IndianaHB 1003First Regular Session 124th General Assembly (2025)HouseWALLET

Health matters.

Summary

Specifies that the Medicaid fraud control unit's (MFCU) investigation of Medicaid fraud may include the investigation of provider fraud, insurer fraud, duplicate billing, and other instances of fraud. Permits the attorney general to enter into a data sharing agreement with specified state agencies and authorizes the MFCU to analyze this data to carry out its investigative duties. Provides that all complaints made to the MFCU are confidential until an action is filed concerning the complaint. Requires the office of the secretary of family and social services to establish: (1) metrics to assess the quality of care and patient outcomes; and (2) transparency and accountability safeguards; for a specified long term care risk based managed care program. Requires, not later than July 31, 2026, a clinical laboratory and diagnostic imaging facility to post certain pricing information for services determined by the department of insurance. Allows: (1) a manufacturer to provide; and (2) a patient to receive; individualized investigational treatment if certain conditions are met. Requires an Indiana nonprofit hospital system to report a list of facilities that may submit a bill on an institutional provider form and report the facility code for each facility. Adds provisions concerning payments by insurers, health maintenance organizations, employers, and other responsible persons to qualified providers that are providing services in an office setting. Requires good faith estimates for health care services to be provided at least two business days (rather than five business days) before the health care services are scheduled to be provided. Removes language concerning the disclosure of a trade secret from provisions that allow for a health plan sponsor to access and audit claims data. Provides that when a health carrier is in the process of negotiating a health provider contract with a health provider facility or provider, the health carrier must provide certain information to the health provider facility or provider. Prohibits certain provisions from being included in a health provider contract. Allows the department of insurance to: (1) enter into partnerships and joint ventures to encourage best practices in the appropriate and effective use of prior authorization in health care; and (2) receive information regarding prior authorization disputes. Requires the department of insurance to prepare a report with findings and recommendations related to the prior authorization dispute information. Requires, not later than September 1, 2025, the department of insurance to issue a request for information concerning ways to better enable medical consumers to compare and shop for medical and health care services. Provides that an insurer or a health maintenance organization may not deny a claim for reimbursement on the sole basis that the referring provider is an out of network provider. Requires, if a fully credentialed physician becomes employed with another employer or establishes or relocates a medical practice in Indiana, an insurer and health maintenance organization to provisionally credential the physician for 60 days or until the physician is fully credentialed, whichever is earlier. Requires the Indiana department of health, in consultation with the office of technology, to study the feasibility of developing certain standards regarding medical records and data.

insurancethe senatehealth and provider servicesinsurance and financial institutionsappropriations

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16 provisions identified: 13 benefits, 0 costs, 3 mixed.

Patients gain out-of-network payment protections

Insurers and health maintenance organizations cannot deny payment for covered care solely because the referring provider is out of network. This applies to policies and contracts issued or entered into, delivered, changed, or renewed after June 30, 2025. Separately, out-of-network practitioners cannot seek more than the plan’s established network rate without required notice, disclosures, and signed patient consent. These arrangements require at least five business days’ notice and a clear form explaining network status and billing limits. Without required notice and consent, bills must clearly state that patients owe no more than the network rate plus applicable copays, deductibles, and coinsurance.

Seriously ill patients gain treatment pathway

Beginning July 1, 2025, Indiana establishes a pathway for individualized investigational drugs, biological products, and devices. A physician must confirm a life-threatening or severely debilitating disease and document eligibility. Patients must consider FDA-approved options, receive a recommendation based on biological or genomic analysis, and give written informed consent. The framework covers eligible facilities operating under federal human-subject research protections. Indiana’s medical board cannot discipline doctors solely for recommending this treatment to eligible patients, but other disciplinary grounds remain.

