Louisiana Revised Statutes 22:1245 – Plan of operation
Terms Used In Louisiana Revised Statutes 22:1245
- Commissioner: means the commissioner of insurance. See Louisiana Revised Statutes 22:1242
- Health insurance issuer: means any entity that offers health insurance coverage through a policy or certificate of insurance subject to state law that regulates the business of insurance. See Louisiana Revised Statutes 22:1242
- insured: means a person, including a spouse or dependent, who is enrolled in or insured by a health insurance issuer for health insurance coverage. See Louisiana Revised Statutes 22:1242
- network: means an entity other than a health insurance issuer that, through contracts with health care providers, provides or arranges for access by groups of enrollees or insureds 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 22:1242
- Prime network: means a network that requires contracted health care providers to accept the amount payable for covered health care services as payment in full for such services. See Louisiana Revised Statutes 22:1242
- Recourse: An arrangement in which a bank retains, in form or in substance, any credit risk directly or indirectly associated with an asset it has sold (in accordance with generally accepted accounting principles) that exceeds a pro rata share of the bank's claim on the asset. If a bank has no claim on an asset it has sold, then the retention of any credit risk is recourse. Source: FDIC
A. A health insurance issuer shall submit a plan of operation to the commissioner for review and approval whereby the health insurance issuer establishes policies and procedures:
(1) For the determination of program eligibility of employers, as set forth in La. Rev. Stat. 22:1243.
(2) Relative to the program network criteria, as set forth in La. Rev. Stat. 22:1244, and which shall contain at least the following:
(a) Evidence that all covered Prime Network services are available and accessible through Prime Network providers, including demonstration that:
(i) Covered Prime Network services can be provided by Prime Network providers with reasonable promptness with respect to geographic location, hours of operation, and availability of after hour care. The hours of operation and availability of after hour care shall reflect usual practice in the local area. Geographic availability shall reflect usual practice in the community.
(ii) The number of Prime Network providers in the service area is sufficient, with respect to current and expected policyholders.
(iii) There are participation agreements with Prime Network providers that contain provisions prohibiting Prime Network providers from billing, collecting, or otherwise seeking reimbursement or recourse against any insured or enrollee, except for applicable amounts representing copayments, coinsurance, deductibles, or noncovered services.
(b) A statement or map providing a clear description of the service area.
(c) A formal description of the formal organization or structure of the health insurance issuer.
(d) The written criteria for selection, retention, and removal of Prime Network providers.
(e) A list and description of Prime Network providers, by specialty, if any.
B.(1) A health insurance issuer shall file any proposed changes to the plan of operation with the commissioner prior to implementing the changes. Changes shall be considered approved by the commissioner after thirty days unless specifically disapproved. The health insurance issuer shall notify the commissioner of any changes of Prime Network providers.
(2) Any updated list of Prime Network providers shall be filed with the commissioner at least quarterly.
(3) A health insurance issuer shall make full and fair disclosure, in writing, of the provisions, restrictions, and limitations of the policy or certificate to each applicant. The disclosure shall include at least the following:
(a) An outline of coverage and itemized benefits.
(b) A description of the rights of the insured or enrollee.
C. The Office of Group Benefits and participating health insurance issuers, respectively, shall be responsible for the administration of the minimal benefit hospital and medical plans or policies, as well as any other insurance products offered pursuant to this program, and shall bear all risk of loss therefor.
Acts 2003, No. 528, §1, eff. June 24, 2003; Acts 2004, No. 493, §1, eff. June 25, 2004; Redesignated from La. Rev. Stat. 22:3104 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009.
NOTE: Former La. Rev. Stat. 22:1245 redesignated as La. Rev. Stat. 22:1926 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009.