Terms Used In Louisiana Revised Statutes 22:1216

  • Board: means the board of directors of the plan. See Louisiana Revised Statutes 22:1202
  • Commissioner: means the commissioner of insurance. See Louisiana Revised Statutes 22:1202
  • Health and accident insurance: means hospital and medical expense incurred policies, nonprofit service plan corporation contracts, and coverages provided by health maintenance organizations, individual practices, associations, the Office of Group Benefits, and other similar entities and self-insurers. See Louisiana Revised Statutes 22:1202
  • Insurance arrangement: means any plan, program, contract, or any other arrangement under which one or more natural or juridical persons provide to their employees or participants, whether directly or indirectly, health care services or benefits other than through an insurer. See Louisiana Revised Statutes 22:1202
  • Insured: means any natural person domiciled in this state, other than a member of the plan, who is eligible to receive benefits from any insurer or insurance arrangement as defined in this Section. See Louisiana Revised Statutes 22:1202
  • Insurer: means any insurance company or other entity authorized to transact and transacting health and accident insurance business in this state. See Louisiana Revised Statutes 22:1202
  • Obligation: An order placed, contract awarded, service received, or similar transaction during a given period that will require payments during the same or a future period.
  • Plan: means the Louisiana Health Plan as created in La. See Louisiana Revised Statutes 22:1202
  • Plan of operation: means the plan of operation of the plan, including articles, bylaws, and operating rules, adopted by the board pursuant to La. See Louisiana Revised Statutes 22:1202

§1216. Health and accident policy provisions; service charges; penalties

            A. Any health and accident insurance policy issued under this Subpart or Subpart J of Part III of Chapter 4 of this Title, and any health and accident insurance policy having effect in this state, shall provide coverage without regard to the insured‘s obligation of deductibles or copayments for the service charges assessed pursuant to La. Rev. Stat. 22:1209. The service charges assessed to a patient pursuant to La. Rev. Stat. 22:1209 shall be mandated benefits of any health and accident insurance coverage issued by any insurer or insurance arrangement, except an insolvent insurer, over and above any insurance policy limits, negotiated per diem, or managed care arrangement.

            B. Each service charge for each patient admission specified in La. Rev. Stat. 22:1209 shall be paid by the insurer or insurance arrangement in accordance with the plan of operation adopted pursuant to La. Rev. Stat. 22:1205. Failure to pay a service charge for each patient pursuant to this Section shall cause the insurer or insurance arrangement to be liable to the Louisiana Health Plan, the commissioner of insurance, or both for a fine in an amount determined by the board, not to exceed five hundred dollars plus interest. Any insurer or insurance arrangement found to have failed to comply with this Section by paying each service charge for each patient admission specified in La. Rev. Stat. 22:1209 on three or more occasions during a six-month period shall be liable for a fine in an amount determined by the board, of not less than five hundred dollars and not more than one thousand five hundred dollars per failure to pay each service charge for each patient admission, together with attorney fees, interest, and court costs. The Louisiana Health Plan, the commissioner, or both are specifically authorized to conduct audits of insurers or insurance arrangements in order to enforce compliance with this Section.

            C. For the purposes of this Section, “insurance” or “insurance arrangement” also includes any policy or plan of insurance or of self-insurance that provides payment, indemnity, or reimbursement for charges resulting from accident, injury, or illness when an employer, insurer, or tortfeasor is responsible for those charges.

            D. For purposes of this Section, “insurance” or “insurance arrangement” shall not include the Office of Group Benefits program.

            E. This Section shall not be effective until approval of the plan provided for in La. Rev. Stat. 22:1203(E)(2).

            Acts 2020, No. 313, §1, eff. June 12, 2020.

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