Authority: IC 12-15-44.5-9

Affected: IC 12-15-44.5

Sec. 5. (a) A provider shall be reimbursed for covered services as follows:

1. (1) Until the member's deductible is met, with POWER account funds accessed through the member's POWER account and paid by the managed care organization. If the member lacks sufficient POWER account funds at the time of service, the managed care organization shall pay for any portion of the plan reimbursement rate that cannot be paid with POWER account funds but shall reconcile these prepaid amounts as additional POWER account funds are received from the member.
2. (2) For all covered preventive care services, which are not subject to the member's deductible, by the managed care organization.
3. (3) For covered services under the member's health plan after the deductible has been met, by the managed care organization.

The provider shall be reimbursed at the plan reimbursement rate.

(b) Reimbursement shall not be available for services provided to individuals who are not enrolled in the plan on the date the service is provided except as provided under the following:

1. (1) To those individuals whose coverage dates back to the first of the month as outlined in 405 IAC 10-3-2 or 405 IAC 10-3-3.
2. (2) To an individual in accordance with section 3(b) and 3(c) of this rule.

(c) The plan reimbursement rate defined in 405 IAC 10-2-1(38) does not include:

1. (1) critical access hospital payments;
2. (2) graduate medical education payments; or
3. (3) disproportionate share hospital payments.

(d) Managed care organizations shall reimburse federally qualified health centers and rural health clinics for covered services at the Medicare all-inclusive rate for each visit. In the event the amount paid by managed care organizations is less than the amount set forth in 42 U.S.C. 1396a(bb), the office shall make a supplemental payment in accordance with 42 U.S.C. 1396a(bb)(5).

(Office of the Secretary of Family and Social Services; 405 IAC 10-9-5; filed May 18, 2015, 12:34 p.m.: 20150617-IR-405140339FRA; filed Jan 19, 2018, 8:42 a.m.: 20180214-IR-405170484FRA; errata filed Feb 22, 2018, 9:36 a.m.: 20180307-IR-405180114ACA; readopted filed Oct 16, 2024, 11:20 a.m.: 20241113-IR-405230817RFA)