Experimental treatment brings costs and protections

Manufacturers operating in eligible facilities can offer individualized investigational treatment under federal law, but do not have to supply it. They can provide it free or charge patients manufacturing costs. Written consent must explain approved options, why they are unlikely to help, treatment risks, and best, worst, and most likely outcomes. It must warn about possible insurance noncoverage, patient expenses unless coverage is legally or contractually required, and possible hospice ineligibility. Patients or guardians must consent; heirs are not liable for related outstanding debt if an eligible patient dies during treatment. The treatment chapter creates no new cause of action against manufacturers for treatment harms.

Hospitals must post prices for patients

Hospitals and outpatient surgery centers must post required prices online by December 31, 2025. Lists must include services they offer among 70 federally named services, plus their 30 most common additional services. Centers offering fewer than 30 additional services must list all of them. Each entry must describe the service and show applicable charges for private in-network plans, Medicare, Medicare Advantage, and Medicaid. Entries must also show self-pay charges without charity help and charges with the maximum help allowed by the facility’s policy.

Insurers must answer cost requests faster

Beginning July 1, 2025, health insurers must answer requested estimates for ordered nonemergency care within two business days, down from five. The deadline starts when the insurer receives the needed information. Estimates are free and valid for 30 days. Network plans must identify whether the facility and each scheduled practitioner are in network. Insurer websites for members must clearly state the two-business-day deadline for payment estimates or applicable benefit limits.

Patients and providers gain price disclosures

Provider contracts entered into, changed, or renewed after June 30, 2025 cannot block sharing prices and out-of-pocket costs with members. Allowed payment amounts and service fees can also be shared with treating providers. Insurers must give providers proposed service fees, statewide payment amounts at the 25th, 50th, and 75th percentiles, and administrative denial criteria. Providers must share their own payment amounts at those same percentiles. These disclosure rules do not set patient prices.

Patients get faster medical cost estimates

Beginning July 1, 2025, practitioners and facilities must provide requested nonemergency estimates within two business days after receiving needed information, down from five. Estimates are free, valid for 30 days, and not binding; medical needs can change the final cost. The request-based requirement excludes Medicaid recipients, while Medicare estimates must use available Medicare rates or cost-sharing rates. The short-scheduling exception shrinks from five business days to two business days after care is ordered. Providers must clearly explain estimate rights through at least three specified communication methods, including the two-business-day deadline. Providers and facilities must explain in writing bills exceeding estimates by more than the greater of $100 or 5%. Applicable exemptions remain for certain federally regulated providers.

Patients get imaging and lab prices

Covered imaging centers and clinical labs must post prices online by July 31, 2026. Indiana’s insurance department must publish separate lists of 50 imaging services and 50 lab services by May 1, 2026. Entries must include plain-language descriptions, discounted cash prices, and applicable lowest and highest negotiated prices without identifying insurers. The imaging rule excludes hospital-owned or hospital-operated facilities and specified dental, optometrist, and practitioner offices.

Insurers face stronger provider network oversight

Beginning July 1, 2025, Indiana must require insurer networks to meet standards at least as strict as federal Medicare agency standards. Reviews must consider the availability and variety of independent specialists serving in-network facilities. The insurance department can form partnerships to improve prior authorization, meaning plan-required preapproval, including utilization review. Late-2025 information collection covers prior authorization disputes and network access, with a report to lawmakers due December 1, 2026.

Patients get free digital health records

Beginning July 1, 2025, providers cannot charge for digital copies of electronic health records. They also cannot charge for digital access through platforms that let health record systems share information. Covered records include medical history and may include electronic billing and administrative records. Paper-copy fees are limited to amounts set by Indiana insurance department rules.

Patients get free X-ray copies

Beginning July 1, 2025, patients or their designees get free access to or copies of X-ray images. Patients must make a written request and give reasonable notice; original mammograms are excluded. Providers must keep images, including digital and microfilm images, for at least five years. Providers must tell patients about retention and free copies. Limited protection from civil liability for accidental destruction does not prevent professional discipline for violations.

