Provision of claims data by third party administrator; compliance with federal law; complaint process

Sec. 11. (a) Not later than thirty (30) days after a request by a contract holder of a direct to employer health care arrangement, a third party administrator that has contracted to administer a direct to employer health care arrangement shall provide claims data to the contract holder. The claims data must include the following: (1) The effective date of coverage. (2) The total number of covered individuals. (3) The total monthly earned premium. (4) The total monthly dollar value of paid claims, regardless of the period in which the claims were incurred. (5) The: (A) beginning and end date of the period for which claims were paid; and (B) percentage of claims that were paid in: (i) less than thirty (30) days; (ii) thirty (30) days to sixty (60) days; (iii) sixty-one (61) to ninety (90) days; and (iv) over ninety (90) days. (6) The reserve value as of the beginning of the period and the reserve value as of the date through which the paid claims data was obtained. (7) A description of each large or catastrophic claim exceeding fifty thousand dollars ($50,000), including: (A) the diagnosis; (B) the dollar amount of the claim; (C) whether the claim is opened or closed; and (D) the length of time the claim was open. (8) Any other claims data requested by the contract holder. (b) Information provided under this section must be provided in accordance with the federal Health Insurance Portability and Accountability Act, including 45 CFR Part 160 and Part 164, Subparts A and E. (c) Before January 1, 2026, the department shall establish a process for a contract holder of a direct to employer health care arrangement to file a complaint with the department that a third party administrator violated this section. The department shall conduct an examination under IC 27-1-3.1 upon receiving a complaint under this subsection.