2016 Indiana Code TITLE 5. STATE AND LOCAL ADMINISTRATION ARTICLE 10. PUBLIC EMPLOYEE BENEFITS CHAPTER 8. GROUP INSURANCE FOR PUBLIC EMPLOYEES
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IC 5-10-8
Chapter 8. Group Insurance for Public Employees
IC 5-10-8-0.1
Application of certain amendments to chapter
Sec. 0.1. The following amendments to this chapter apply as
follows:
(1) The amendments made to section 2 of this chapter (before
its repeal) and section 3 of this chapter (before its repeal) by
P.L.46-1985 do not affect contracts:
(A) entered into before; and
(B) in effect on;
July 1, 1986.
(2) The addition of section 7.2 of this chapter by P.L.35-1992
applies to a contract between the state and a prepaid health care
delivery plan that is entered into or renewed after June 30,
1992.
(3) The amendments made to section 7.2 of this chapter by
P.L.170-1999 apply to a self-insurance program or a contract
between the state and a health maintenance organization
established, entered into, or renewed after June 30, 1999.
(4) The addition of section 7.5 of this chapter by P.L.170-1999
applies to a self-insurance program or a contract between the
state and a health maintenance organization established, entered
into, or renewed after June 30, 1999.
(5) The addition of section 13 of this chapter by P.L.251-2003
applies to an employee health benefit plan that is entered into,
issued, delivered, amended, or renewed after June 30, 2003.
(6) The amendments made to section 7.7 of this chapter by
P.L.196-2005 apply to a self-insurance program or a contract
with a prepaid health care delivery plan that is established,
entered into, delivered, amended, or renewed after June 30,
2005.
(7) The addition of section 14 of this chapter by P.L.109-2008
applies to a state employee health plan that is established,
entered into, delivered, amended, or renewed after June 30,
2008.
As added by P.L.220-2011, SEC.65.
IC 5-10-8-0.3
Use of certain accrued benefits by state employees
Sec. 0.3. The benefits accrued by an employee under 31 IAC
1-9-5 (before its repeal) or 31 IAC 2-11-6 (before its repeal) that are
unused after June 30, 1989, may be used by the employee after June
30, 1989, in accordance with the rules required by section 7(d) of this
chapter, as amended by P.L.27-1988. The rules required by section
7(d) of this chapter, as amended by P.L.27-1988, must provide that
an employee who:
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(1) is subject to section 7(d) of this chapter; and
(2) has less than five (5) years of continuous full-time
employment after June 30, 1989;
will be credited with special sick leave on a pro rata basis after June
30, 1989.
As added by P.L.220-2011, SEC.66.
IC 5-10-8-0.4
Legalization of certain payments of deductible portion of group
health insurance
Sec. 0.4. Payment of the deductible portion of group health
insurance by a public employer before July 1, 1989, is legalized.
As added by P.L.220-2011, SEC.67.
IC 5-10-8-0.5
Repealed
(As added by P.L.220-2011, SEC.68. Repealed by P.L.91-2014,
SEC.8.)
IC 5-10-8-1
Definitions
Sec. 1. The following definitions apply in this chapter:
(1) "Employee" means:
(A) an elected or appointed officer or official, or a full-time
employee;
(B) if the individual is employed by a school corporation, a
full-time or part-time employee;
(C) for a local unit public employer, a full-time or part-time
employee or a person who provides personal services to the
unit under contract during the contract period; or
(D) a senior judge appointed under IC 33-24-3-7;
whose services have continued without interruption at least
thirty (30) days.
(2) "Group insurance" means any of the kinds of insurance
fulfilling the definitions and requirements of group insurance
contained in IC 27-1.
(3) "Insurance" means insurance upon or in relation to human
life in all its forms, including life insurance, health insurance,
disability insurance, accident insurance, hospitalization
insurance, surgery insurance, medical insurance, and
supplemental medical insurance.
(4) "Local unit" includes a city, town, county, township, public
library, municipal corporation (as defined in IC 5-10-9-1),
school corporation, or charter school.
(5) "New traditional plan" means a self-insurance program
established under section 7(b) of this chapter to provide health
care coverage.
(6) "Public employer" means the state or a local unit, including
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any board, commission, department, division, authority,
institution, establishment, facility, or governmental unit under
the supervision of either, having a payroll in relation to persons
it immediately employs, even if it is not a separate taxing unit.
With respect to the legislative branch of government, "public
employer" or "employer" refers to the following:
(A) The president pro tempore of the senate, with respect to
former members or employees of the senate.
(B) The speaker of the house, with respect to former
members or employees of the house of representatives.
(C) The legislative council, with respect to former
employees of the legislative services agency.
(7) "Public employer" does not include a state educational
institution.
(8) "Retired employee" means:
(A) in the case of a public employer that participates in the
public employees' retirement fund, a former employee who
qualifies for a benefit under IC 5-10.3-8 or IC 5-10.2-4;
(B) in the case of a public employer that participates in the
teachers' retirement fund under IC 5-10.4, a former employee
who qualifies for a benefit under IC 5-10.4-5; and
(C) in the case of any other public employer, a former
employee who meets the requirements established by the
public employer for participation in a group insurance plan
for retired employees.
(9) "Retirement date" means the date that the employee has
chosen to receive retirement benefits from the employees'
retirement fund.
As added by Acts 1980, P.L.8, SEC.41. Amended by P.L.39-1986,
SEC.1; P.L.56-1989, SEC.1; P.L.39-1990, SEC.1; P.L.40-1990,
SEC.1; P.L.233-1999, SEC.1; P.L.50-2000, SEC.1; P.L.13-2001,
SEC.7; P.L.98-2004, SEC.65; P.L.2-2006, SEC.14; P.L.2-2007,
SEC.81; P.L.194-2007, SEC.1; P.L.91-2011, SEC.1.
IC 5-10-8-2
Repealed
(Repealed by P.L.24-1985, SEC.25(c).)
IC 5-10-8-2.1
Repealed
(Repealed by P.L.1-1991, SEC.32.)
IC 5-10-8-2.2
Public safety employees; surviving spouses; dependents
Sec. 2.2. (a) As used in this section, "dependent" means a natural
child, stepchild, or adopted child of a public safety employee who:
(1) is less than eighteen (18) years of age;
(2) is at least eighteen (18) years of age and has a physical or
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mental disability (using disability guidelines established by the
Social Security Administration); or
(3) is at least eighteen (18) and less than twenty-three (23) years
of age and is enrolled in and regularly attending a secondary
school or is a full-time student at an accredited college or
university.
(b) As used in this section, "public safety employee" means a
full-time firefighter, police officer, county police officer, or sheriff.
(c) This section applies only to local unit public employers and
their public safety employees.
(d) A local unit public employer may provide programs of group
health insurance for its active and retired public safety employees
through one (1) of the following methods:
(1) By purchasing policies of group insurance.
(2) By establishing self-insurance programs.
(3) If the local unit public employer is a school corporation, by
electing to provide the coverage through a state employee health
plan under section 6.7 of this chapter.
A local unit public employer may provide programs of group
insurance other than group health insurance for the local unit public
employer's active and retired public safety employees by purchasing
policies of group insurance and by establishing self-insurance
programs. However, the establishment of a self-insurance program
is subject to the approval of the unit's fiscal body.
(e) A local unit public employer may pay a part of the cost of
group insurance for its active and retired public safety employees.
However, a local unit public employer that provides group life
insurance for its active and retired public safety employees shall pay
a part of the cost of that insurance.
(f) A local unit public employer may not cancel an insurance
contract under this section during the policy term of the contract.
(g) After June 30, 1989, a local unit public employer that provides
a group health insurance program for its active public safety
employees shall also provide a group health insurance program to the
following persons:
(1) Retired public safety employees.
(2) Public safety employees who are receiving disability
benefits under IC 36-8-6, IC 36-8-7, IC 36-8-7.5, IC 36-8-8, or
IC 36-8-10.
(3) Surviving spouses and dependents of public safety
employees who die while in active service or after retirement.
(h) A public safety employee who is retired or has a disability and
is eligible for group health insurance coverage under subsection
(g)(1) or (g)(2):
(1) may elect to have the person's spouse, dependents, or spouse
and dependents covered under the group health insurance
program at the time the person retires or becomes disabled;
(2) must file a written request for insurance coverage with the
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employer within ninety (90) days after the person retires or
begins receiving disability benefits; and
(3) must pay an amount equal to the total of the employer's and
the employee's premiums for the group health insurance for an
active public safety employee (however, the employer may elect
to pay any part of the person's premiums).
(i) Except as provided in IC 36-8-6-9.7(f), IC 36-8-6-10.1(h),
IC 36-8-7-12.3(g), IC 36-8-7-12.4(j), IC 36-8-7.5-13.7(h),
IC 36-8-7.5-14.1(i), IC 36-8-8-13.9(d), IC 36-8-8-14.1(h), and
IC 36-8-10-16.5 for a surviving spouse or dependent of a public
safety employee who dies in the line of duty, a surviving spouse or
dependent who is eligible for group health insurance under
subsection (g)(3):
(1) may elect to continue coverage under the group health
insurance program after the death of the public safety
employee;
(2) must file a written request for insurance coverage with the
employer within ninety (90) days after the death of the public
safety employee; and
(3) must pay the amount that the public safety employee would
have been required to pay under this section for coverage
selected by the surviving spouse or dependent (however, the
employer may elect to pay any part of the surviving spouse's or
dependents' premiums).
(j) The eligibility for group health insurance under this section for
a public safety employee who is retired or has a disability ends on the
earlier of the following:
(1) When the public safety employee becomes eligible for
Medicare coverage as prescribed by 42 U.S.C. 1395 et seq.
(2) When the employer terminates the health insurance program
for active public safety employees.
(k) A surviving spouse's eligibility for group health insurance
under this section ends on the earliest of the following:
(1) When the surviving spouse becomes eligible for Medicare
coverage as prescribed by 42 U.S.C. 1395 et seq.
(2) When the unit providing the insurance terminates the health
insurance program for active public safety employees.
(3) The date of the surviving spouse's remarriage.
(4) When health insurance becomes available to the surviving
spouse through employment.
(l) A dependent's eligibility for group health insurance under this
section ends on the earliest of the following:
(1) When the dependent becomes eligible for Medicare
coverage as prescribed by 42 U.S.C. 1395 et seq.
(2) When the unit providing the insurance terminates the health
insurance program for active public safety employees.
(3) When the dependent no longer meets the criteria set forth in
subsection (a).
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(4) When health insurance becomes available to the dependent
through employment.
(m) A public safety employee who is on leave without pay is
entitled to participate for ninety (90) days in any group health
insurance program maintained by the local unit public employer for
active public safety employees if the public safety employee pays an
amount equal to the total of the employer's and the employee's
premiums for the insurance. However, the employer may pay all or
part of the employer's premium for the insurance.
