Indiana Surprise Billing

Overview

Indiana House Enrolled Act 1004 (effective July 1, 2022) provides state-level surprise billing protection. The federal No Surprises Act (effective January 1, 2022) provides additional protections for all plans nationwide. Together, these laws protect Indiana patients from surprise bills for emergency care at any facility, post-stabilization services, and scheduled non-emergency services at in-network facilities provided by out-of-network providers. Payment disputes are resolved through the federal Independent Dispute Resolution (IDR) process, not passed to patients.

Key Requirements

1. Emergency Care Standard: Patients pay in-network cost-sharing for emergency care regardless of provider or facility network status.
2. In-Network Facility Services: For scheduled services at in-network facilities, out-of-network providers cannot balance bill without 72-hour advance written consent from the patient.
3. Good Faith Estimates: Providers must supply written cost estimates for scheduled services, detailing expected costs to help patients make informed decisions.
4. Federal IDR Process: Provider and insurer disputes over surprise billing services are resolved through federal Independent Dispute Resolution, not passed to the patient.
5. All Plan Types: Federal NSA applies to all health plans, including self-funded ERISA employer plans exempt from state insurance regulation.

Penalties and Enforcement

The Indiana Department of Insurance (IDOI) enforces Indiana HEA 1004 for state-regulated plans. The Centers for Medicare and Medicaid Services (CMS) enforces the federal No Surprises Act for all plan types. Violations include failing to adjust claims to in-network rates, refusing to honor advance consent rules, and failing to provide Good Faith Estimates. Violators are subject to enforcement action, required refunds to patients, and civil penalties.

Appeals and Exceptions

Patients have appeal rights for any claim determination related to surprise billing. The primary exception is advance written consent for elective out-of-network services (72 hours). Emergency and post-stabilization services have no exceptions and are fully covered. The federal IDR process resolves provider-insurer disputes without patient involvement.

Interaction with Federal Law

Indiana HEA 1004 applies to state-regulated health plans. The federal No Surprises Act applies to all plans nationwide. For Indiana patients, both laws provide overlapping protections. For state-regulated plans, both laws apply; for ERISA self-funded plans, federal law governs. The strongest protections available apply in all cases.

Common Questions