Louisiana Revised Statutes 22:1019.2 – Network adequacy
Terms Used In Louisiana Revised Statutes 22:1019.2
- Commissioner: means the commissioner of insurance. See Louisiana Revised Statutes 22:1019.1
- Contract: A legal written agreement that becomes binding when signed.
- Covered health care services: means health care services that are either covered and payable under the terms of health insurance coverage or required by law to be covered. See Louisiana Revised Statutes 22:1019.1
- Covered person: means a policyholder, subscriber, enrollee, insured, or other individual participating in a health benefit plan. See Louisiana Revised Statutes 22:1019.1
- Emergency services: means health care items and services furnished or required to evaluate and treat an emergency medical condition. See Louisiana Revised Statutes 22:1019.1
- Essential community providers: means providers that serve predominantly low-income, medically underserved individuals, including those providers defined in Section 340B(a)(4) of the Public Health Service Act and providers described in Section 1927(c)(1)(D)(i)(IV) of the Social Security Act as set forth by Section 221 of Public Law 111-8. See Louisiana Revised Statutes 22:1019.1
- Health benefit plan: means a policy, contract, certificate, or subscriber agreement entered into, offered, or issued by a health insurance issuer to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services. See Louisiana Revised Statutes 22:1019.1
- Health care facility: means an institution providing health care services or a health care setting, including but not limited to hospitals and other licensed inpatient centers, ambulatory surgical or treatment centers, skilled nursing centers, diagnostic, laboratory and imaging centers, and rehabilitation and other therapeutic health settings. See Louisiana Revised Statutes 22:1019.1
- Health care services: means services, items, supplies, or drugs for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or disease. See Louisiana Revised Statutes 22:1019.1
- Health insurance issuer: means an entity subject to the insurance laws and regulations of this state, or subject to the jurisdiction of the commissioner, that contracts or offers to contract, or enters into an agreement to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services, including a sickness and accident insurance company, a health maintenance organization, a preferred provider organization or any similar entity, or any other entity providing a plan of health insurance or health benefits. See Louisiana Revised Statutes 22:1019.1
- Healthcare services: means services, items, supplies, or drugs for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or disease. See Louisiana Revised Statutes 22:1020.1
- network: means an entity, including a health insurance issuer, that, through contracts or agreements with health care providers, provides or arranges for access by groups of covered persons to health care services by health care providers who are not otherwise or individually contracted directly with a health insurance issuer. See Louisiana Revised Statutes 22:1019.1
- Person: means an individual, a corporation, a partnership, an association, a joint venture, a joint stock company, a trust, an unincorporated organization, any similar entity, or any combination thereof. See Louisiana Revised Statutes 22:1019.1
- provider: means a health care professional or a health care facility. See Louisiana Revised Statutes 22:1019.1
A. A health insurance issuer providing a health benefit plan shall maintain a network that is sufficient in numbers and types of healthcare providers to ensure that all healthcare services to covered persons will be accessible without unreasonable delay. In the case of emergency services and any ancillary emergency healthcare services, covered persons shall have access twenty-four hours per day, seven days per week. Sufficiency shall be determined in accordance with the requirements of this Subpart. In determining sufficiency criteria, the criteria shall include but not be limited to ratios of healthcare providers to covered persons by specialty, ratios of primary care providers to covered persons, geographic accessibility, waiting times for appointments with participating providers, hours of operation, and volume of technological and specialty services available to serve the needs of covered persons requiring technologically advanced or specialty care.
B.(1) Each health insurance issuer shall maintain a network of providers that includes but is not limited to providers that specialize in mental health and substance abuse services, facility-based physicians, and providers that are essential community providers.
(2) A health insurance issuer shall establish and maintain adequate arrangements to ensure reasonable proximity of participating providers to the primary residences of covered persons. In determining whether a health insurance issuer has complied with this Paragraph, the commissioner shall give due consideration to the relative availability of health care providers in the service area under consideration and the geographic composition of the service area. The commissioner may consider a health insurance issuer’s adjacent service area networks that may augment health care providers if a health care provider deficiency exists within the service area.
(3) A health insurance issuer shall monitor, on an ongoing basis, the ability, clinical capacity, and legal authority of its participating providers to furnish all contracted health care services to covered persons.
(4) Repealed by Acts 2018, No. 290, §2, eff. Jan. 1, 2019.