(n) A local unit public employer may provide group health
insurance for retired public safety employees or their spouses not
covered by subsections (g) through (l) and may provide group health
insurance that contains provisions more favorable to retired public
safety employees and their spouses than required by subsections (g)
through (l). A local unit public employer may provide group health
insurance to a public safety employee who is on leave without pay
for a longer period than required by subsection (m), and may
continue to pay all or a part of the employer's premium for the
insurance while the employee is on leave without pay.
As added by P.L.58-1989, SEC.2. Amended by P.L.41-1990, SEC.2;
P.L.286-2001, SEC.1; P.L.86-2003, SEC.1; P.L.2-2005, SEC.15;
P.L.99-2007, SEC.13; P.L.3-2008, SEC.24; P.L.182-2009(ss),
SEC.65; P.L.91-2014, SEC.9.
IC 5-10-8-2.5
Repealed
(Repealed by P.L.14-1986, SEC.19.)
IC 5-10-8-2.6
Local unit public employers and employees; programs;
self-insurance; payment of part of cost; noncancelability; retired
employees
Sec. 2.6. (a) This section applies only to local unit public
employers and their employees. This section does not apply to public
safety employees, surviving spouses, and dependents covered by
section 2.2 of this chapter.
(b) A public employer may provide programs of group insurance
for its employees and retired employees. The public employer may,
however, exclude part-time employees and persons who provide
services to the unit under contract from any group insurance
coverage that the public employer provides to the employer's
full-time employees. A public employer may provide programs of
group health insurance under this section through one (1) of the
following methods:
(1) By purchasing policies of group insurance.
(2) By establishing self-insurance programs.
(3) If the local unit public employer is a school corporation, by
electing to provide the coverage through a state employee health
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plan under section 6.7 of this chapter.
A public employer may provide programs of group insurance other
than group health insurance under this section by purchasing policies
of group insurance and by establishing self-insurance programs.
However, the establishment of a self-insurance program is subject to
the approval of the unit's fiscal body.
(c) A public employer may pay a part of the cost of group
insurance, but shall pay a part of the cost of group life insurance for
local employees. A public employer may pay, as supplemental
wages, an amount equal to the deductible portion of group health
insurance as long as payment of the supplemental wages will not
result in the payment of the total cost of the insurance by the public
employer.
(d) An insurance contract for local employees under this section
may not be canceled by the public employer during the policy term
of the contract.
(e) After June 30, 1986, a public employer shall provide a group
health insurance program under subsection (g) to each retired
employee:
(1) whose retirement date is:
(A) after May 31, 1986, for a retired employee who was a
teacher (as defined in IC 20-18-2-22) for a school
corporation; or
(B) after June 30, 1986, for a retired employee not covered
by clause (A);
(2) who will have reached fifty-five (55) years of age on or
before the employee's retirement date but who will not be
eligible on that date for Medicare coverage as prescribed by 42
U.S.C. 1395 et seq.;
(3) who will have completed twenty (20) years of creditable
employment with a public employer on or before the employee's
retirement date, ten (10) years of which must have been
completed immediately preceding the retirement date; and
(4) who will have completed at least fifteen (15) years of
participation in the retirement plan of which the employee is a
member on or before the employee's retirement date.
(f) A group health insurance program required by subsection (e)
must be equal in coverage to that offered active employees and must
permit the retired employee to participate if the retired employee
pays an amount equal to the total of the employer's and the
employee's premiums for the group health insurance for an active
employee and if the employee, within ninety (90) days after the
employee's retirement date, files a written request with the employer
for insurance coverage. However, the employer may elect to pay any
part of the retired employee's premiums.
(g) A retired employee's eligibility to continue insurance under
subsection (e) ends when the employee becomes eligible for
Medicare coverage as prescribed by 42 U.S.C. 1395 et seq., or when
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the employer terminates the health insurance program. A retired
employee who is eligible for insurance coverage under subsection (e)
may elect to have the employee's spouse covered under the health
insurance program at the time the employee retires. If a retired
employee's spouse pays the amount the retired employee would have
been required to pay for coverage selected by the spouse, the
spouse's subsequent eligibility to continue insurance under this
section is not affected by the death of the retired employee. The
surviving spouse's eligibility ends on the earliest of the following:
(1) When the spouse becomes eligible for Medicare coverage as
prescribed by 42 U.S.C. 1395 et seq.
(2) When the employer terminates the health insurance
program.
(3) Two (2) years after the date of the employee's death.
(4) The date of the spouse's remarriage.
(h) This subsection does not apply to an employee who is entitled
to group insurance coverage under IC 20-28-10-2(b). An employee
who is on leave without pay is entitled to participate for ninety (90)
days in any group health insurance program maintained by the public
employer for active employees if the employee pays an amount equal
to the total of the employer's and the employee's premiums for the
insurance. However, the employer may pay all or part of the
employer's premium for the insurance.
(i) A public employer may provide group health insurance for
retired employees or their spouses not covered by subsections (e)
through (g) and may provide group health insurance that contains
provisions more favorable to retired employees and their spouses
than required by subsections (e) through (g). A public employer may
provide group health insurance to an employee who is on leave
without pay for a longer period than required by subsection (h), and
may continue to pay all or a part of the employer's premium for the
insurance while the employee is on leave without pay.
As added by P.L.1-1991, SEC.33. Amended by P.L.286-2001, SEC.2;
P.L.1-2005, SEC.76; P.L.182-2009(ss), SEC.66; P.L.91-2014,
SEC.10.
IC 5-10-8-2.7
Insurance of rostered volunteers
Sec. 2.7. (a) As used in this section, "rostered volunteer" means
a volunteer:
(1) whose name has been entered on a roster of volunteers for
a volunteer program operated by a local unit; and
(2) who has been approved by the proper authorities of the local
unit.
The term does not include a volunteer firefighter (as defined in
IC 36-8-12-2) or an inmate assigned to a correctional facility
operated by the state or a local unit.
(b) As used in this section, "local unit" does not include a school
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corporation.
(c) The fiscal body of a local unit may elect to provide insurance
for rostered volunteers for life, accident, or sickness coverage.
As added by P.L.51-1993, SEC.1.
IC 5-10-8-3
Repealed
(Repealed by P.L.24-1985, SEC.25(c).)
IC 5-10-8-3.1
Employees withholding from salaries or wages; retired employees;
assignment of part of retirement benefit
Sec. 3.1. (a) A public employer that contracts for a group
insurance plan or establishes a self-insurance plan for its employees
may withhold or cause to be withheld from participating employees'
salaries or wages whatever part of the cost of the plan the employees
are required to pay. The chief fiscal officer responsible for issuing
paychecks or warrants to the employees shall make deductions from
the individual employees' paychecks or warrants to pay the premiums
for the insurance. Except as provided by section 7(d) of this chapter,
the fiscal officer shall require written authorization from state
employees, and may require written authorization from local
employees, to make the deductions. One (1) authorization signed by
an employee is sufficient authorization for the fiscal officer to
continue to make deductions for this purpose until revoked in writing
by the employee.
(b) A public employer that contracts for a group insurance plan or
establishes a self-insurance plan for its retired employees may
require that the retired employees pay any part of the cost of the plan
that is not paid by the public employer. A retired employee may
assign part or all of the retired employee's benefit payable under
IC 5-10.3-8, IC 5-10.4-5, or any other retirement program for this
required payment.
As added by P.L.24-1985, SEC.10. Amended by P.L.27-1988, SEC.3;
P.L.2-2006, SEC.15.
IC 5-10-8-4
Discrimination as to form of insurance between certain employees;
exception
Sec. 4. Self-insurance plans for state employees involving income
disability insurance, principal amount accident insurance, or both,
must not, as to the form or forms of the insurance, discriminate
between the employees of any department, commission, board,
division, facility, institution, authority, or other establishment, except
that the contributions for the insurance and benefits from the
insurance may be equitably graduated in relation to:
(1) the employment compensation schedule; and
(2) if actuarially justified, the employee's age.
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As added by Acts 1980, P.L.8, SEC.41. Amended by P.L.24-1985,
SEC.11; P.L.27-1988, SEC.4.
IC 5-10-8-5
Establishment of common and unified plan of group insurance
Sec. 5. Two (2) or more local public employers may establish a
common and unified plan of group insurance for their employees,
including retired local employees. The plan shall be effected through
a trust, agency, or any other legal arrangement with careful
accounting and fiscal responsibility.
As added by Acts 1980, P.L.8, SEC.41. Amended by P.L.24-1985,
SEC.12.
IC 5-10-8-6
Establishment of common and unified plans by state law
enforcement agencies; trust fund for prefunding state
contributions and OPEB liability
Sec. 6. (a) The state police department, conservation officers of
the department of natural resources, and the state excise police may
establish common and unified plans of self-insurance for their
employees, including retired employees, as separate entities of state
government. These plans may be administered by a private agency,
business firm, limited liability company, or corporation. Any
modification to:
(1) eligibility requirements;
(2) required premiums; or
(3) any other plan provisions;
that increases the amount of the state's contribution to the plan or that
increases the post-employment liability under the plan may not be
made unless the modification is approved by the budget agency with
an annual review of the modifications by the budget committee.
(b) Except as provided in this section and IC 5-10-14, the state
agencies listed in subsection (a) may not pay as the employer part of
benefits for any employee or retiree an amount greater than that paid
for other state employees for group insurance.
(c) This subsection applies to a health benefit plan for an
individual described in subsection (a). After June 30, 2011, at least
one (1) time in each state fiscal year, the budget agency shall
determine the average amount of contributions made under
IC 5-10-8.5-15 and IC 5-10-8.5-16 to participants in a health
reimbursement arrangement or other separate fund under IC 5-10-8.5
in the immediately preceding state fiscal year. In the state fiscal year
beginning July 1, 2011, the amount determined under this section
must exclude contributions made to persons described in
IC 5-10-8.5-15(c) and IC 5-10-8.5-16(f). An amount equal to the
average amount determined under this subsection multiplied by the
number of participants (other than retired participants) in the plans
described in subsection (a) shall be transferred to the plans described
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in subsection (a). The amount transferred under this subsection shall
be proportionally allocated to each plan relative to the number of
members in each plan. The amount allocated to a plan under this
subsection shall be allocated among the participants in the plan in the
same manner as other employer contributions. Funds shall be used
only to reduce unfunded other post-employment benefit (OPEB)
liability and not to increase benefits or reduce premiums.
