerning the:
(A) granting of program services; and
(B) amount of program services to be granted;
to an applicant or a recipient that the office believes are justified and in conformity with the program.
As added by P.L.273-1999, SEC.177.
Chapter 9- Confidentiality and Release of Information
IC 12-17.6-9
Chapter 9. Confidentiality and Release of Information
IC 12-17.6-9-1
Sec. 1. This chapter does not apply until January 1, 2000.
As added by P.L.273-1999, SEC.177.
IC 12-17.6-9-2
Sec. 2. The following concerning a program applicant or recipient under the program are confidential, except as otherwise provided in this chapter:
(1) An application.
(2) An investigation report.
(3) An information.
(4) A record.
As added by P.L.273-1999, SEC.177.
IC 12-17.6-9-3
Sec. 3. The use and the disclosure of the information described in this chapter to persons authorized by law in connection with the official duties relating to:
(1) financial audits;
(2) legislative investigations; or
(3) other purposes directly connected with the administration of the program;
is authorized.
As added by P.L.273-1999, SEC.177.
IC 12-17.6-9-4
Sec. 4. (a) The release and use of information of a general nature shall be provided as needed for adequate interpretation or development of the program.
(b) The information described in subsection (a) includes the following:
(1) Total program expenditures.
(2) The number of recipients.
(3) Statistical and social data used in connection with studies.
(4) Reports or surveys on health and welfare problems.
As added by P.L.273-1999, SEC.177.
IC 12-17.6-9-5
Sec. 5. The office shall make available the following to providers for immediate access to information indicating whether an individual is eligible for the program:
(1) A twenty-four (24) hour telephone system.
(2) A computerized data retrieval system.
As added by P.L.273-1999, SEC.177.
IC 12-17.6-9-6
Sec. 6. Information released under section 5 of this chapter is limited to the following:
(1) Disclosure of whether an individual is eligible for the program.
(2) The date the individual became eligible for the program and the individual's program number.
(3) Restrictions, if any, on the scope of services to be reimbursed under the program for the individual.
As added by P.L.273-1999, SEC.177.
IC 12-17.6-9-7
Sec. 7. Information obtained by a provider under this chapter concerning an individual's eligibility for the program is confidential and may not be disclosed to any person.
As added by P.L.273-1999, SEC.177.
IC 12-17.6-9-8
Sec. 8. If it is established that a provision of this chapter causes the program to be ineligible for federal financial participation, the provision is limited or restricted to the extent that is essential to make the program eligible for federal financial participation.
As added by P.L.273-1999, SEC.177.
Creation of the Children’s Health Policy Board
IC 4-23-27
Chapter 27. Children's Health Policy Board
IC 4-23-27-1
Sec. 1. As used in this chapter, "board" refers to the children's health policy board established by section 2 of this chapter.
As added by P.L.273-1999, SEC.162.
IC 4-23-27-2
Sec. 2. The children's health policy board is established.
As added by P.L.273-1999, SEC.162.
IC 4-23-27-3
Sec. 3. The board consists of the following members:
(1) The secretary of the family and social services administration.
(2) The state health commissioner.
(3) The insurance commissioner of Indiana.
(4) The state personnel director.
(5) The budget director.
(6) The state superintendent of public instruction.
(7) The director of the division of mental health.
As added by P.L.273-1999, SEC.162.
IC 4-23-27-4
Sec. 4. The governor shall appoint a member of the board as chair of the board.
As added by P.L.273-1999, SEC.162.
IC 4-23-27-5
Sec. 5. (a) Four (4) members of the board constitute a quorum.
(b) The affirmative vote of at least four (4) members of the board is required for the board to take any official action.
As added by P.L.273-1999, SEC.162.
IC 4-23-27-6
Sec. 6. (a) The board shall meet monthly at the call of the chair.
(b) The board shall hold public hearings in diverse locations throughout the state at least three (3) times each year.
As added by P.L.273-1999, SEC.162.
IC 4-23-27-7
YAMD.1999
Sec. 7. The board shall direct policy coordination of children's health programs by doing the following:
(1) Developing a comprehensive policy in the following areas:
(A) Appropriate delivery systems of care.
(B) Enhanced access to care.
(C) The use of various program funding for maximum efficiency.
(D) The optimal provider participation in various programs.
(E) The potential for expanding health insurance coverage to other populations.
(F) Technology needs, including development of an electronic claim administration, payment, and data collection system that allows providers to have the following:
(I) Point of service claims payments.
(ii) Instant claims adjudication.
(iii) Point of service health status information.
(iv) Claims related data for analysis.
(G) Appropriate organizational structure to implement health policy in the state.
(2) Coordinating aspects of existing children's health programs, including the children's health insurance program, Medicaid managed care for children, first steps, and children's special health care services, in order to achieve a more seamless system easily accessible by participants and providers, specifically in the following areas:
(A) Identification of potential enrollees.
(B) Outreach.
(C) Eligibility criteria.
(D) Enrollment.
(E) Benefits and coverage issues.
(F) Provider requirements.
(G) Evaluation.
(H) Procurement policies.
(I) Information technology systems, including technology to coordinate payment for services provided through the children's health insurance program under IC 12-17.6 with:
(I) services provided to children with special health needs; and
(ii) public health programs designed to protect all children.
(3) Reviewing, analyzing, disseminating, and using data when making policy decisions.
(4) Overseeing implementation of the children's health insurance program under IC 12-17.6, including:
(A) reviewing:
(I) benefits provided by;
(ii) eligibility requirements for; and
(iii) each evaluation of;
the children's health insurance program on an annual basis in light of available funding; and
(B) making recommendations for changes to the children's health insurance program to the office of the children's health insurance program established under IC 12-17.6-2-1.
As added by P.L.273-1999, SEC.162.
IC 4-23-27-8
Sec. 8. The board may draw upon the expertise of other boards, committees, and individuals whenever the board determines that such expertise is needed.
As added by P.L.273-1999, SEC.162
