Good Faith Estimates

Effective beginning July 1, 2021, except as provided in subsection (l) of HEA 1004, a practitioner shall provide to a covered individual, at least five (5) days before the health care service is scheduled to be provided to the covered individual, a good faith estimate of the amount that the practitioner intends to charge the covered individual for the health care service and in compliance HEA 1004 — CC 1 5 with IC 25-1-9.8-14(a).

(i) An out of network practitioner who provides health care services at an in network facility to a covered individual may not be reimbursed more for the health care services than allowed according to the rate or amount of compensation established by the covered individual’s network plan unless all of the following conditions are met:

At least five (5) days before the health care services are scheduled to be provided to the covered individual, the practitioner provides to the covered individual, on a form separate from any other form provided to the covered individual by the practitioner, a statement inconspicuous type at least as large as 14 point type that meets the following requirements:

a. Includes a notice reading substantially as follows: “[Name of practitioner] intends to charge you more for [name or description of health care services] than allowed according to the rate or amount of compensation established by the network plan applying to your coverage. [Name of practitioner] is not entitled to charge this much for [name or description of healthcare services] unless you give your written consent to the charge.”.

b. Sets forth the practitioner’s good faith estimate of the amount that the practitioner intends to charge for the health care services provided to the covered individual.

c. Includes a notice reading substantially as follows concerning the good faith estimate set forth under clause (B): “The estimate of our intended charge for [name or description of health care services] set forth in this statement is provided in good faith and is our best estimate of the amount we will charge. If our actual charge for [name or description of health care services] exceeds our estimate, we will explain to you why the charge exceeds the estimate.”.

The covered individual signs the statement provided under subdivision (1), signifying the covered individual’s consent to the charge for the health care services being greater than allowed according to the rate or amount of compensation established by the network plan.

(j) If an out of network practitioner does not meet the requirements of subsection (i), the out of network practitioner shall include on any bill remitted to a covered individual a written HEA 1004 — CC 1 6 statement in 14 point type stating that the covered individual is not responsible for more than the rate or amount of compensation established by the covered individual’s network plan plus any required copayment, deductible, or coinsurance.

(k) If a covered individual’s network plan remits reimbursement to the covered individual for health care services subject to the reimbursement limitation of subsection (i), the network plan shall provide with the reimbursement a written statement in 14 point type that states that the covered individual is not responsible for more than the rate or amount of compensation established by the covered individual’s network plan and that is included in the reimbursement plus any required copayment, deductible, or coinsurance.

(l) If the charge of a practitioner for health care services provided to a covered individual exceeds the estimate provided to the covered individual under subsection (i)(1)(B), the facility or practitioner shall explain in a writing provided to the covered individual why the charge exceeds the estimate.

(m) An in-network practitioner is not required to provide a covered individual with the good faith estimate required under subsection (h) if the nonemergency healthcare service is scheduled to be performed by the practitioner within five (5) business days after the health care service is ordered.

(n) The department of insurance shall adopt emergency rules under IC 4-22-2-37.1 to specify the requirements of the notifications set forth in subsections (j) and (k).

More Information on Practitioner Good Faith Estimates

For definitions of terms used in this section, and further details on requirements for good faith estimates, please refer to IC 25-1-9.8.

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