(d) Trust funds may be established to carry out the purposes of
this section. A trust fund established under this subsection is
considered a trust fund for purposes of IC 4-9.1-1-7. Money may not
be transferred, assigned, or otherwise removed from a trust fund
established under this subsection by the state board of finance, the
budget agency, or any other state agency. Money in a trust fund
established under this subsection does not revert to the state general
fund at the end of any state fiscal year. A trust fund established under
this subsection consists of appropriations, revenues, or transfers to
the trust fund under IC 4-12-1. Contributions to a trust fund
established under this subsection are irrevocable. A trust fund
established under this subsection must be limited to providing
prefunding of annual required contributions and to cover OPEB
liability for covered individuals. Funds may be used only for these
purposes and not to increase benefits or reduce premiums. A trust
fund established under this subsection shall be established to comply
with and be administered in a manner that satisfies the Internal
Revenue Code requirements concerning a trust fund for prefunding
annual required contributions and for covering OPEB liability for
covered individuals. All assets in a trust fund established under this
subsection:
(1) are dedicated exclusively to providing benefits to covered
individuals and their beneficiaries according to the terms of the
health plan; and
(2) are exempt from levy, sale, garnishment, attachment, or
other legal process.
A trust fund established under this subsection shall be administered
by the agency employing the covered individuals. The expenses of
administering a trust fund established under this subsection shall be
paid from money in the trust fund. The treasurer of state shall invest
the money in a trust fund established under this subsection not
currently needed to meet the obligations of the trust fund in the same
manner as other public money may be invested.
As added by Acts 1980, P.L.8, SEC.41. Amended by Acts 1982,
P.L.36, SEC.1; P.L.24-1985, SEC.13; P.L.14-1986, SEC.11;
P.L.8-1993, SEC.53; P.L.24-2005, SEC.1; P.L.170-2005, SEC.15;
P.L.1-2006, SEC.95; P.L.227-2007, SEC.55; P.L.229-2011, SEC.68;
P.L.138-2012, SEC.2.
IC 5-10-8-6.5
General assembly members and former members
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Sec. 6.5. (a) A member of the general assembly may elect to
participate in either:
(1) the plan of self-insurance established by the state police
department under section 6 of this chapter;
(2) the plan of self-insurance established by the state personnel
department under section 7 of this chapter; or
(3) a prepaid health care delivery plan established under section
7 of this chapter.
(b) A former member of the general assembly who meets the
criteria for participation in a group health insurance program
provided under section 8(e) or 8.1 of this chapter may elect to
participate in either:
(1) the plan of self-insurance established by the state police
department under section 6 of this chapter; or
(2) a group health insurance program provided under section
8(e) or 8.1 of this chapter.
(c) A member of the general assembly or former member of the
general assembly who chooses a plan described in subsection (a)(1)
or (b)(1) shall pay any amount of both the employer and the
employee share of the cost of the coverage that exceeds the cost of
the coverage under the new traditional plan.
As added by P.L.233-1999, SEC.2.
IC 5-10-8-6.6
Repealed
(As added by P.L.286-2001, SEC.3. Amended by P.L.91-2014,
SEC.11. Repealed by P.L.121-2016, SEC.7.)
IC 5-10-8-6.7
Election of state employee health care program by school
corporation
Sec. 6.7. (a) As used in this section, "state employee health plan"
means a:
(1) self-insurance program established under section 7(b) of this
chapter; or
(2) contract with a prepaid health care delivery plan entered into
under section 7(c) of this chapter;
to provide group health coverage for state employees.
(b) The state personnel department shall allow a school
corporation or charter school to elect to provide coverage of health
care services for active and retired employees of the school
corporation under any state employee health plan. If a school
corporation or charter school elects to provide coverage of health
care services for active and retired employees of the school
corporation or charter school under a state employee health plan, it
must provide coverage for all active and retired employees of the
school corporation or charter school under the state employee health
plan (other than any employees covered by an Indiana
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comprehensive health insurance association policy or individuals
who retire from the school corporation before July 1, 2010, or charter
school before July 1, 2011) if coverage was provided for these
employees under the prior policies.
(c) The following apply if a school corporation or charter school
elects to provide coverage for active and retired employees of the
school corporation or charter school under subsection (b):
(1) The state shall not pay any part of the cost of the coverage.
(2) The coverage provided to an active or retired school
corporation or charter school employee under this section must
be the same as the coverage provided to an active or retired
state employee under the state employee health plan.
(3) Notwithstanding sections 2.2 and 2.6 of this chapter:
(A) the school corporation or charter school shall pay for the
coverage provided to an active or retired school corporation
or charter school employee under this section an amount not
more than the amount paid by the state for coverage
provided to an active or retired state employee under the
state employee health plan; and
(B) an active or retired school corporation or charter school
employee shall pay for the coverage provided to the active
or retired school corporation or charter school employee
under this section an amount that is at least equal to the
amount paid by an active or retired state employee for
coverage provided to the active or retired state employee
under the state employee health plan.
However, this subdivision does not apply to contractual
commitments made by a school corporation to individuals who
retire before July 1, 2010, or by a charter school to individuals
who retire before July 1, 2011.
(4) The school corporation or charter school shall pay any
administrative costs of the school corporation's or charter
school's participation in the state employee health plan.
(5) The school corporation or charter school shall provide the
coverage elected under subsection (b) for a period of at least
three (3) years beginning on the date the coverage of the school
corporation or charter school employees under the state
employee health plan begins.
(d) The state personnel department shall provide an enrollment
period at least every thirty (30) days for a school corporation or
charter school that elects to provide coverage under subsection (b).
(e) The state personnel department may adopt rules under
IC 4-22-2 to implement this section.
(f) Neither this section nor a school corporation's or charter
school's election to participate in a state employee health plan as
provided in this section impairs the rights of an exclusive
representative of the certificated or noncertificated employees of the
school corporation or charter school to collectively bargain all
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matters related to school employee health insurance programs and
benefits.
As added by P.L.182-2009(ss), SEC.67. Amended by
P.L.182-2009(ss), SEC.515; P.L.109-2010, SEC.1; P.L.91-2011,
SEC.2; P.L.6-2012, SEC.26.
IC 5-10-8-6.8
Consolidation of certain school corporations; state employee health
plan
Sec. 6.8. (a) This section applies to a school corporation that
results from the consolidation, reorganization, or merger, after May
1, 2012, of:
(1) a school corporation that has elected to provide coverage of
health care services for active and retired employees of the
school corporation under a state employee health plan; and
(2) a school corporation that has not elected to provide coverage
of health care services for active and retired employees of the
school corporation under a state employee health plan.
(b) A school corporation that results from a consolidation,
reorganization, or merger described in subsection (a) must allow an
individual for whom the school corporation described in subsection
(a)(1) had (as of the effective date of the consolidation,
reorganization, or merger) health insurance liability under a state
employee health plan to continue the individual's coverage under the
state employee health plan for at least five (5) years, as long as the
individual otherwise remains eligible for coverage under the plan.
(c) This SECTION expires January 1, 2018.
As added by P.L.145-2012, SEC.2.
IC 5-10-8-7
Group insurance; self-insurance; health services; disability plans;
trust fund for prefunding state contributions and OPEB liability
Sec. 7. (a) The state, excluding state educational institutions, may
not purchase or maintain a policy of group insurance, except:
(1) life insurance for the state's employees;
(2) long term care insurance under a long term care insurance
policy (as defined in IC 27-8-12-5), for the state's employees;
or
(3) an insurance policy that provides coverage that supplements
coverage provided under a United States military health care
plan.
(b) With the consent of the governor, the state personnel
department may establish self-insurance programs to provide group
insurance other than life or long term care insurance for state
employees and retired state employees. The state personnel
department may contract with a private agency, business firm,
limited liability company, or corporation for administrative services.
A commission may not be paid for the placement of the contract. The
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department may require, as part of a contract for administrative
services, that the provider of the administrative services offer to an
employee terminating state employment the option to purchase,
without evidence of insurability, an individual policy of insurance.
(c) Notwithstanding subsection (a), with the consent of the
governor, the state personnel department may contract for health
services for state employees through one (1) or more prepaid health
care delivery plans.
(d) The state personnel department shall adopt rules under
IC 4-22-2 to establish long term and short term disability plans for
state employees (except employees who hold elected offices (as
defined by IC 3-5-2-17)). The plans adopted under this subsection
may include any provisions the department considers necessary and
proper and must:
(1) require participation in the plan by employees with six (6)
months of continuous, full-time service;
(2) require an employee to make a contribution to the plan in
the form of a payroll deduction;
(3) require that an employee's benefits under the short term
disability plan be subject to a thirty (30) day elimination period
and that benefits under the long term plan be subject to a six (6)
month elimination period;
(4) prohibit the termination of an employee who is eligible for
benefits under the plan;
(5) provide, after a seven (7) day elimination period, eighty
percent (80%) of base biweekly wages for an employee disabled
by injuries resulting from tortious acts, as distinguished from
passive negligence, that occur within the employee's scope of
state employment;
(6) provide that an employee's benefits under the plan may be
reduced, dollar for dollar, if the employee derives income from:
(A) Social Security;
(B) the public employees' retirement fund;
(C) the Indiana state teachers' retirement fund;
(D) pension disability;
(E) worker's compensation;
(F) benefits provided from another employer's group plan; or
(G) remuneration for employment entered into after the
disability was incurred.
(The department of state revenue and the department of
workforce development shall cooperate with the state personnel
department to confirm that an employee has disclosed complete
and accurate information necessary to administer subdivision
(6).);
(7) provide that an employee will not receive benefits under the
plan for a disability resulting from causes specified in the rules;
and
(8) provide that, if an employee refuses to:
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(A) accept work assignments appropriate to the employee's
medical condition;
(B) submit information necessary for claim administration;
or
(C) submit to examinations by designated physicians;
the employee forfeits benefits under the plan.
(e) This section does not affect insurance for retirees under
IC 5-10.3 or IC 5-10.4.
(f) The state may pay part of the cost of self-insurance or prepaid
health care delivery plans for its employees.
(g) A state agency may not provide any insurance benefits to its
employees that are not generally available to other state employees,
unless specifically authorized by law.
(h) The state may pay a part of the cost of group medical and life
coverage for its employees.
(i) To carry out the purposes of this section, a trust fund may be
established. The trust fund established under this subsection is
considered a trust fund for purposes of IC 4-9.1-1-7. Money may not
be transferred, assigned, or otherwise removed from the trust fund
established under this subsection by the state board of finance, the
budget agency, or any other state agency. Money in a trust fund
established under this subsection does not revert to the state general
fund at the end of any state fiscal year. The trust fund established
under this subsection consists of appropriations, revenues, or
transfers to the trust fund under IC 4-12-1. Contributions to the trust
fund are irrevocable. The trust fund must be limited to providing
prefunding of annual required contributions and to cover OPEB
liability for covered individuals. Funds may be used only for these
purposes and not to increase benefits or reduce premiums. The trust
fund shall be established to comply with and be administered in a
manner that satisfies the Internal Revenue Code requirements
concerning a trust fund for prefunding annual required contributions
and for covering OPEB liability for covered individuals. All assets
in the trust fund established under this subsection:
(1) are dedicated exclusively to providing benefits to covered
individuals and their beneficiaries according to the terms of the
health plan; and
(2) are exempt from levy, sale, garnishment, attachment, or
other legal process.
