(a) An association policy issued under this chapter may pay an amount for medically necessary eligible expenses related to the diagnosis or treatment of illness or injury that exceed the deductible and coinsurance amounts applicable under section 4 of this chapter. Payment under an association policy must be based on one (1) or a combination of the following reimbursement methods, as determined by the board of directors:

1. (1) The association's usual and customary fee schedule in effect on January 1, 2004. If payment is based on the usual and customary fee schedule in effect on January 1, 2004, the rates of reimbursement under the fee schedule must be adjusted annually by a percentage equal to the percentage change in the Indiana medical care component of the Consumer Price Index for all Urban Consumers, as published by the United States Bureau of Labor Statistics during the preceding calendar year.

2. (2) A health care provider network arrangement. If payment is based on a health care provider network arrangement, reimbursement under an association policy must be made according to:

   1. (A) a network fee schedule for network health care providers and nonnetwork health care providers; and
   2. (B) any additional coinsurance that applies to the insured under the association policy if the insured obtains health care services from a nonnetwork health care provider.
3. (3) Reimbursement for an eligible expense in an amount equal to not less than the federal Medicare reimbursement rate for the eligible expense plus ten percent (10%).

(b) Eligible expenses are the charges for the following health care services and articles to the extent furnished by a health care provider in an emergency situation or furnished or prescribed by a physician:

1. (1) Hospital services, including charges for the institution's most common semiprivate room, and for private room only when medically necessary, but limited to a total of one hundred eighty
2. (180) days in a year.
3. (2) Professional services for the diagnosis or treatment of injuries, illnesses, or conditions, other than mental or dental, that are rendered by a physician or, at the physician's direction, by the physician's staff of registered or licensed nurses, and allied health professionals.
4. (3) The first twenty (20) professional visits for the diagnosis or treatment of one (1) or more mental conditions rendered during the year by one (1) or more physicians or, at their direction, by their staff of registered or licensed nurses, and allied health professionals.
5. (4) Drugs and contraceptive devices requiring a physician's prescription.
6. (5) Services of a skilled nursing facility for not more than one hundred eighty (180) days in a year.
7. (6) Services of a home health agency up to two hundred seventy
8. (270) days of service a year.
9. (7) Use of radium or other radioactive materials.
10. (8) Oxygen.
11. (9) Anesthetics.
12. (10) Prostheses, other than dental.
13. (11) Rental of durable medical equipment which has no personal use in the absence of the condition for which prescribed.
14. (12) Diagnostic X-rays and laboratory tests.

15. (13) Oral surgery for:

    1. (A) excision of partially or completely erupted impacted teeth;
    2. (B) excision of a tooth root without the extraction of the entire tooth; or
    3. (C) the gums and tissues of the mouth when not performed in connection with the extraction or repair of teeth.
16. (14) Services of a physical therapist and services of a speech therapist.
17. (15) Professional ambulance services to the nearest health care facility qualified to treat the illness or injury.

18. (16) Other medical supplies required by a physician's orders.

    An association policy may also include comparable benefits for those who rely upon spiritual means through prayer alone for healing upon such conditions, limitations, and requirements as may be determined by the board of directors.

(c) A managed care organization that issues an association policy may not refuse to enter into an agreement with a hospital solely because the hospital has not obtained accreditation from an accreditation organization that:

1. (1) establishes standards for the organization and operation of hospitals;
2. (2) requires the hospital to undergo a survey process for a fee paid by the hospital; and
3. (3) was organized and formed in 1951.

(d) This section does not prohibit a managed care organization from using performance indicators or quality standards that:

1. (1) are developed by private organizations; and
2. (2) do not rely upon a survey process for a fee charged to the hospital to evaluate performance.

(f) The following are not eligible expenses in any association policy within the scope of this chapter:

1. (1) Services for which a charge is not made in the absence of insurance or for which there is no legal obligation on the part of the patient to pay.
2. (2) Services and charges made for benefits provided under the laws of the United States, including Medicare and Medicaid, military service connected disabilities, medical services provided for members of the armed forces and their dependents or for employees of the armed forces of the United States, medical services financed in the future on behalf of all citizens by the United States.

3. (3) Benefits which would duplicate the provision of services or payment of charges for any care for injury or disease either:

   1. (A) arising out of and in the course of an employment subject to a worker's compensation or similar law; or

   2. (B) for which benefits are payable without regard to fault under a coverage statutorily required to be contained in any motor vehicle or other liability insurance policy or equivalent self-insurance.

      However, this subdivision does not authorize exclusion of charges that exceed the benefits payable under the applicable worker's compensation or no-fault coverage.

4. (4) Care which is primarily for a custodial or domiciliary purpose.
5. (5) Cosmetic surgery unless provided as a result of an injury or medically necessary surgical procedure.
6. (6) Any charge for services or articles the provision of which is not within the scope of the license or certificate of the institution or individual rendering the services.

(i) This chapter does not prohibit the association or its administrator from implementing uniform procedures to review the medical necessity and cost effectiveness of proposed treatment, confinement, tests, or other medical procedures. Those procedures may take the form of preadmission review for nonemergency hospitalization, case management review to verify that covered individuals are aware of treatment alternatives, or other forms of utilization review. Any cost containment techniques of this type must be adopted by the board of directors and approved by the commissioner.

As added by Acts 1981, P.L.249, SEC.1. Amended by P.L.28-1988, SEC.106; P.L.253-1989, SEC.3; P.L.116-1994, SEC.66; P.L.259-1995, SEC.1; P.L.51-2004, SEC.7; P.L.229-2011, SEC.252.