Citations Affected: IC 27-8-28.
Synopsis: Determination of medical necessity. Requires a
determination of medical necessity to be made by a qualified physician,
in writing, and based on medical information. Specifies certain criteria
on which a determination of medical necessity must be based.
Effective: July 1, 2000.
January 10, 2000, read first time and referred to Committee on Health and Provider
A BILL FOR AN ACT to amend the Indiana Code concerning
IS ADDED TO THE INDIANA CODE AS
A NEW CHAPTER TO READ AS FOLLOWS [EFFECTIVE JULY
Chapter 28. Determination of Medical Necessity
Sec. 1. As used in this chapter, "covered individual" means an individual covered under a health plan.
Sec. 2. As used in this chapter, "health plan" includes the following:
(1) Every policy of accident and sickness insurance (as defined in IC 27-8-5-1 ), whether written on an individual basis, a group basis, a franchise basis, or a blanket basis that is issued, delivered, or renewed in Indiana.
(2) Every group contract (as defined in IC 27-13-1-16 ) or individual contract (as defined in IC 27-13-1-21 ) that is delivered, executed, or renewed in Indiana through which a health maintenance organization furnishes health care services.
(3) Every health care plan of a state or local governmental entity that provides coverage for health care services on a self-insurance basis in Indiana.
Sec. 3. A determination regarding the medical necessity of care or services covered under a health plan must be:
(1) provided to the covered individual and the treating physician in writing;
(2) based on medical information related to the covered individual's diagnosis that is provided by:
(A) the covered individual;
(B) the covered individual's representative;
(C) the treating physician; and
(D) any other person involved in the care of the covered individual;
(3) made by a physician who is qualified and trained in the area of the covered individual's diagnosis; and
(4) based on the criteria specified in section 4 of this chapter.
Sec. 4. The physician making the determination under section 3 of this chapter shall determine that care or services are medically necessary if one (1) of the following criteria is satisfied:
(1) The care or service will or is reasonably expected to prevent or delay the onset or progression of an illness, disease, condition, disability, or injury.
(2) The care or service will or is reasonably expected to:
(A) correct, cure, eliminate, reduce, or ameliorate; or
(B) alleviate painful effects of;
the illness, disease, condition, disability, or injury.
(3) The care or service will:
(A) assist in the prevention of secondary conditions; or
(B) achieve, maintain, or improve functional capacity in performance of daily activities.
(4) The care or service is necessary to assess or screen for an illness, disease, condition, disability, or injury.
(5) The care or service is necessary to establish a diagnosis.
(6) The care or service is necessary to prolong life.
Sec. 5. If care or services are determined to be medically necessary under this chapter, coverage for the care or services:
(1) must be provided under the health plan;
(2) must be sufficient in amount, duration, and scope to reasonably achieve the purpose of the care or services; and
(3) may not be denied or reduced due solely to the type of illness, disease, condition, disability, or injury.
Sec. 6. This chapter does not add to or otherwise change the terms of coverage included in a health plan under which a covered individual receives coverage.
SECTION 2. [EFFECTIVE JULY 1, 2000] IC 27-8-28, as added by this act, applies to a determination of medical necessity made after June 30, 2000.