The trust fund established under this subsection shall be administered
by the state personnel department. The expenses of administering the
trust fund shall be paid from money in the trust fund. The treasurer
of state shall invest the money in the trust fund not currently needed
to meet the obligations of the trust fund in the same manner as other
public money may be invested.
As added by P.L.28-1983, SEC.50. Amended by P.L.24-1985,
SEC.14; P.L.39-1986, SEC.4; P.L.14-1986, SEC.12; P.L.27-1988,
SEC.5; P.L.8-1993, SEC.54; P.L.21-1995, SEC.10; P.L.14-1996,
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SEC.5; P.L.41-1997, SEC.1; P.L.286-2001, SEC.4; P.L.2-2006,
SEC.16; P.L.158-2006, SEC.2; P.L.2-2007, SEC.82; P.L.138-2012,
SEC.3; P.L.91-2014, SEC.12; P.L.121-2016, SEC.8.
IC 5-10-8-7.1
Coverage for autism spectrum disorder
Sec. 7.1. (a) As used in this section, "covered individual" means
an individual who is:
(1) covered under a self-insurance program established under
section 7(b) of this chapter to provide group health coverage; or
(2) entitled to health services under a contract with a prepaid
health care delivery plan that is entered into or renewed under
section 7(c) of this chapter.
(b) As used in this section, "autism spectrum disorder" means a
neurological condition, including Asperger's syndrome and autism,
as defined in the most recent edition of the Diagnostic and Statistical
Manual of Mental Disorders of the American Psychiatric
Association.
(c) A self-insurance program established under section 7(b) of this
chapter to provide health care coverage must provide a covered
individual with coverage for the treatment of an autism spectrum
disorder. Coverage provided under this section is limited to treatment
that is prescribed by the covered individual's treating physician in
accordance with a treatment plan. A self-insurance program may not
deny or refuse to issue coverage on, refuse to contract with, or refuse
to renew, refuse to reissue, or otherwise terminate or restrict
coverage on, an individual under an insurance policy or health plan
solely because the individual is diagnosed with an autism spectrum
disorder.
(d) A contract with a prepaid health care delivery plan that is
entered into or renewed under section 7(c) of this chapter must
provide a covered individual with services for the treatment of an
autism spectrum disorder. Services provided under this section are
limited to treatment that is prescribed by the covered individual's
treating physician in accordance with a treatment plan. A prepaid
health care delivery plan may not deny or refuse to provide services
to, or refuse to renew, refuse to reissue, or otherwise terminate or
restrict services to, an individual solely because the individual is
diagnosed with an autism spectrum disorder.
(e) The coverage required by subsection (c) and services required
by subsection (d) may not be subject to dollar limits, deductibles,
copayments, or coinsurance provisions that are less favorable to a
covered individual than the dollar limits, deductibles, copayments,
or coinsurance provisions that apply to physical illness generally
under the self-insurance program or contract with a prepaid health
care delivery plan.
As added by P.L.148-2001, SEC.1. Amended by P.L.188-2013,
SEC.2.
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IC 5-10-8-7.2
Breast cancer; definitions; self-insurance programs; health
maintenance organizations; diagnostic services
Sec. 7.2. (a) As used in this section, "breast cancer diagnostic
service" means a procedure intended to aid in the diagnosis of breast
cancer. The term includes procedures performed on an inpatient basis
and procedures performed on an outpatient basis, including the
following:
(1) Breast cancer screening mammography.
(2) Surgical breast biopsy.
(3) Pathologic examination and interpretation.
(b) As used in this section, "breast cancer outpatient treatment
services" means procedures that are intended to treat cancer of the
human breast and that are delivered on an outpatient basis. The term
includes the following:
(1) Chemotherapy.
(2) Hormonal therapy.
(3) Radiation therapy.
(4) Surgery.
(5) Other outpatient cancer treatment services prescribed by a
physician.
(6) Medical follow-up services related to the procedures set
forth in subdivisions (1) through (5).
(c) As used in this section, "breast cancer rehabilitative services"
means procedures that are intended to improve the results of or to
ameliorate the debilitating consequences of the treatment of breast
cancer and that are delivered on an inpatient or outpatient basis. The
term includes the following:
(1) Physical therapy.
(2) Psychological and social support services.
(3) Reconstructive plastic surgery.
(d) As used in this section, "breast cancer screening
mammography" means a standard, two (2) view per breast, low-dose
radiographic examination of the breasts that is:
(1) furnished to an asymptomatic woman; and
(2) performed by a mammography services provider using
equipment designed by the manufacturer for and dedicated
specifically to mammography in order to detect unsuspected
breast cancer.
The term includes the interpretation of the results of a breast cancer
screening mammography by a physician.
(e) As used in this section, "covered individual" means a female
individual who is:
(1) covered under a self-insurance program established under
section 7(b) of this chapter to provide group health coverage; or
(2) entitled to services under a contract with a health
maintenance organization (as defined in IC 27-13-1-19) that is
entered into or renewed under section 7(c) of this chapter.
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(f) As used in this section, "mammography services provider"
means an individual or facility that:
(1) has been accredited by the American College of Radiology;
(2) meets equivalent guidelines established by the state
department of health; or
(3) is certified by the federal Department of Health and Human
Services for participation in the Medicare program (42 U.S.C.
1395 et seq.).
(g) As used in this section, "woman at risk" means a woman who
meets at least one (1) of the following descriptions:
(1) A woman who has a personal history of breast cancer.
(2) A woman who has a personal history of breast disease that
was proven benign by biopsy.
(3) A woman whose mother, sister, or daughter has had breast
cancer.
(4) A woman who is at least thirty (30) years of age and has not
given birth.
(h) A self-insurance program established under section 7(b) of this
chapter to provide health care coverage must provide covered
individuals with coverage for breast cancer diagnostic services,
breast cancer outpatient treatment services, and breast cancer
rehabilitative services. The coverage must provide reimbursement for
breast cancer screening mammography at a level at least as high as:
(1) the limitation on payment for screening mammography
services established in 42 CFR 405.534(b)(3) according to the
Medicare Economic Index at the time the breast cancer
screening mammography is performed; or
(2) the rate negotiated by a contract provider according to the
provisions of the insurance policy;
whichever is lower. The costs of the coverage required by this
subsection may be paid by the state or by the employee or by a
combination of the state and the employee.
(i) A contract with a health maintenance organization that is
entered into or renewed under section 7(c) of this chapter must
provide covered individuals with breast cancer diagnostic services,
breast cancer outpatient treatment services, and breast cancer
rehabilitative services.
(j) The coverage required by subsection (h) and services required
by subsection (i) may not be subject to dollar limits, deductibles, or
coinsurance provisions that are less favorable to covered individuals
than the dollar limits, deductibles, or coinsurance provisions
applying to physical illness generally under the self-insurance
program or contract with a health maintenance organization.
(k) The coverage for breast cancer diagnostic services required by
subsection (h) and the breast cancer diagnostic services required by
subsection (i) must include the following:
(1) In the case of a covered individual who is at least thirty-five
(35) years of age but less than forty (40) years of age, at least
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one (1) baseline breast cancer screening mammography
performed upon the individual before she becomes forty (40)
years of age.
(2) In the case of a covered individual who is:
(A) less than forty (40) years of age; and
(B) a woman at risk;
at least one (1) breast cancer screening mammography
performed upon the covered individual every year.
(3) In the case of a covered individual who is at least forty (40)
years of age, at least one (1) breast cancer screening
mammography performed upon the individual every year.
(4) Any additional mammography views that are required for
proper evaluation.
(5) Ultrasound services, if determined medically necessary by
the physician treating the covered individual.
(l) The coverage for breast cancer diagnostic services required by
subsection (h) and the breast cancer diagnostic services required by
subsection (i) shall be provided in addition to any benefits
specifically provided for x-rays, laboratory testing, or wellness
examinations.
As added by P.L.35-1992, SEC.1. Amended by P.L.26-1994, SEC.1;
P.L.170-1999, SEC.1.
IC 5-10-8-7.3
Early intervention services for first steps children
Sec. 7.3. (a) As used in this section, "covered individual" means
an individual who is:
(1) covered under a self-insurance program established under
section 7(b) of this chapter to provide group health coverage; or
(2) entitled to services under a contract with a prepaid health
care delivery plan that is entered into or renewed under section
7(c) of this chapter.
(b) As used in this section, "early intervention services" means
services provided to a first steps child under IC 12-12.7-2 and 20
U.S.C. 1432(4).
(c) As used in this section, "first steps child" means an infant or
toddler from birth through two (2) years of age who is enrolled in the
Indiana first steps program and is a covered individual.
(d) As used in this section, "first steps program" refers to the
program established under IC 12-12.7-2 and 20 U.S.C. 1431 et seq.
to meet the needs of:
(1) children who are eligible for early intervention services; and
(2) their families.
The term includes the coordination of all available federal, state,
local, and private resources available to provide early intervention
services within Indiana.
(e) As used in this section, "health benefits plan" means a:
(1) self-insurance program established under section 7(b) of this
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chapter to provide group health coverage; or
(2) contract with a prepaid health care delivery plan that is
entered into or renewed under section 7(c) of this chapter.
(f) A health benefits plan that provides coverage for early
intervention services shall reimburse the first steps program a
monthly fee established by the division of disability and
rehabilitative services established by IC 12-9-1-1. The monthly fee
shall be provided instead of claims processing of individual claims.
(g) The reimbursement required under subsection (f) may not be
applied to any annual or aggregate lifetime limit on the first steps
child's coverage under the health benefits plan.
(h) The first steps program may pay required deductibles,
copayments, or other out-of-pocket expenses for a first steps child
directly to a provider. A health benefits plan shall apply any
payments made by the first steps program to the health benefits plan's
deductibles, copayments, or other out-of-pocket expenses according
to the terms and conditions of the health benefits plan.
As added by P.L.121-1999, SEC.1. Amended by P.L.246-2005,
SEC.47; P.L.93-2006, SEC.2; P.L.229-2011, SEC.69.
IC 5-10-8-7.5
Prostate specific antigen test
Sec. 7.5. (a) As used in this section, "covered individual" means
a male individual who is:
(1) covered under a self-insurance program established under
section 7(b) of this chapter to provide group health coverage; or
(2) entitled to services under a contract with a health
maintenance organization (as defined in IC 27-13-1-19) that is
entered into or renewed under section 7(c) of this chapter.
(b) As used in this section, "prostate specific antigen test" means
a standard blood test performed to determine the level of prostate
specific antigen in the blood.
(c) A self-insurance program established under section 7(b) of this
chapter to provide health care coverage must provide covered
individuals with coverage for prostate specific antigen testing.
(d) A contract with a health maintenance organization that is
entered into or renewed under section 7(c) of this chapter must
provide covered individuals with prostate specific antigen screening.
