OVERVIEW: Amends
405 IAC 5-3-14 to reduce the time frame for making prior authorization decisions to seven calendar days. Amends
405 IAC 9-2-13 to revise the definition of "emergency services". Amends
405 IAC 9-3-2 to clarify retroactive coverage is not provided for under the plan. Amends
405 IAC 9-4-4 to require insurers and the association to follow standards set forth by the office when assisting individuals with the plan renewal process and to make other technical changes. Amends
405 IAC 9-4-5 to add as grounds for ineligibility the falsification of information on the plan application and to make other technical changes. Amends
405 IAC 9-4-6 to outline the process for providing notification when enrollment is reopened and to make clarifying technical changes. Amends
405 IAC 9-6-1 to update the enhanced services plan screening process for applicants and members. Amends
405 IAC 9-7-2 to revise coverage of skilled nursing facility services and family planning services, to update the requirements for notifying members close to exceeding the annual and lifetime reimbursement limitations, and to make other technical changes. Amends
405 IAC 9-7-6 to revise the coverage policy for pharmacy services, including legend drugs, nonlegend drugs, nonlegend insulin, and
vitamins. Amends
405 IAC 9-7-8 to identify the insurer's ability to provide a more generous preventative care services benefit and to make other technical changes. Amends
405 IAC 9-7-10 to clarify covered out-of-network nurse practitioner services, to provide out-of-network coverage for services provided by FQHCs and RHCs, and to make other technical changes. Amends
405 IAC 9-7-11 concerning self-referral services to identify additional services that shall not require referral from a member's primary care provider and to make other technical changes. Amends
405 IAC 9-7-12 to require publication of prior authorization policies by the insurers and the association and to reduce the time frame for making prior authorization decisions to seven calendar days. Amends
405 IAC 9-7-13 to revise the noncoverage policy for vitamins, supplements, and over-the-counter drugs. Amends
405 IAC 9-8-2 to make conforming changes. Amends
405 IAC 9-8-3 to identify the process for purchasing buy-in coverage. Amends
405 IAC 9-8-5 to include risk-based managed care as a component of the Medicaid program that can pay pregnancy related claims and to make other technical changes. Amends
405 IAC 9-9-7 to clarify reimbursement for preventative care services and the reimbursement rate for hospitals, FQHCs/RHCs,
and pharmacy services. Amends
405 IAC 9-9-8 concerning permissible member payments to delete the option for paying for the difference in cost between a brand name drug and generic substitute. Amends
405 IAC 9-10-7 concerning changing insurers to make conforming technical changes. Amends
405 IAC 9-10-9 to require the return of excess rollover balances to the state and to make conforming technical changes. Amends
405 IAC 9-10-10 to prohibit the billing of individuals for claims originally denied but upheld on appeal under certain circumstances. Amends
405 IAC 9-10-11 concerning member debt to make conforming changes. Amends
405 IAC 9-10-13 to clarify the payroll deduction payment option. Amends
405 IAC 9-10-14 to require application of lump sum employer contributions equally to member POWER account contributions each month throughout the coverage term. Amends
405 IAC 9-10-17 to update the insurer and association responsibilities for POWER account balance transfers. Amends
405 IAC 9-10-21 concerning failure to renew participation to make conforming changes. Questions and comments concerning the proposed rule may be submitted to the Small Business Regulatory Coordinator for this rule. Statutory authority:
IC 12-8-6-3;
IC 12-8-6-5;
IC 12-15-1-10;
IC 12-15-21-2;
IC 12-15-21-3;
IC 12-15-44.2-19.