(5) A health insurance issuer shall annually file with the commissioner an access plan meeting the requirements of this Subpart for each of the health benefit plans that the health insurance issuer offers in this state. Any existing, new, or initial filing of policy forms by a health insurance issuer shall include the network of providers, if any, to be used in connection with the policy forms. If benefits under a health insurance policy do not rely on a network of providers, the health insurance issuer shall state this fact in the policy form filing. The health insurance issuer may request the commissioner to consider sections of the access plan to contain proprietary or trade secret information that shall not be made public in accordance with the Public Records Law, La. Rev. Stat. 44:1 et seq., or to contain protected health information that shall not be made public in accordance with La. Rev. Stat. 22:42.1. If the commissioner concurs with the request, those sections of the access plan shall not be subject to the Public Records Law or shall not be made public in accordance with La. Rev. Stat. 22:42.1 as applicable. The health insurance issuer shall make the access plans, absent any such proprietary or trade secret information and protected health information, available and readily accessible on its business premises and shall provide the plans to any interested party upon request, subject to the provisions of the Public Records Law and La. Rev. Stat. 22:42.1.
C. A health insurance issuer shall file an access plan for written approval from the commissioner for existing health benefit plans and prior to offering a new health benefit plan. Additionally, a health insurance issuer shall inform the commissioner if the health insurance issuer enters a new service or market area and shall submit an updated access plan demonstrating that the health insurance issuer’s network in the new service or market area is adequate and consistent with this Subpart. Each access plan, including riders and endorsements, shall be identified by a form number in the lower left hand corner of the first page of the form. A health insurance issuer shall update an existing access plan whenever it makes any material change to an existing health benefit plan. The access plan shall describe or contain, at a minimum, each of the following:
(1) The health insurance issuer’s network which includes but is not limited to the availability of and access to centers of excellence for transplant and other medically intensive services as well as the availability of critical care services, such as advanced trauma centers and burn units.
(2) The health insurance issuer’s procedure for making referrals within and outside its network.
(3) The health insurance issuer’s process for monitoring and ensuring, on an ongoing basis, the sufficiency of the network to meet the health care needs of populations that enroll in its health benefit plans and general provider availability in a given geographic area.
(4) The health insurance issuer’s efforts to address the needs of covered persons with limited English proficiency and illiteracy, with diverse cultural and ethnic backgrounds, or with physical and mental disabilities.
(5) The health insurance issuer’s methods for assessing the health care needs of covered persons and their satisfaction with services.
(6) The health insurance issuer’s method of informing covered persons of the health benefit plan’s services and features, including but not limited to the health benefit plan’s utilization review procedure, grievance procedure, external review procedure, process for choosing and changing providers, and procedures for providing and approving emergency services and specialty care. Additional information relating to these processes shall be available upon request and accessible via the health insurance issuer’s website.
(7) The health insurance issuer’s system for ensuring coordination and continuity of care for covered persons referred to specialty physicians, for covered persons using ancillary health care services, including social services and other community resources, and for ensuring appropriate discharge planning.
(8) The health insurance issuer’s processes for enabling covered persons to change primary care professionals, for medical care referrals, and for ensuring that participating providers that require the use of health care facilities have hospital admission privileges.
(9) The health insurance issuer’s proposed plan for providing continuity of care in the event of contract termination between the health insurance issuer and any of its participating providers, as required by La. Rev. Stat. 22:1005, or in the event of the health insurance issuer’s insolvency or other inability to continue operations. This description shall explain how covered persons will be notified of contract termination, including but not limited to the effective date of the contract termination, the health insurance issuer’s insolvency, or other cessation of operations, and how such covered persons will be transferred to other providers in a timely manner.
(10) A geographic map of the area proposed to be served by the health benefit plan by both parish and zip code.
(11) The policies and procedures to ensure access to covered health care services under each of the following circumstances:
(a) When the covered health care service is not available from a participating provider in any case when a covered person has made a good faith effort to utilize participating providers for a covered service and it is determined that the health insurance issuer does not have the appropriate participating providers due to insufficient number, type, or distance, the health insurance issuer shall ensure, by terms contained in the health benefit plan, that the covered person will be provided the covered health care service.
(b) When the covered person has a medical emergency within the network’s service area.
(c) When the covered person has a medical emergency outside the network’s service area.
(12) Any other information required by the commissioner to determine compliance with the provisions of this Subpart.
D. A health insurance issuer shall file any proposed material changes to the access plan with the commissioner prior to implementation of any such changes. The removal or withdrawal of any hospital or multi-specialty clinic from a health insurance issuer’s network shall constitute a material change and shall be filed with the commissioner in accordance with the provisions of this Subpart. Changes shall be considered approved by the commissioner after sixty days unless specifically disapproved in writing by the commissioner prior to expiration of the sixty days.
(1) A listing of health care facilities and the number of hospital beds at each network health care facility.
(2) The ratio of participating providers to current covered persons.
(3) Any other information requested by the commissioner.
Acts 2013, No. 205, §1, eff. June 10, 2013; Acts 2018, No. 290, §2, eff. Jan. 1, 2019; Acts 2022, No. 589, §1, eff. Jan. 1, 2023.