(e) The coverage required under subsections (c) and (d) must
include the following:
(1) At least one (1) prostate specific antigen test annually for a
covered individual who is at least fifty (50) years of age.
(2) At least one (1) prostate specific antigen test annually for a
covered individual who is less than fifty (50) years of age and
who is at high risk for prostate cancer according to the most
recent published guidelines of the American Cancer Society.
(f) The coverage required under this section may not be subject to
dollar limits, deductibles, copayments, or coinsurance provisions that
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are less favorable to covered individuals than the dollar limits,
deductibles, copayments, or coinsurance provisions applying to
physical illness generally under the self-insurance program or
contract with a health maintenance organization.
(g) The coverage for prostate specific antigen screening shall be
provided in addition to benefits specifically provided for x-rays,
laboratory testing, or wellness examinations.
As added by P.L.170-1999, SEC.2.
IC 5-10-8-7.7
Surgical treatment for morbid obesity
Sec. 7.7. (a) As used in this section, "covered individual" means
an individual who is covered under a health care plan.
(b) As used in this section, "health care plan" means:
(1) a self-insurance program established under section 7(b) of
this chapter to provide group health coverage; or
(2) a contract entered into under section 7(c) of this chapter to
provide health services through a prepaid health care delivery
plan.
(c) As used in this section, "health care provider" means a:
(1) physician licensed under IC 25-22.5; or
(2) hospital licensed under IC 16-21;
that provides health care services for surgical treatment of morbid
obesity.
(d) As used in this section, "morbid obesity" means:
(1) a body mass index of at least thirty-five (35) kilograms per
meter squared, with comorbidity or coexisting medical
conditions such as hypertension, cardiopulmonary conditions,
sleep apnea, or diabetes; or
(2) a body mass index of at least forty (40) kilograms per meter
squared without comorbidity.
For purposes of this subsection, body mass index is equal to weight
in kilograms divided by height in meters squared.
(e) Except as provided in subsection (f), the state shall provide
coverage for nonexperimental, surgical treatment by a health care
provider of morbid obesity:
(1) that has persisted for at least five (5) years; and
(2) for which nonsurgical treatment that is supervised by a
physician has been unsuccessful for at least six (6) consecutive
months.
(f) The state may not provide coverage for surgical treatment of
morbid obesity for a covered individual who is less than twenty-one
(21) years of age unless two (2) physicians licensed under IC 25-22.5
determine that the surgery is necessary to:
(1) save the life of the covered individual; or
(2) restore the covered individual's ability to maintain a major
life activity (as defined in IC 4-23-29-6);
and each physician documents in the covered individual's medical
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record the reason for the physician's determination.
As added by P.L.78-2000, SEC.1. Amended by P.L.196-2005, SEC.1;
P.L.102-2006, SEC.1.
IC 5-10-8-7.8
Colorectal cancer testing coverage
Sec. 7.8. (a) As used in this section, "covered individual" means
an individual who is:
(1) covered under a self-insurance program established under
section 7(b) of this chapter to provide group health coverage; or
(2) entitled to services under a contract with a health
maintenance organization (as defined in IC 27-13-1-19) that is
entered into or renewed under section 7(c) of this chapter.
(b) A:
(1) self-insurance program established under section 7(b) of this
chapter to provide health care coverage; or
(2) contract with a health maintenance organization that is
entered into or renewed under section 7(c) of this chapter;
must provide coverage for colorectal cancer examinations and
laboratory tests for cancer for any nonsymptomatic covered
individual, in accordance with the current American Cancer Society
guidelines.
(c) For a covered individual who is:
(1) at least fifty (50) years of age; or
(2) less than fifty (50) years of age and at high risk for
colorectal cancer according to the most recent published
guidelines of the American Cancer Society;
the coverage required under this section must meet the requirements
set forth in subsection (d).
(d) A covered individual may not be required to pay an additional
deductible or coinsurance for the colorectal cancer examination and
laboratory testing benefit that is greater than an annual deductible or
coinsurance established for similar benefits under a self-insurance
program or contract with a health maintenance organization. If the
program or contract does not cover a similar benefit, a deductible or
coinsurance may not be set at a level that materially diminishes the
value of the colorectal cancer examination and laboratory testing
benefit required under this section.
As added by P.L.54-2000, SEC.1.
IC 5-10-8-8
Retired employees; ability of employer to pay premiums
Sec. 8. (a) This section applies only to the state and employees
who are not covered by a plan established under section 6 of this
chapter.
(b) After June 30, 1986, the state shall provide a group health
insurance plan to each retired employee:
(1) whose retirement date is:
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(A) after June 29, 1986, for a retired employee who was a
member of the field examiners' retirement fund;
(B) after May 31, 1986, for a retired employee who was a
member of the Indiana state teachers' retirement fund; or
(C) after June 30, 1986, for a retired employee not covered
by clause (A) or (B);
(2) who will have reached fifty-five (55) years of age on or
before the employee's retirement date but who will not be
eligible on that date for Medicare coverage as prescribed by 42
U.S.C. 1395 et seq.; and
(3) who:
(A) for an employee who retires before January 1, 2007, will
have completed:
(i) twenty (20) years of creditable employment with a
public employer on or before the employee's retirement
date, ten (10) years of which shall have been completed
immediately preceding the retirement; and
(ii) at least fifteen (15) years of participation in the
retirement plan of which the employee is a member on or
before the employee's retirement date; or
(B) for an employee who retires after December 31, 2006,
will have completed fifteen (15) years of creditable
employment with a public employer on or before the
employee's retirement date, ten (10) years of which shall
have been completed immediately preceding the retirement.
(c) The state shall provide a group health insurance program to
each retired employee:
(1) who is a retired judge;
(2) whose retirement date is after June 30, 1990;
(3) who is at least sixty-two (62) years of age;
(4) who is not eligible for Medicare coverage as prescribed by
42 U.S.C. 1395 et seq.; and
(5) who has at least eight (8) years of service credit as a
participant in the Indiana judges' retirement fund, with at least
eight (8) years of that service credit completed immediately
preceding the judge's retirement.
(d) The state shall provide a group health insurance program to
each retired employee:
(1) who is a retired participant under the prosecuting attorneys
retirement fund;
(2) whose retirement date is after January 1, 1990;
(3) who is at least sixty-two (62) years of age;
(4) who is not eligible for Medicare coverage as prescribed by
42 U.S.C. 1395 et seq.; and
(5) who has at least ten (10) years of service credit as a
participant in the prosecuting attorneys retirement fund, with at
least ten (10) years of that service credit completed immediately
preceding the participant's retirement.
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(e) The state shall make available a group health insurance
program to each former member of the general assembly or surviving
spouse of each former member, if the former member:
(1) is no longer a member of the general assembly;
(2) is not eligible for Medicare coverage as prescribed by 42
U.S.C. 1395 et seq. or, in the case of a surviving spouse, the
surviving spouse is not eligible for Medicare coverage as
prescribed by 42 U.S.C. 1395 et seq.; and
(3) has at least ten (10) years of service credit as a member in
the general assembly.
A former member or surviving spouse of a former member who
obtains insurance under this section is responsible for paying both
the employer and the employee share of the cost of the coverage.
(f) The group health insurance program required under
subsections (b) through (e) and subsection (k) must be equal to that
offered active employees. The retired employee may participate in
the group health insurance program if the retired employee pays an
amount equal to the employer's and the employee's premium for the
group health insurance for an active employee and if the retired
employee within ninety (90) days after the employee's retirement
date files a written request for insurance coverage with the employer.
Except as provided in subsection (l), the employer may elect to pay
any part of the retired employee's premium with respect to insurance
coverage under this chapter.
(g) Except as provided in subsection (j), a retired employee's
eligibility to continue insurance under this section ends when the
employee becomes eligible for Medicare coverage as prescribed by
42 U.S.C. 1395 et seq., or when the employer terminates the health
insurance program. A retired employee who is eligible for insurance
coverage under this section may elect to have the employee's spouse
covered under the health insurance program at the time the employee
retires. If a retired employee's spouse pays the amount the retired
employee would have been required to pay for coverage selected by
the spouse, the spouse's subsequent eligibility to continue insurance
under this section is not affected by the death of the retired
employee. The surviving spouse's eligibility ends on the earliest of
the following:
(1) When the spouse becomes eligible for Medicare coverage as
prescribed by 42 U.S.C. 1395 et seq.
(2) When the employer terminates the health insurance
program.
(3) Two (2) years after the date of the employee's death.
(4) The date of the spouse's remarriage.
(h) This subsection does not apply to an employee who is entitled
to group insurance coverage under IC 20-28-10-2(b). An employee
who is on leave without pay is entitled to participate for ninety (90)
days in any health insurance program maintained by the employer for
active employees if the employee pays an amount equal to the total
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of the employer's and the employee's premiums for the insurance.
(i) An employer may provide group health insurance for retired
employees or their spouses not covered by this section and may
provide group health insurance that contains provisions more
favorable to retired employees and their spouses than required by this
section. A public employer may provide group health insurance to an
employee who is on leave without pay for a longer period than
required by subsection (h).
(j) An employer may elect to permit former employees and their
spouses, including surviving spouses, to continue to participate in a
group health insurance program under this chapter after the former
employee (who is otherwise qualified under this chapter to
participate in a group insurance program) or spouse has become
eligible for Medicare coverage as prescribed by 42 U.S.C. 1395 et
seq.
(k) The state shall provide a group health insurance program to
each retired employee:
(1) who was employed as a teacher in a state institution under:
(A) IC 11-10-5;
(B) IC 12-24-3;
(C) IC 16-33-3;
(D) IC 16-33-4;
(E) IC 20-21-2-1; or
(F) IC 20-22-2-1;
(2) who is at least fifty-five (55) years of age on or before the
employee's retirement date;
(3) who is not eligible for Medicare coverage as prescribed by
42 U.S.C. 1395 et seq.; and
(4) who:
(A) has at least fifteen (15) years of service credit as a
participant in the retirement fund of which the employee is
a member on or before the employee's retirement date; or
(B) completes at least ten (10) years of service credit as a
participant in the retirement fund of which the employee is
a member immediately before the employee's retirement.
(l) The president pro tempore of the senate and the speaker of the
house of representatives may not elect to pay any part of the
premium for insurance coverage under this chapter for a former
member of the general assembly or the spouse of a former member
of the general assembly whose last day of service as a member of the
general assembly is after July 31, 2007.
As added by P.L.39-1986, SEC.5. Amended by P.L.42-1990, SEC.1;
P.L.67-1995, SEC.1; P.L.233-1999, SEC.3; P.L.13-2001, SEC.8;
P.L.1-2005, SEC.77; P.L.178-2006, SEC.3; P.L.43-2007, SEC.12;
P.L.91-2014, SEC.13.
