Bill Text: IN SB0580 | 2011 | Regular Session | Introduced
Bill Title: Indiana health exchange.
Spectrum: Bipartisan Bill
Status: (Introduced - Dead) 2011-01-27 - Senator Miller added as second author [SB0580 Detail]
Download: Indiana-2011-SB0580-Introduced.html
Citations Affected: IC 27-18.
Synopsis: Indiana health exchange. Requires the commissioner of the
department of insurance and the secretary of family and social services
to perform certain tasks and report to the health finance commission to
design, implement, and administer the Indiana health exchange in
accordance with federal law. Specifies certain exchange related
requirements, including financial requirements and health plan
certification requirements.
Effective: July 1, 2011.
January 20, 2011, read first time and referred to Committee on Health and Provider
Services.
PRINTING CODE. Amendments: Whenever an existing statute (or a section of the Indiana Constitution) is being amended, the text of the existing provision will appear in this style type, additions will appear in this style type, and deletions will appear in
Additions: Whenever a new statutory provision is being enacted (or a new constitutional provision adopted), the text of the new provision will appear in this style type. Also, the word NEW will appear in that style type in the introductory clause of each SECTION that adds a new provision to the Indiana Code or the Indiana Constitution.
Conflict reconciliation: Text in a statute in this style type or
A BILL FOR AN ACT to amend the Indiana Code concerning
insurance.
ARTICLE 18. INDIANA HEALTH EXCHANGE
Chapter 1. Definitions
Sec. 1. (a) The definitions in this chapter apply throughout this article.
(b) As used in this article, a reference to any of the following is a reference to the act as in effect on July 1, 2011:
(1) The federal Public Health Service Act.
(2) The Internal Revenue Code.
(3) The federal Social Security Act.
Sec. 2. "Carrier" means an entity regulated under this title that contracts to provide, deliver, arrange for, pay for, or reimburse the cost of health care services.
Sec. 3. "Commissioner" refers to the commissioner of insurance appointed under IC 27-1-1-2.
Sec. 4. "Department" refers to the department of insurance created by IC 27-1-1-1.
Sec. 5. "Educated consumer" means an individual who is knowledgeable about the health care system and has experience in making informed decisions regarding health, medical, and scientific matters.
Sec. 6. (a) "Eligible entity" means an entity that has experience in individual and small group health insurance or benefit administration, or other experience relevant to the responsibilities of the exchange.
(b) The term includes the office of Medicaid policy and planning.
(c) The term does not include a carrier or an affiliate of a carrier.
Sec. 7. "Exchange" means the Indiana health exchange established under IC 27-18-2-1.
Sec. 8. (a) "Health plan" means a policy, contract, certificate, or agreement offered or issued by a carrier to provide, deliver, arrange for, pay for, or reimburse the costs of health care services.
(b) The term does not include the following:
(1) Accident only, credit, dental, vision, Medicare supplement, long term care, or disability income insurance.
(2) Coverage issued as a supplement to liability insurance.
(3) Automobile medical payment insurance.
(4) A specified disease policy.
(5) A short term insurance plan that:
(A) may not be renewed; and
(B) has a duration of not more than six (6) months.
(6) A policy that provides indemnity benefits not based on any expense incurred requirement, including a plan that provides coverage for:
(A) hospital confinement, critical illness, or intensive care; or
(B) gaps for deductibles or copayments.
(7) Worker's compensation or similar insurance.
(8) A student health plan.
(9) A supplemental plan that always pays in addition to other coverage.
(10) An employer sponsored health benefit plan that is:
(A) provided to individuals who are eligible for Medicare; and
(B) not marketed as, or held out to be, a Medicare
supplement policy.
Sec. 9. "Plain language" has the meaning set forth in Section
1311(e)(3)(B) of the PPACA.
Sec. 10. "PPACA" refers to the federal Patient Protection and
Affordable Care Act (P.L. 111-148), as amended by the federal
Health Care and Education Reconciliation Act of 2010 (P.L.
111-152), and regulations or guidance issued under those acts, as
in effect on July 1, 2011.
Sec. 11. "Qualified dental plan" means a limited scope dental
plan that is certified under IC 27-18-4.
Sec. 12. "Qualified employer" means a small employer that:
(1) elects to make its full time employees eligible for at least
one (1) qualified health plan offered through the small
business health options program; and
(2) either:
(A) elects to provide coverage through the small business
health options program to all of its eligible employees who
are principally employed in Indiana; or
(B) has its principal place of business in Indiana and elects
to provide coverage through the small business health
options program to all of its eligible employees, regardless
of where the eligible employees are employed.
