Section 405 IAC 14-5-13 - Out-of-network servicesAuthority: IC 12-15-1-10; IC 12-17.6-2-11
Affected: IC 12-15-5; IC 12-15-12; IC 12-17.6-2
Sec. 13.
(a) An MCO may limit its coverage to services provided by in-network providers after the MCO meets network access standards related to providing necessary covered medical services within designated time, distance, and access standards set forth in the MCO's contract with the office. This ability to limit to in-network providers is based on the requirements for in sections 5, 10, and 12 of this rule.(b) If an MCO cannot meet the network access standards described in subsection (a), the MCO shall authorize and pay for a member to receive services by a provider not contracted with the MCO under 42 CFR 438.206(b)(4).(c) The cost to a member for out-of-network services shall be not greater than it would be if the services were furnished by a provider contracted with the MCO under 42 CFR 438.206(b)(5).(d) The MCO shall reimburse both in-network and out-of-network providers for covered services at a rate not less than the minimum fee schedule rate set by the state under 405 IAC 1-8-3.(e) Out-of-network physician services are reimbursed at one hundred percent (100%) of the prior year Medicare rates.Office of the Secretary of Family and Social Services; 405 IAC 14-5-13; filed 8/30/2024, 11:42 a.m.: 20240925-IR-405240180FRA