IC 5-10-8-8.1
Retired legislators
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Sec. 8.1. (a) This section applies only to the state and former
legislators.
(b) As used in this section, "legislator" means a member of the
general assembly.
(c) After June 30, 1988, the state shall provide to each retired
legislator:
(1) whose retirement date is after June 30, 1988;
(2) who is not participating in a group health insurance
coverage plan:
(A) including Medicare coverage as prescribed by 42 U.S.C.
1395 et seq.; but
(B) not including a group health insurance plan provided by
the state or a health insurance plan provided under
IC 27-8-10;
(3) who served as a legislator for at least ten (10) years; and
(4) who participated in a group health insurance plan provided
by the state on the legislator's retirement date;
a group health insurance program that is equal to that offered active
employees.
(d) A retired legislator who qualifies under subsection (c) may
participate in the group health insurance program if the retired
legislator:
(1) pays an amount equal to the employer's and employee's
premium for the group health insurance for an active employee;
and
(2) within ninety (90) days after the legislator's retirement date
files a written request for insurance coverage with the
employer.
(e) Except as provided in section 8(j) of this chapter, a retired
legislator's eligibility to continue insurance under this section ends
when the member becomes eligible for Medicare coverage as
prescribed by 42 U.S.C. 1395 et seq., or when the employer
terminates the health insurance program.
(f) A retired legislator who is eligible for insurance coverage
under this section may elect to have the legislator's spouse covered
under the health insurance program at the time the legislator retires.
If a retired legislator's spouse pays the amount the retired legislator
would have been required to pay for coverage selected by the spouse,
the spouse's subsequent eligibility to continue insurance under this
section is not affected by the death of the retired legislator and is not
affected by the retired legislator's eligibility for Medicare. Except as
provided in section 8(j) of this chapter, the spouse's eligibility ends
on the earliest of the following:
(1) When the spouse becomes eligible for Medicare coverage as
prescribed by 42 U.S.C. 1395 et seq.
(2) When the employer terminates the health insurance
program.
(3) The date of the spouse's remarriage.
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(g) The surviving spouse of a legislator who dies or has died in
office may elect to participate in the group health insurance program
if all of the following apply:
(1) The deceased legislator would have been eligible to
participate in the group health insurance program under this
section had the legislator retired on the day of the legislator's
death.
(2) The surviving spouse files a written request for insurance
coverage with the employer.
(3) The surviving spouse pays an amount equal to the
employer's and employee's premium for the group health
insurance for an active employee.
(h) Except as provided in section 8(j) of this chapter, the
eligibility of the surviving spouse of a legislator to purchase group
health insurance under subsection (g) ends on the earliest of the
following:
(1) When the employer terminates the health insurance
program.
(2) The date of the spouse's remarriage.
(3) When the spouse becomes eligible for Medicare coverage as
prescribed by 42 U.S.C. 1395 et seq.
As added by P.L.43-1988, SEC.2. Amended by P.L.36-1992, SEC.1;
P.L.22-1998, SEC.2; P.L.233-1999, SEC.4; P.L.13-2001, SEC.9.
IC 5-10-8-8.2
Former legislators
Sec. 8.2. (a) As used in this section, "former legislator" means a
former member of the general assembly.
(b) As used in this section, "dependent" means an unmarried
person who:
(1) is:
(A) a dependent child, stepchild, foster child, or adopted
child of a former legislator or spouse of a former legislator;
or
(B) a child who resides in the home of a former legislator or
spouse of a former legislator who has been appointed legal
guardian for the child; and
(2) is:
(A) less than twenty-three (23) years of age;
(B) at least twenty-three (23) years of age, incapable of
self-sustaining employment by reason of mental or physical
disability, and is chiefly dependent on a former legislator or
spouse of a former legislator for support and maintenance;
or
(C) at least twenty-three (23) years of age and less than
twenty-five (25) years of age and is enrolled in and is a
full-time student at an accredited college or university.
(c) As used in this section, "spouse" means a person who is or was
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married to a former legislator.
(d) After June 30, 2001, the state shall provide to a former
legislator:
(1) whose last day of service as a member of the general
assembly was after December 31, 2000;
(2) who served in all or part of at least four (4) terms of the
general assembly (as defined in IC 2-2.1-1-1);
(3) who pays an amount equal to the employee's and employer's
premium for the group health insurance for an active employee;
and
(4) who files a written request for insurance coverage with the
employer within ninety (90) days after the former legislator's:
(A) last day of service as a member of the general assembly;
or
(B) retirement date;
a group health insurance program that is equal to that offered to
active employees.
(e) Except as provided by section 8(j) of this chapter, the
eligibility of a former legislator to continue insurance under this
section ends when the former legislator becomes eligible for
Medicare coverage as prescribed by 42 U.S.C. 1395 et seq. or when
the employer terminates the health insurance program.
(f) A former legislator who is eligible for insurance coverage
under this section may elect to have a spouse or dependent of the
former legislator covered under the health insurance program. A
former legislator who makes an election under this subsection must
pay the employee's and employer's premium for the group health
insurance program for an active employee that is attributable to the
inclusion of a spouse or dependent.
(g) A spouse or dependent may continue insurance under this
section after the death of the former legislator if the spouse or
dependent pays the amount the former legislator would have been
required to pay for coverage selected by the spouse or dependent.
(h) Except as provided under section 8(j) of this chapter, the
eligibility of a spouse to continue insurance under this section ends
on the earliest of the following:
(1) When the employer terminates the health insurance
program.
(2) The date of the legislative spouse's remarriage.
(3) When the required amount for coverage is not paid with
respect to the spouse.
(4) When the spouse becomes eligible for Medicare coverage as
prescribed by 42 U.S.C. 1395 et seq.
(i) The eligibility of a dependent to continue insurance under this
section ends on the earliest of the following:
(1) When the employer terminates the health insurance
program.
(2) The date the dependent no longer meets the definition of a
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dependent.
(3) When the required amount for coverage is not paid with
respect to the dependent.
(j) The spouse of a deceased former legislator may elect to
participate in the group health insurance program under this section
if all of the following apply:
(1) The deceased legislator:
(A) died after December 31, 2000, while serving as a
member of the general assembly; and
(B) served in all or part of at least four (4) terms of the
general assembly (as defined in IC 2-2.1-1-1).
(2) The surviving spouse files a written request for insurance
coverage with the employer.
(3) The surviving spouse pays an amount equal to the
employee's and employer's premium for the group health
insurance for an active employee, including any amount with
respect to covered dependents of the former legislator.
(k) Except as provided under section 8(j) of this chapter, the
eligibility of the surviving spouse under subsection (j) ends on the
earliest of the following:
(1) When the employer terminates the health insurance
program.
(2) The date of the spouse's remarriage.
(3) When the required amount for coverage is not paid with
respect to the spouse and any covered dependent.
(4) When the surviving spouse becomes eligible for Medicare
coverage as prescribed by 42 U.S.C. 1395 et seq.
As added by P.L.13-2001, SEC.10. Amended by P.L.1-2007, SEC.26.
IC 5-10-8-8.3
Former state and legislative employees; health benefit plans
Sec. 8.3. (a) As used in this section, "department" refers to the
state personnel department.
(b) The department shall establish, or contract for the
establishment of, at least two (2) retiree health benefit plans to be
available for former employees of:
(1) the state; and
(2) the legislative branch of government;
whose employer elects under section 8(j) of this chapter to permit its
former employees to continue to participate in a health insurance
program under this chapter after the employees have become eligible
for Medicare coverage. At least one (1) of the plans offered to former
employees must include coverage for prescription drugs comparable
to a Medicare plan that provides prescription drug benefits. This
subsection expires July 1, 2014.
(c) The department shall not, after June 30, 2014, amend or renew
a retiree health benefit plan described in subsection (b) that is in
effect on June 30, 2014.
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(d) A retiree health benefit plan described in subsection (b) that
is in effect on June 30, 2014, terminates on the first plan renewal
date occurring after June 30, 2014.
As added by P.L.13-2001, SEC.11. Amended by P.L.91-2014,
SEC.14.
IC 5-10-8-8.4
Revocation or alteration by employer
Sec. 8.4. Except as provided by an enactment of the general
assembly, an election by an employer under:
(1) section 8(f) of this chapter concerning the payment of a
retired employee's premium; or
(2) section 8(j) of this chapter concerning Medicare coverage
and program eligibility;
may not be revoked or altered at any time by the employer or a
subsequent employer to the detriment of a person entitled to benefits
under section 8.2 of this chapter.
As added by P.L.184-2001, SEC.6.
IC 5-10-8-8.5
Establishment of retiree health benefit trust fund
Sec. 8.5. (a) The retiree health benefit trust fund is established to
provide funding for a retiree health benefit plan developed under
IC 5-10-8.5.
(b) The trust fund shall be administered by the budget agency. The
expenses of administering the trust fund shall be paid from money in
the trust fund. The trust fund consists of cigarette tax revenues
deposited in the fund under IC 6-7-1-28.1(7) and other
appropriations, revenues, or transfers to the trust fund under
IC 4-12-1.
(c) The treasurer of state shall invest the money in the trust fund
not currently needed to meet the obligations of the trust fund in the
same manner as other public money may be invested.
(d) The trust fund is considered a trust fund for purposes of
IC 4-9.1-1-7. Money may not be transferred, assigned, or otherwise
removed from the trust fund by the state board of finance, the budget
agency, or any other state agency.
(e) The trust fund shall be established and administered in a
manner that complies with Internal Revenue Code requirements
concerning health reimbursement arrangement (HRA) trusts.
Contributions by the state to the trust fund are irrevocable. All assets
held in the trust fund must be held for the exclusive benefit of
participants of the retiree health benefit plan developed under
IC 5-10-8.5 and their beneficiaries. All assets in the trust fund:
(1) are dedicated exclusively to providing benefits to
participants of the plan and their beneficiaries according to the
terms of the plan; and
(2) are exempt from levy, sale, garnishment, attachment, or
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other legal process.
(f) Money in the trust fund does not revert to the state general
fund at the end of any state fiscal year.
(g) The money in the trust fund is appropriated to the budget
agency for providing the retiree health benefit plan developed under
IC 5-10-8.5.
As added by P.L.182-2009(ss), SEC.68.
IC 5-10-8-9
Coverage of services for mental illness
Sec. 9. (a) This section does not apply if the application of this
section would increase the premiums of the health services policy or
plan, as certified under IC 27-8-5-15.7, by more than four percent
(4%) as a result of complying with subsection (c).
(b) As used in this section, "coverage of services for mental
illness" includes benefits with respect to mental health services as
defined by the contract, policy, or plan for health services. The term
includes services for the treatment of substance abuse and chemical
dependency when the services are required in the treatment of a
mental illness.
(c) If the state enters into a contract for health services through
prepaid health care delivery plans, medical self-insurance, or group
health insurance for state employees, the contract may not permit
treatment limitations or financial requirements on the coverage of
services for mental illness if similar limitations or requirements are
not imposed on the coverage of services for other medical or surgical
conditions.