Sec. 13. "Qualified health plan" means a health plan that has in
effect a certification that the health plan meets the criteria for
certification described in Section 1311(c) of the PPACA and
IC 27-18-4.
Sec. 14. "Qualified individual" means an individual, regardless
of age, who:
(1) seeks to enroll in a qualified health plan offered to
individuals through the exchange;
(2) is an Indiana resident;
(3) at the time of enrollment is not incarcerated, other than
incarceration pending the disposition of charges; and
(4) is reasonably expected to be, for the entire period for
which enrollment is sought, a citizen or national of the United
States or an alien lawfully present in the United States.
Sec. 15. "Secretary" refers to the secretary of the United States
Department of Health and Human Services.
Sec. 16. (a) "Small employer" means an employer that employed
an average of not more than one hundred (100) employees during
the preceding calendar year.
(b) For purposes of this section, the following apply:
(1) Persons treated as a single employer under subsection (b), (c), (m), or (o) of Section 414 of the Internal Revenue Code are considered a single employer.
(2) An employer and a predecessor employer are considered a single employer.
(3) All employees, including part-time employees and employees who are not eligible for health coverage through the employer, must be counted.
(4) If an employer was not in existence throughout the preceding calendar year, the determination of whether the employer is a small employer must be based on the average number of employees that is reasonably expected to be employed by the employer on business days in the current calendar year.
(5) An employer that:
(A) makes enrollment in a qualified health plan available to the employer's employees through the small business health option program; and
(B) would cease to be a small employer by reason of an increase in the number of the employer's employees;
is considered a small employer for purposes of this article until the employer ceases to make enrollment through the small business health option program available to the employer's employees.
Chapter 2. Indiana Health Exchange
Sec. 1. The Indiana health exchange shall be established by the commissioner to:
(1) facilitate the purchase of qualified health plans by individuals in the individual insurance market; and
(2) provide for establishment of a small business health options program to facilitate enrollment of employees of qualified small employers in qualified health plans offered in the small group insurance market.
Sec. 2. (a) The commissioner and the secretary of family and social services shall, not later than September 30, 2011:
(1) hold public meetings with health care providers, insurers, consumers, and other interested parties concerning the design, establishment, and administration of the exchange; and
(2) make a recommendation to the health finance commission established by IC 2-5-23-3 concerning the following:
(A) Whether the exchange should be administered by an
agency of the state or a nonprofit organization.
(B) A list of states with which the state of Indiana should
cooperate to form an interstate exchange.
(C) Other provisions necessary for the implementation of
the exchange.
(b) This section expires December 31, 2012.
Sec. 3. (a) The health finance commission established by
IC 2-5-23-3 shall, not later than October 31, 2011, study and make
a recommendation to the general assembly for legislation necessary
to design, establish, and implement the exchange, including the
following:
(1) The administrator described in section 2(a)(2)(A) of this
chapter.
(2) Any necessary governing structure for the exchange.
(3) Authority and responsibilities of the exchange, including
procedures for staff hiring and procurement of resources.
(4) Responsibilities of state agencies in coordination of
activities with the exchange.
(5) Other recommendations determined appropriate by the
health finance commission.
(b) The commissioner shall apply for federal certification of the
exchange not later than October 1, 2012.
(c) This section expires December 31, 2014.
Sec. 4. As the funds become available, the commissioner and the
secretary of family and social services shall apply for federal grant
funds related to the development or implementation of the
exchange.
Sec. 5. The exchange shall do the following:
(1) Facilitate the purchase and sale of qualified health plans.
(2) Provide for the establishment of a small business health
option program to assist qualified small employers in Indiana
in facilitating the enrollment of employees in qualified health
plans.
(3) Maintain, or require employees of the exchange to
maintain, a producer license under IC 27-1-15.6.
Sec. 6. The exchange may do the following:
(1) Contract with an eligible entity for any of the functions of
the exchange described in this article.
(2) Enter into information sharing agreements with federal
and state agencies and other states' exchanges to carry out the
responsibilities of the exchange under this article. An
agreement entered into under this subdivision must include
adequate protections with respect to the confidentiality of the
information to be shared and comply with all state and
federal law.
Chapter 3. Functions of the Exchange
Sec. 1. The exchange shall make qualified health plans available
to qualified individuals and qualified employers, beginning with
effective dates not later than January 1, 2014.
