Sec. 15. All contracts with providers or with entities subcontracting for the provision of limited health services to enrollees on a prepayment basis or other basis must contain, or shall be construed to contain, the following terms and conditions:

(1) If the limited service health maintenance organization fails to pay for limited health services for any reason whatsoever, including insolvency or breach of this contract, the enrollees shall not be liable to the provider for any sums owed to the provider under this contract.

Terms Used In Indiana Code 27-13-34-15

  • Amendment: A proposal to alter the text of a pending bill or other measure by striking out some of it, by inserting new language, or both. Before an amendment becomes part of the measure, thelegislature must agree to it.
  • Contract: A legal written agreement that becomes binding when signed.
  • enrollee: means an individual who is entitled to limited health services under a contract with an entity authorized to provide or arrange for limited health services under this chapter. See Indiana Code 27-13-34-1
  • limited health services: refers to :

    Indiana Code 27-13-34-3

  • limited service health maintenance organization: means a corporation, partnership, limited liability company, or other entity that undertakes to provide or arrange a limited health service on a prepayment basis or other basis. See Indiana Code 27-13-34-4
  • provider: means a physician, a dentist, an optometrist, a health facility, or other person or institution that is licensed or otherwise authorized to deliver or furnish limited health service. See Indiana Code 27-13-34-5
  • Trustee: A person or institution holding and administering property in trust.
(2) No provider or agent, trustee, representative, or assignee of a provider may maintain an action at law or attempt to collect from the enrollee sums that the limited service health maintenance organization owes to the provider.

(3) These provisions do not prohibit the collection of:

(A) uncovered charges consented to by enrollees; or

(B) copayments;

from enrollees.

(4) The contract may not provide for a financial or other penalty to a primary care provider for making a referral permitted under IC 27-13-36-5(a), but may provide for reasonable cost sharing between the primary care provider and the limited service health maintenance organization for the additional costs incurred as a result of services provided by an out of network provider.

(5) These provisions survive the termination of this contract, regardless of the reason for the termination.

(6) For not more than ninety (90) days after the termination of this contract, the provider must complete procedures in progress on an enrollee receiving treatment for a specific condition, at the same schedule of copayment or other applicable charge that is in effect on the effective date of termination of the contract.

(7) An amendment to the provisions of this contract set forth in subdivisions (1) through (6) must be:

(A) submitted to; and

(B) approved by;

the commissioner before it becomes effective.

As added by P.L.26-1994, SEC.25. Amended by P.L.69-1998, SEC.13.

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