Indiana Balance Billing Law

Overview

Indiana House Enrolled Act 1004 (HEA 1004), effective July 1, 2022, protects patients from balance billing for emergency services and scheduled non-emergency services at in-network facilities provided by out-of-network providers. Patients are responsible only for their in-network deductible, copay, and coinsurance amounts. Out-of-network providers must bill the insurer directly and cannot pursue patients for amounts above in-network cost-sharing in covered situations.

Key Requirements

1. Emergency Service Coverage: Patients pay only in-network cost-sharing for emergency care at any hospital, regardless of provider network status.
2. In-Network Facility Services: Out-of-network providers at in-network facilities cannot balance bill for scheduled services unless advance written consent is obtained from the patient.
3. Patient Cost-Sharing Limits: Patients are responsible only for applicable deductible, copay, and coinsurance amounts under their in-network benefit levels.
4. Out-of-Network Provider Obligations: Out-of-network providers must bill the insurer directly at applicable rates. They cannot pursue patients for balance amounts above in-network cost-sharing.
5. Insurer Compliance: Indiana insurers must adjust claims to in-network rates when services are covered under HEA 1004.

Penalties and Enforcement

The Indiana Department of Insurance (IDOI) enforces Indiana HEA 1004. Health insurers and providers that violate balance billing protections are subject to enforcement action. Violations include continuing to process claims at out-of-network rates, refusing to adjust claims, and pursuing patients for balance amounts. Violators are required to refund improperly billed amounts to patients and are subject to citations and penalties.

Appeals and Exceptions

Patients have the right to appeal any claim adjustment or denial related to balance billing protection. The primary exception is advance written consent: patients may waive protections for elective non-emergency services with 72-hour advance written consent. Emergency services have no exceptions. Services at in-network facilities are covered without exception absent valid consent.

Interaction with Federal Law

Indiana HEA 1004 applies to state-regulated health plans. The federal No Surprises Act (effective January 1, 2022) applies to all health plans, including self-funded ERISA plans. For ERISA plans, federal law governs; for state-regulated plans, both Indiana law and federal law apply, with the strongest protections controlling.

Common Questions