Sec. 2. The exchange shall not make available a health plan that
is not a qualified health plan.
Sec. 3. The exchange shall allow a carrier to offer a health plan
that provides limited scope dental benefits that meet the
requirements of Section 9832(c)(2)(A) of the Internal Revenue
Code through the exchange, either separately or in conjunction
with a qualified health plan, if the health plan provides pediatric
dental benefits that meet the requirements of Section 1302(b)(1)(J)
of the PPACA.
Sec. 4. The exchange or a carrier that offers health plans
through the exchange may not charge an individual a fee or
penalty for termination of coverage if the individual enrolls in
another type of minimum essential coverage because the individual
has become newly eligible for the coverage or because the
individual's employer sponsored coverage has become affordable
under the standards of Section 36B(c)(2)(C) of the Internal
Revenue Code.
Sec. 5. The exchange shall do the following:
(1) Implement procedures for certification, recertification,
and decertification, consistent with guidelines developed by
the secretary under Section 1311(c) of the PPACA and
IC 27-18-4, of health plans as qualified health plans.
(2) Provide for the operation of a toll free telephone hotline to
respond to requests for assistance.
(3) Provide for enrollment periods, as provided under Section
1311(c)(6) of the PPACA
(4) Maintain an Internet web site through which enrollees and
prospective enrollees of qualified health plans may obtain
standardized comparative information concerning the
qualified health plans.
(5) Assign a rating to each qualified health plan offered
through the exchange in accordance with the criteria
developed by the secretary under Section 1311(c)(3) of the
PPACA, and determine each qualified health plan's level of
coverage in accordance with regulations issued by the
secretary under Section 1302(d)(2)(A) of the PPACA.
(6) Use a standardized format for presenting health benefit
options in the exchange, including the use of the uniform
outline of coverage established under Section 2715 of the
federal Public Health Service Act.
(7) In accordance with Section 1413 of the PPACA:
(A) inform individuals of eligibility requirements for the
Medicaid program under Title XIX of the federal Social
Security Act, the Children's Health Insurance Program
under Title XXI of the federal Social Security Act, or an
applicable state or local public program; and
(B) if through screening of the application by the exchange,
the exchange determines that an individual is eligible for
a program listed in clause (A), enroll the individual in the
program.
(8) Establish and make available by electronic means a
calculator to determine the actual cost of coverage after
application of any premium tax credit under Section 36B of
the Internal Revenue Code and any cost sharing reduction
under Section 1402 of the PPACA.
(9) Establish a small business health option program through
which qualified employers may access coverage for
employees, which must enable a qualified employer to specify
a level of coverage so that any of the employees may enroll in
any qualified health plan offered through the small business
health option program at the specified level of coverage.
(10) Subject to Section 1411 of the PPACA, grant a
certification attesting that, for purposes of the individual
responsibility penalty under Section 5000A of the Internal
Revenue Code, an individual is exempt from the individual
responsibility requirement or from the penalty imposed by
Section 5000A of the Internal Revenue Code because:
(A) there is no affordable qualified health plan available
through the exchange, or the individual's employer,
covering the individual; or
(B) the individual meets the requirements for any other
exemption from the individual responsibility requirement
or penalty.
(11) Transfer to the federal secretary of the treasury the
following:
(A) A list of the individuals who are issued a certification
under subdivision (10), including the name and taxpayer
identification number of each individual.
(B) The name and taxpayer identification number of each
individual who was an employee of an employer but who
was determined to be eligible for the premium tax credit
under Section 36B of the Internal Revenue Code because:
(i) the employer did not provide minimum essential
coverage; or
(ii) the employer provided the minimum essential
coverage but it was determined under Section
36B(c)(2)(C) of the Internal Revenue Code to be
unaffordable to the employee or not to provide the
required minimum actuarial value.
(C) The name and taxpayer identification number of:
(i) each individual who notifies the exchange under
Section 1411(b)(4) of the PPACA that the individual has
changed employers; and
(ii) each individual who ceases coverage under a
qualified health plan during a plan year and the effective
date of the cessation.
(12) Provide to each employer the name of each employee of
the employer described in subdivision (11)(B) who ceases
coverage under a qualified health plan during a plan year and
the effective date of the cessation.
(13) Perform duties required of the exchange by the secretary
of the federal secretary of the treasury related to determining
eligibility for premium tax credits, reduced cost sharing, or
individual responsibility requirement exemptions.