(d) This section applies to a contract for health services through
prepaid health care delivery plans, medical self-insurance, or group
medical coverage for state employees that is issued, entered into, or
renewed after June 30, 1997.
(e) This section does not require the contract for health services
to offer mental health benefits.
As added by P.L.42-1997, SEC.1. Amended by P.L.81-1999, SEC.1;
P.L.291-2001, SEC.230.
IC 5-10-8-10
Examining infants for HIV; payment
Sec. 10. (a) The state shall cover the testing required under
IC 16-41-6-4 and the examinations required under IC 16-41-17-2
under a:
(1) self-insurance program established or maintained under
section 7(b) of this chapter to provide group health coverage;
and
(2) contract entered into or renewed under section 7(c) of this
chapter to provide health services through a prepaid health care
delivery plan.
(b) Payment to a hospital for a test required under IC 16-41-6-4
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must be in an amount equal to the hospital's actual cost of performing
the test.
As added by P.L.91-1999, SEC.1. Amended by P.L.237-2003, SEC.1.
IC 5-10-8-10.5
Dental care provisions required
Sec. 10.5. (a) As used in this section, "child" means an individual
who is less than nineteen (19) years of age.
(b) As used in this section, "covered individual" means a child or
an individual:
(1) with a physical or mental impairment that substantially
limits one (1) or more of the major life activities of the
individual; or
(2) who:
(A) has a record of; or
(B) is regarded as;
having an impairment described in subdivision (1).
(c) If the state enters into a contract for basic health care services
(as defined in IC 27-13-1-4) through prepaid health care delivery
plans, medical self-insurance, or group health insurance for state
employees, the contract must include coverage for anesthesia and
hospital charges for dental care for a covered individual if the mental
or physical condition of the covered individual requires dental
treatment to be rendered in a hospital or an ambulatory outpatient
surgical center. The Indications for General Anesthesia, as published
in the reference manual of the American Academy of Pediatric
Dentistry, are the utilization standards for determining whether
performing dental procedures necessary to treat the covered
individual's condition under general anesthesia constitutes
appropriate treatment.
(d) A health care contractor that issues a contract for basic health
care services as described in subsection (c) may:
(1) require prior authorization for hospitalization or treatment
in an ambulatory outpatient surgical center for dental care
procedures in the same manner that prior authorization is
required for hospitalization or treatment of other covered
medical conditions; and
(2) restrict coverage to include only procedures performed by
a licensed dentist who has privileges at the hospital or
ambulatory outpatient surgical center.
(e) This section does not apply to treatment rendered for temporal
mandibular joint disorders (TMJ).
As added by P.L.189-1999, SEC.1.
IC 5-10-8-11
Use of diagnostic or procedure codes
Sec. 11. (a) As used in this section, "administrator" means:
(1) the state personnel department;
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(2) an entity with which the state contracts to administer health
coverage under section 7(b) of this chapter; or
(3) a prepaid health care delivery plan with which the state
contracts under section 7(c) of this chapter.
(b) As used in this section, "health care plan" has the meaning set
forth in section 7.7 of this chapter.
(c) As used in this section, "provider" has the meaning set forth
in IC 27-8-11-1.
(d) Not more than ninety (90) days after the effective date of a
diagnostic or procedure code described in this subsection:
(1) an administrator shall begin using the most current version
of the:
(A) current procedural terminology (CPT);
(B) international classification of diseases (ICD);
(C) American Psychiatric Association's Diagnostic and
Statistical Manual of Mental Disorders (DSM);
(D) current dental terminology (CDT);
(E) Healthcare common procedure coding system (HCPCS);
and
(F) third party administrator (TPA);
codes under which the administrator pays claims for services
provided under a health care plan; and
(2) a provider shall begin using the most current version of the:
(A) current procedural terminology (CPT);
(B) international classification of diseases (ICD);
(C) American Psychiatric Association's Diagnostic and
Statistical Manual of Mental Disorders (DSM);
(D) current dental terminology (CDT);
(E) Healthcare common procedure coding system (HCPCS);
and
(F) third party administrator (TPA);
codes under which the provider submits claims for payment for
services provided under a health care plan.
(e) If a provider provides services that are covered under a health
care plan:
(1) after the effective date of the most current version of a
diagnostic or procedure code described in subsection (d); and
(2) before the administrator begins using the most current
version of the diagnostic or procedure code;
the administrator shall reimburse the provider under the version of
the diagnostic or procedure code that was in effect on the date that
the services were provided.
As added by P.L.161-2001, SEC.1. Amended by P.L.66-2002, SEC.1.
IC 5-10-8-12
Department report of the number of stimulant medication
prescriptions for covered children diagnosed with certain disorders
Sec. 12. (a) As used in this section, "covered individual" means
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an individual who is covered under an employee health plan.
(b) As used in this section, "employee health plan" means:
(1) a self-insurance program established under section 7(b) of
this chapter; or
(2) a contract with a prepaid health care delivery plan entered
into under section 7(c) of this chapter;
that provides a prescription drug benefit.
(c) The state personnel department may report to the drug
utilization review board established by IC 12-15-35-19, not later than
October 1 of each calendar year, the number of covered individuals
who are:
(1) less than eighteen (18) years of age; and
(2) prescribed a stimulant medication approved by the federal
Food and Drug Administration for the treatment of attention
deficit disorder or attention deficit hyperactivity disorder.
As added by P.L.107-2002, SEC.3.
IC 5-10-8-13
Mail order or Internet based pharmacy
Sec. 13. (a) As used in this section, "covered individual" means
an individual who is entitled to coverage under an employee health
benefit plan.
(b) As used in this section, "employee health benefit plan" means
a group plan of self-insurance, policy, or contract that:
(1) provides coverage for prescription drugs; and
(2) is established, purchased, or entered into by an employer for
the benefit of the employer's employees.
(c) As used in this section, "employer" means the following:
(1) A public employer.
(2) A state educational institution.
(d) As used in this section, "mail order or Internet based
pharmacy" has the meaning set forth in IC 25-26-18-1.
(e) An employee health benefit plan that provides coverage for
prescription drugs may designate a mail order or an Internet based
pharmacy to provide prescription drugs to a covered individual.
(f) An employee health benefit plan may not require a covered
individual to obtain a prescription drug from a pharmacy designated
under subsection (e) as a condition of coverage.
As added by P.L.251-2003, SEC.1. Amended by P.L.2-2007, SEC.83.
IC 5-10-8-14
Coverage for prosthetic devices
Sec. 14. (a) As used in this section, "covered individual" means
an individual who is entitled to coverage under a state employee
health plan.
(b) As used in this section, "orthotic device" means a medically
necessary custom fabricated brace or support that is designed as a
component of a prosthetic device.
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(c) As used in this section, "prosthetic device" means an artificial
leg or arm.
(d) As used in this section, "state employee health plan" means a:
(1) self-insurance program established under section 7(b) of this
chapter; or
(2) contract with a prepaid health care delivery plan that is
entered into or renewed under section 7(c) of this chapter;
to provide group health coverage. The term does not include a dental
or vision plan.
(e) A state employee health plan must provide coverage for
orthotic devices and prosthetic devices, including repairs or
replacements, that:
(1) are provided or performed by a person that is:
(A) accredited as required under 42 U.S.C. 1395m(a)(20); or
(B) a qualified practitioner (as defined in 42 U.S.C.
1395m(h)(1)(F)(iii));
(2) are determined by the covered individual's physician to be
medically necessary to restore or maintain the covered
individual's ability to perform activities of daily living or
essential job related activities; and
(3) are not solely for comfort or convenience.
(f) The:
(1) coverage required under subsection (e) must be equal to the
coverage that is provided for the same device, repair, or
replacement under the federal Medicare program (42 U.S.C.
1395 et seq.); and
(2) reimbursement under the coverage required under
subsection (e) must be equal to the reimbursement that is
provided for the same device, repair, or replacement under the
federal Medicare reimbursement schedule, unless a different
reimbursement rate is negotiated.
This subsection does not require a deductible under a state employee
health plan to be equal to a deductible under the federal Medicare
program.
(g) Except as provided in subsections (h) and (i), the coverage
required under subsection (e):
(1) may be subject to; and
(2) may not be more restrictive than;
the provisions that apply to other benefits under the state employee
health plan.
(h) The coverage required under subsection (e) may be subject to
utilization review, including periodic review, of the continued
medical necessity of the benefit.
(i) Any lifetime maximum coverage limitation that applies to
prosthetic devices and orthotic devices:
(1) must not be included in; and
(2) must be equal to;
the lifetime maximum coverage limitation that applies to all other
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items and services generally under the state employee health plan.
(j) For purposes of this subsection, "items and services" does not
include preventive services for which coverage is provided under a
high deductible health plan (as defined in 26 U.S.C. 220(c)(2) or 26
U.S.C. 223(c)(2)). The coverage required under subsection (e) may
not be subject to a deductible, copayment, or coinsurance provision
that is less favorable to a covered individual than the deductible,
copayment, or coinsurance provisions that apply to other items and
services generally under the state employee health plan.
As added by P.L.109-2008, SEC.1.
IC 5-10-8-14.8
Employee health plan providing coverage for prescription eye
drops
Sec. 14.8. (a) This section applies to an employee health plan that
provides coverage for prescription eye drops.
(b) As used in this section, "covered individual" means an
individual who is entitled to coverage under a state employee health
plan.
(c) As used in this section, "state employee health plan" means
one (1) of the following:
(1) A self-insurance program established under section 7(b) of
this chapter to provide group health coverage.
(2) A contract with a prepaid health care delivery plan that is
entered into or renewed under section 7(c) of this chapter.
(d) A state employee health plan must provide coverage for a
refill of prescription eye drops if the following are met:
(1) For a thirty (30) day supply, the covered individual requests
the refill not earlier than twenty-five (25) days after the date the
prescription eye drops were last dispensed to the covered
individual.
(2) For a ninety (90) day supply, the covered individual requests
the refill not earlier than seventy-five (75) days after the date
the prescription eye drops were last dispensed to the covered
individual.
(3) The prescribing practitioner has indicated on the
prescription that the prescription eye drops are refillable and the
refill requested by the covered individual does not exceed the
refillable amount remaining on the prescription.
(e) The coverage required by subsection (d) must not be subject
to dollar limits, copayments, deductibles, or coinsurance provisions
that are less favorable to a covered individual than the dollar limits,
copayments, deductibles, or coinsurance provisions that apply to
coverage for prescription drugs generally under the state employee
health plan.
(f) This section applies to a state employee health plan issued,
delivered, amended, or renewed after December 31, 2015.
As added by P.L.43-2015, SEC.1.
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IC 5-10-8-14.9
Coverage of methadone
Sec. 14.9. (a) This section applies to an employee health plan that
is established, entered into, amended, or renewed after June 30,
2015.