Medicaid gains fraud and quality oversight

Beginning July 1, 2025, Indiana’s Medicaid fraud unit gains broader authority over provider fraud, insurer fraud, and duplicate billing. Its authority also covers misuse of patients’ private funds and abuse or neglect, including federally permitted investigations in board-and-care facilities. The attorney general can arrange data sharing with state revenue, family services, motor vehicles, and workforce agencies. The unit can use shared information only for its legal duties, and complaints stay confidential until a related legal action is filed. Indiana’s family services agency must also set care-quality and patient-outcome measures and transparency safeguards for Medicaid risk-based managed care. These oversight changes do not set new eligibility rules or benefit amounts.

Health plans gain fuller audit records

Beginning July 1, 2025, covered contracts must give plan sponsors ownership of claims data, subject to federal health privacy rules. Covered contracts include those entered into, issued, changed, or renewed after June 30, 2024. Health-plan and pharmacy benefit audits can no longer hide claim or payment information as trade secrets; privacy-related changes remain allowed. Eligible parties can request one audit per calendar year, with at least six months between requests where applicable. Pharmacy benefit managers must disclose rebates by drug category, claims data, manufacturer and purchasing-group revenue, and actual pharmacy payments. They cannot charge audit or auditor-selection fees, must help obtain third-party information, and must acknowledge requests within ten business days. Contracts entered into, renewed, or changed after June 30, 2024 cannot evade the pharmacy audit duties.

Doctors keep temporary insurer approval

Beginning July 1, 2025, insurers and health maintenance organizations must temporarily approve certain doctors already fully approved by them. This applies when doctors change Indiana employers or start or move an Indiana practice. Doctors must hold an Indiana license, Indiana reciprocity granted before July 1, 2026, or a license from a medical-licensure-compact state. Temporary approval ends after 60 days or upon full approval, whichever comes first. Plans must pay applicable agreement rates, using the new employer’s agreement when available or the prior agreement specified by law.

Hospital-employed providers face office billing rules

Beginning July 1, 2025, covered providers are legally authorized individuals or entities employed by Indiana nonprofit hospital systems. Covered offices provide routine exams, diagnosis, or non-invasive treatment more than 250 yards from a partly or wholly system-owned hospital’s main building. Hospital campuses and sites within 250 yards of a hospital remote location are excluded; surgery and invasive procedures do not qualify. Covered providers cannot use place-of-service codes 21 or 22 for office care. Beginning January 1, 2026, payors must use the physician fee schedule for covered in-network office claims filed on CMS 1500 forms or electronic equivalents. Payors can use contract or legal remedies for paid bills that violate the rules; providers can use contract dispute procedures. Payors or Indiana nonprofit hospital systems can report violations, and the health department can fine providers $1,000 per day.

Insurers and hospitals face contract limits

Provider contracts entered into, changed, or renewed after June 30, 2025 cannot block insurers from creating or changing select or tiered networks. Contracts cannot force all facilities into one tier or require all-or-nothing participation. Providers must have an opt-out right at least 60 days before a new select or tiered plan is submitted for approval. Beginning July 1, 2025, contracts involving a provider facility are void if they require renegotiation after legal changes. They are also void if they guarantee repayment of a law’s or regulation’s financial effects.

Sponsors & Cosponsors

Sponsor

Brad Barrett
Republican • House

Cosponsors

Ed Charbonneau
Republican • Senate
Lonnie Randolph
Democratic • Senate
Matt Lehman
Republican • House
Tony Isa
Republican • House
Tyler Johnson
Republican • Senate

Roll Call Votes

All Roll Calls

Yes: 211 • No: 78

House vote • 4/24/2025

Rules Suspended. Conference Committee Report 1: adopted by the House

Yes: 67 • No: 25

Senate vote • 4/24/2025

Rules Suspended. Conference Committee Report 1: adopted by the Senate

Yes: 30 • No: 20

Senate vote • 4/15/2025

Third reading: passed

Yes: 48 • No: 1

House vote • 2/18/2025