(14) Select entities qualified to serve as navigators in
accordance with Section 1311(i) of the PPACA, and standards
developed by the secretary, and award grants to enable
navigators to do the following:
(A) Conduct public education activities to raise awareness
of the availability of qualified health plans.
(B) Distribute fair and impartial information concerning
enrollment in qualified health plans, and the availability of
premium tax credits under Section 36B of the Internal
Revenue Code and cost sharing reductions under Section
1402 of the PPACA.
(C) Facilitate enrollment in qualified health plans.
(D) Provide referrals to an applicable office of health
insurance consumer assistance or health insurance
ombudsman established under Section 2793 of the federal
Public Health Service Act, or another appropriate state
agency, for an enrollee with a grievance, complaint, or
question regarding a health plan, coverage, or a
determination under the health plan or coverage.
(E) Provide information in a manner that is culturally and
linguistically appropriate to the needs of the population
being served by the exchange.
(15) Review the rate of premium growth within the exchange
and outside the exchange, and consider the information in
developing recommendations on whether to continue limiting
qualified employer status to small employers.
(16) Credit the amount of any free choice voucher to the
monthly premium of the health plan in which a qualified
employee is enrolled, in accordance with Section 10108 of the
PPACA, and collect the amount credited from the offering
employer.
(17) Consult with interested parties relevant to carrying out
the activities required by the article, including the following:
(A) Educated consumers who are enrollees in qualified
health plans.
(B) Individuals and entities with experience in facilitating
enrollment in qualified health plans.
(C) Representatives of small businesses and self-employed
individuals.
(D) The office of Medicaid policy and planning.
(E) Advocates for enrolling hard to reach populations.
(18) Meet the following financial integrity requirements:
(A) Keep an accurate accounting of all activities, receipts,
and expenditures and annually submit to the secretary, the
governor, the commissioner, and the general assembly in
an electronic format under IC 5-14-6 a report concerning
the accounting.
(B) Fully cooperate with any investigation conducted by
the commissioner, or the secretary under the secretary's
authority under the PPACA, and allow the secretary, in
coordination with the inspector general of the United
States Department of Health and Human Services, to do
the following:
(i) Investigate the affairs of the exchange.
(ii) Examine the properties and records of the exchange.
(iii) Require periodic reports in relation to the activities
undertaken by the exchange.
(C) In carrying out its activities under this article, not use
any funds intended for the administrative and operational
expenses of the exchange for staff retreats, promotional
giveaways, excessive executive compensation, or promotion
of federal or state legislative and regulatory modifications.
Chapter 4. Health Plan Certification
Sec. 1. The exchange may certify a health plan as a qualified
health plan if the health plan meets the following requirements:
(1) The health plan provides the essential health benefits
package described in Section 1302(a) of the PPACA, except
that the health plan is not required to provide essential health
benefits that duplicate the minimum benefits of qualified
dental plans, as provided in section 5 of this chapter, if:
(A) the exchange determines that at least one (1) qualified
dental plan is available to supplement the health plan's
coverage; and
(B) the carrier makes prominent disclosure at the time the
carrier offers the health plan, in a form approved by the
exchange, that the health plan does not provide the full
range of pediatric essential health benefits, and that
qualified dental plans providing pediatric essential health
benefits and other dental benefits not covered by the health
plan are offered through the exchange.
(2) The premium rates and contract language have been
approved by the commissioner.
(3) The health plan provides at least a bronze level of
coverage, as determined under IC 27-18-3-5(5), unless the
health plan is certified as a qualified catastrophic plan, meets
the requirements of the PPACA for catastrophic plans, and
will be offered only to individuals who are eligible for
catastrophic coverage.
(4) The health plan's cost sharing requirements do not exceed
the limits established under Section 1302(c)(1) of the PPACA,
and if the health plan is offered through the small business
health option program, the health plan's deductible does not
exceed the limits established under Section 1302(c)(2) of the
PPACA.
(5) The carrier that offers the health plan meets the following
requirements:
(A) Is licensed and in good standing to offer health
insurance coverage in Indiana.
(B) Offers at least one (1) qualified health plan in the silver
level and at least one (1) qualified health plan in the gold
level through the individual exchange and the small
business health option program.
(C) Charges the same premium rate for each qualified
health plan without regard to whether the health plan is
offered through the exchange and without regard to
whether the health plan is offered directly from the carrier
or through an insurance producer.
(D) Does not charge cancellation fees or penalties in
violation of IC 27-18-3-4.
(E) Complies with the regulations developed by the
secretary under Section 1311(d) of the PPACA and any
requirements established by the exchange.
