Indiana implements new ownership reporting requirements, authorizes health entity market concentration investigation

Changes to the existing state transaction notice law

Indiana’s current state transaction law (enacted effective July 1, 2024) requires “health care entities,” which is broadly defined to include insurers, PBMs, private equity partnerships, and “any organization or business that provides diagnostic, medical, surgical, dental treatment or rehabilitative care” that is “involved in” a merger or acquisition with another health care entity, with total assets taken between the parties of $10M, to report the transaction to the Attorney General at least 90 days prior to closing. IC § 25-1-8.5-1 et seq. The law does not give the Attorney General explicit authority to disapprove a transaction, but permits the Attorney General to issue a civil investigative demand if, based on its initial review of a health care entity’s notice, it has concerns about the transaction. In practice, the Attorney General has been granting “notices of no further action” upon completing review of a transaction, even though such clearance is not explicitly contemplated in the statute. 

Effective July 1, 2025, HB 1666 exempts from the transaction notice law a health care provider that is majority owned (or would be majority owned after the majority or acquisition) by Indiana-licensed health care practitioners who routinely furnish health care services in the practitioner-owned practice. See HB 1666 § 9. 

The state’s transaction notice law is otherwise unchanged. Among other things, prior versions of the legislation would have made transactions between health care entities explicitly subject to “approval of the attorney general,” or created a “health care entity merger approval board” to “evaluate” and “approve or deny” proposed transactions. This language was ultimately dropped from the bill. 

Market concentration investigations

Effective July 1, 2025, HB 1666 authorizes the Indiana Attorney General to, at any time, “investigate the market concentration of a health care entity,” including by issuing a civil investigative demand to that entity. HB 1666 § 10. As noted above, under existing law, the Attorney General may issue a civil investigative demand when a health care entity submits a transaction notice or, more broadly, when “the attorney general has reasonable cause to believe that a person may” possess evidence “relevant to an investigation” regarding any “statute enforced by the attorney general” or to criminal violations. See IC §§ 25-1-8.5-4(e), 4-6-3-3. Therefore, it is unclear how meaningfully this expands the Attorney General’s existing authority to investigate health care antitrust matters. 

New ownership reporting requirements

HB 1666 establishes a number of new reporting requirements for health care entities: 

Hospitals. Effective July 1, 2025, HB 1666 requires hospitals to include ownership information in annual reports already submitted to the state under IC § 16-21-6-3, which generally cover detailed financial and billing information. Newly required information includes names, business addresses, and ownership stakes for each person or entity with either an ownership of 5% or more, each practitioner of the hospital with any ownership interest, any person or entity with controlling interest, or any person or entity with interest as a private equity partner. HB 1666 § 5. The report must specify the ownership stake held by each person or entity, and for each person or entity, provide a business address, business website, and if applicable, National Provider Identifier (NPI) number, Taxpayer ID, Employer Identification Number (EIN), Medicare provider number, National Association of Insurance Commissioners (NAIC) identification number. Under existing law, the penalty for a hospital which fails to provide the report by the date required is $1,000 per day the report is overdue. See IC § 16-21-6-3(c). 

Health care entities. HB 1666 establishes a new reporting requirement for “each health care entity that does business in Indiana.” For this purpose, “health care entity” means “any organization or business that provides health care services,” aside from hospitals, insurers, PBMs, TPAs, and entities that do not accept commercial health insurance reimbursement. HB 1666 § 6. “Health care services” is broadly defined to include diagnostic, medical, surgical, dental, or rehabilitative care for the purpose of preventing, alleviating, curing, or healing human illness or injury. Effective January 1, 2026, in-scope health care entities must submit on a biennial basis the same information outlined above for hospitals, as well as information regarding whether the health care entity is a Medicaid provider, and if so, if it “accepted Medicaid recipients during a majority of the preceding two years.” HB 1666 §§ 7, 8. HB 1666 does not establish a fine for non-compliance, but existing Indiana law permits a person “aggrieved” to “petition” a court to force the filing and imposes penalties for false filings. See IC §§ 23-0.5-2-9(a), 23-0.5-2-10.

Insurers, TPAs, and PBMs. Finally, beginning July 1, 2025 (and annually thereafter), HB 1666 requires various health insurers (including HMOs), TPAs, and PBMs to report to the Indiana Department of Insurance (“IDOI”) the same information as outlined above for hospitals. Further, HB 1666 authorizes IDOI to provide this information to the Department of Health. IDOI would also be permitted to assess a fine of $1,000 per day on such insurers for each day their report is past due or to take disciplinary action for repeated violations.

Authored by Jessica Hanna, Jeff Schneider, Lindsey Johnson, Joe Liss, Caroline Farrington, and Rianna Modi.