(b) As used in this section, "state employee health plan" means
one (1) of the following:
(1) A self-insurance program established under section 7(b) of
this chapter to provide group health coverage.
(2) A contract with a prepaid health care delivery plan that is
entered into or renewed under section 7(c) of this chapter.
(c) A state employee health plan may provide coverage for
methadone if the drug is prescribed for the treatment of pain or pain
management as follows:
(1) If the daily dosage is not more than sixty (60) milligrams.
(2) If the daily dosage is more than sixty (60) milligrams, only
if:
(A) prior authorization is obtained; and
(B) a determination of medical necessity has been shown by
the provider.
As added by P.L.209-2015, SEC.1. Amended by P.L.149-2016,
SEC.18.
IC 5-10-8-15
Coverage for care related to cancer clinical trials
Sec. 15. (a) As used in this section, "care method" means the use
of a particular drug or device in a particular manner.
(b) As used in this section, "clinical trial" means a Phase I, II, III,
or IV research study:
(1) that is conducted:
(A) using a particular care method to prevent, diagnose, or
treat a cancer for which:
(i) there is no clearly superior, noninvestigational
alternative care method; and
(ii) available clinical or preclinical data provides a
reasonable basis from which to believe that the care
method used in the research study is at least as effective as
any noninvestigational alternative care method;
(B) in a facility where personnel providing the care method
to be followed in the research study have:
(i) received training in providing the care method;
(ii) expertise in providing the type of care required for the
research study; and
(iii) experience providing the type of care required for the
research study to a sufficient volume of patients to
maintain expertise; and
(C) to scientifically determine the best care method to
prevent, diagnose, or treat the cancer; and
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(2) that is approved or funded by one (1) of the following:
(A) A National Institutes of Health institute.
(B) A cooperative group of research facilities that has an
established peer review program that is approved by a
National Institutes of Health institute or center.
(C) The federal Food and Drug Administration.
(D) The United States Department of Veterans Affairs.
(E) The United States Department of Defense.
(F) The institutional review board of an institution located
in Indiana that has a multiple project assurance contract
approved by the National Institutes of Health Office for
Protection from Research Risks as provided in 45 CFR
46.103.
(G) A research entity that meets eligibility criteria for a
support grant from a National Institutes of Health center.
(c) As used in this section, "covered individual" means an
individual entitled to coverage under a state employee plan.
(d) As used in this section, "nonparticipating provider" means a
health care provider that has not entered into a contract with a state
employee plan to serve as a participating provider.
(e) As used in this section, "participating provider" means a health
care provider that has entered into a contract with a state employee
plan to provide health care services to covered individuals with an
expectation of directly or indirectly receiving payment from the state
employee plan.
(f) As used in this section, "routine care cost" means the cost of
medically necessary services related to the care method that is under
evaluation in a clinical trial. The term does not include the following:
(1) The health care service, item, or investigational drug that is
the subject of the clinical trial.
(2) Any treatment modality that is not part of the usual and
customary standard of care required to administer or support the
health care service, item, or investigational drug that is the
subject of the clinical trial.
(3) Any health care service, item, or drug provided solely to
satisfy data collection and analysis needs that are not used in
the direct clinical management of the patient.
(4) An investigational drug or device that has not been approved
for market by the federal Food and Drug Administration.
(5) Transportation, lodging, food, or other expenses for the
patient or a family member or companion of the patient that are
associated with travel to or from a facility where a clinical trial
is conducted.
(6) A service, item, or drug that is provided by a clinical trial
sponsor free of charge for any new patient.
(7) A service, item, or drug that is eligible for reimbursement
from a source other than a covered individual's state employee
plan, including the sponsor of the clinical trial.
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(g) As used in this section, "state employee plan" means one (1)
of the following:
(1) A self-insurance program established under section 7(b) of
this chapter to provide group health coverage.
(2) A contract with a prepaid health care delivery plan that is
entered into or renewed under section 7(c) of this chapter.
(h) A state employee plan must provide coverage for routine care
costs that are incurred in the course of a clinical trial if the state
employee plan would provide coverage for the same routine care
costs not incurred in a clinical trial.
(i) The coverage that must be provided under this section is
subject to the terms, conditions, restrictions, exclusions, and
limitations that apply generally under the state employee plan,
including terms, conditions, restrictions, exclusions, or limitations
that apply to health care services rendered by participating providers
and nonparticipating providers.
(j) This section does not do any of the following:
(1) Require a state employee plan to provide coverage for
clinical trial services rendered by a participating provider.
(2) Prohibit a state employee plan from providing coverage for
clinical trial services rendered by a participating provider.
(3) Require reimbursement under a state employee plan for
services that are rendered in a clinical trial by a nonparticipating
provider at the same rate of reimbursement that would apply to
the same services rendered by a participating provider.
(k) This section does not create a cause of action against a person
for any harm to a covered individual resulting from a clinical trial.
As added by P.L.109-2009, SEC.1.
IC 5-10-8-16
High breast density
Sec. 16. (a) As used in this section, "covered individual" means
an individual who is entitled to coverage under a state employee
health plan.
(b) As used in this section, "high breast density" means a
condition in which there is a greater amount of breast and connective
tissue in comparison to fat in the breast.
(c) A state employee health plan must provide coverage for an
appropriate medical screening, test, or examination for a female
covered individual who is at least forty (40) years of age and who has
been determined to have high breast density.
As added by P.L.126-2013, SEC.1.
IC 5-10-8-17
Step therapy protocol
Sec. 17. (a) As used in this section, "covered individual" means
an individual entitled to coverage under a state employee health plan.
(b) As used in this section, "preceding prescription drug" means
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a prescription drug that, according to a step therapy protocol, must
be:
(1) first used to treat a covered individual's condition; and
(2) as a result of the treatment under subdivision (1),
determined to be inappropriate to treat the covered individual's
condition;
as a condition of coverage under a state employee health plan for
succeeding treatment with another prescription drug.
(c) As used in this section, "protocol exception" means a
determination by a state employee health plan that, based on a review
of a request for the determination and any supporting documentation:
(1) a step therapy protocol is not medically appropriate for
treatment of a particular covered individual's condition; and
(2) the state employee health plan will:
(A) not require the covered individual's use of a preceding
prescription drug under the step therapy protocol; and
(B) provide immediate coverage for another prescription
drug that is prescribed for the covered individual.
(d) As used in this section, "state employee health plan" refers to
the following that provide coverage for prescription drugs:
(1) A self-insurance program established under section 7(b) of
this chapter.
(2) A contract with a prepaid health care delivery plan that is
entered into or renewed under section 7(c) of this chapter.
The term includes a person that administers prescription drug
benefits on behalf of a state employee health plan.
(e) As used in this section, "step therapy protocol" means a
protocol that specifies, as a condition of coverage under a state
employee health plan, the order in which certain prescription drugs
must be used to treat a covered individual's condition.
(f) As used in this section, "urgent care situation" means a
covered individual's injury or condition about which the following
apply:
(1) If medical care or treatment is not provided earlier than the
time frame generally considered by the medical profession to be
reasonable for a nonurgent situation, the injury or condition
could seriously jeopardize the covered individual's:
(A) life or health; or
(B) ability to regain maximum function;
based on a prudent layperson's judgment.
(2) If medical care or treatment is not provided earlier than the
time frame generally considered by the medical profession to be
reasonable for a nonurgent situation, the injury or condition
could subject the covered individual to severe pain that cannot
be adequately managed, based on the covered individual's
treating health care provider's judgment.
(g) A state employee health plan shall publish on the state
employee health plan's Internet web site, and provide to a covered
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individual in writing, a procedure for the covered individual's use in
requesting a protocol exception. The procedure must include the
following provisions:
(1) A description of the manner in which a covered individual
may request a protocol exception.
(2) That the state employee health plan shall make a
determination concerning a protocol exception request, or an
appeal of a denial of a protocol exception request, not more
than:
(A) in an urgent care situation, one (1) business day after
receiving the request or appeal; or
(B) in a nonurgent care situation, three (3) business days
after receiving the request or appeal.
(3) That a protocol exception will be granted if any of the
following apply:
(A) A preceding prescription drug is contraindicated or will
likely cause an adverse reaction or physical or mental harm
to the covered individual.
(B) A preceding prescription drug is expected to be
ineffective, based on both of the following:
(i) The known clinical characteristics of the covered
individual.
(ii) Known characteristics of the preceding prescription
drug, as found in sound clinical evidence.
(C) The covered individual has previously received:
(i) a preceding prescription drug; or
(ii) another prescription drug that is in the same
pharmacologic class or has the same mechanism of action
as a preceding prescription drug;
and the prescription drug was discontinued due to lack of
efficacy or effectiveness, diminished effect, or an adverse
event.
(D) Based on clinical appropriateness, a preceding
prescription drug is not in the best interest of the covered
individual because the covered individual's use of the
preceding prescription drug is expected to:
(i) cause a significant barrier to the covered individual's
adherence to or compliance with the covered individual's
plan of care;
(ii) worsen a comorbid condition of the covered
individual; or
(iii) decrease the covered individual's ability to achieve or
maintain reasonable functional ability in performing daily
activities.
(4) That when a protocol exception is granted, the state
employee health plan shall notify the covered individual and the
covered individual's health care provider of the authorization
for coverage of the prescription drug that is the subject of the
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protocol exception.
(5) That if:
(A) a protocol exception request; or
(B) an appeal of a denied protocol exception request;
results in a denial of the protocol exception, the state employee
health plan shall provide to the covered individual and the
treating health care provider notice of the denial, including a
detailed, written explanation of the reason for the denial and the
clinical rationale that supports the denial.
(6) That the state employee health plan may request a copy of
relevant documentation from the covered individual's medical
record in support of a protocol exception.
As added by P.L.19-2016, SEC.1.
IC 5-10-8-18
Prescription drug coverage
Sec. 18. (a) The definitions in section 17 of this chapter apply
throughout this section.
(b) This section applies to a state employee health plan that uses
a formulary, cost sharing, or utilization review for prescription drug
coverage.
(c) A state employee health plan shall not remove a prescription
drug from the state employee health plan's formulary, change the cost
sharing requirements that apply to a prescription drug, or change the
utilization review requirements that apply to a prescription drug
unless the state employee health plan does at least one (1) of the
following:
(1) At least sixty (60) days before the removal or change is
effective, send written notice of the removal or change to each
covered individual for whom the prescription drug has been
prescribed during the preceding twelve (12) month period.
(2) At the time a covered individual for whom the prescription
drug has been prescribed during the preceding twelve (12)
month period requests a refill of the prescription drug, provide
to the covered individual:
(A) written notice of the removal or change; and
(B) a sixty (60) day supply of the prescription drug under the
terms that applied before the removal or change.
As added by P.L.19-2016, SEC.2.
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