(6) The health plan meets the requirements of certification as
specified in rules adopted under IC 27-18-6 and regulations
adopted by the secretary under Section 1311(c) of the PPACA,
including minimum standards in the following areas:
(A) Marketing practices.
(B) Network adequacy.
(C) Essential community providers in underserved areas.
(D) Accreditation.
(E) Quality improvement.
(F) Uniform enrollment forms.
(G) Descriptions of coverage.
(H) Information concerning quality measures for health
plan performance.
(7) The exchange determines that making the health plan
available through the exchange is in the interest of qualified
individuals and qualified employers in Indiana.
Sec. 2. The exchange may not exclude a health plan from
certification:
(1) on the basis that the health plan is a fee for service health
plan;
(2) through the imposition of premium price controls by the
exchange; or
(3) on the basis that the health plan provides treatments
necessary to prevent patient deaths in circumstances that the
exchange determines are inappropriate or too costly.
Sec. 3. The exchange shall require each carrier that seeks
certification of a health plan as a qualified health plan to do the
following:
(1) Submit a justification for any premium increase before
implementation of the increase in conformity with
IC 27-8-5-1.5. The carrier shall prominently post the
information on the carrier's Internet web site. The exchange
shall consider the justifying information and the
recommendations provided to the exchange by the
commissioner under Section 2794(b) of the federal Public
Health Service Act in determining whether to allow the
carrier to make a health plan available through the exchange.
(2) In plain language, make available to the public and submit
to the exchange, the secretary, and the commissioner,
accurate and timely disclosure of the following:
(A) Claim payment policies and practices.
(B) Periodic financial disclosures.
(C) Enrollment data.
(D) Disenrollment data.
(E) Data concerning the number of claims denied.
(F) Data concerning rating practices.
(G) Information concerning cost sharing and payments
with respect to out of network coverage.
(H) Information concerning enrollee and participant rights
under Title 1 of the PPACA.
(I) Other information determined appropriate by the
secretary.
(3) Permit individuals to learn in a timely manner upon the
request of the individual, the amount of cost sharing,
including deductibles, copayments, and coinsurance, under
the individual's health plan or coverage that the individual
would be responsible for paying with respect to the furnishing
of a specific item or service by a participating provider.
Minimally, the information must be available to the individual
through an Internet web site and through other means for
individuals without access to the Internet.
Sec. 4. The exchange shall not exempt a carrier seeking
certification of a health plan, regardless of the type or size of the
carrier, from state licensure or solvency requirements and shall
apply the criteria of this chapter in a manner that excludes any
discrimination among carriers participating in the exchange.
Sec. 5. Except as modified by the following or by rules adopted
by the exchange, a dental plan is subject to the requirements of this
chapter for certification as a qualified dental plan:
(1) The carrier:
(A) must be authorized under this title to offer dental
coverage; and
(B) is not required to be authorized under this title to offer
other health benefits.
(2) The dental plan must:
(A) be limited to dental and oral health benefits, without
substantially duplicating the benefits typically offered by
a health plan that does not provide dental coverage; and
(B) include at least the pediatric essential dental benefits
prescribed by the secretary under Section 1302(b)(1)(J) of
the PPACA and other benefits determined necessary by the
exchange or the secretary.
(3) Carriers may jointly offer a comprehensive health plan
through the exchange in which the dental benefits are
provided by a carrier through a qualified dental plan and the
other benefits are provided by a carrier through a qualified
health plan if the qualified dental plan and the qualified
health plan are priced separately and are made available for
purchase separately at the same price.
Chapter 5. Exchange Funding
Sec. 1. The exchange may charge assessments or user fees to
carriers or otherwise may generate the funds necessary to support
the operations of the exchange under this article.
Sec. 2. The exchange shall publish the average cost of licensing,
regulatory fees, and other payments required by the exchange, and
the administrative costs of the exchange, on an Internet web site to
educate consumers on the costs. The information published must
include information concerning money lost to waste, fraud, and
abuse.
Chapter 6. Rules
Sec. 1. The exchange may adopt rules under IC 4-22-2 to
implement this article.
Sec. 2. Rules adopted under this chapter may not conflict or
prevent the application of regulations adopted by the secretary
under the PPACA.
Chapter 7. Relation to Other Law
Sec. 1. Except as provided in this chapter, to the extent that this
article conflicts with the commissioner's authority to regulate the
business of insurance under another provision of IC 27, the other
provision is controlling.
