Louisiana Revised Statutes 22:1244 – Participation and requirements
Terms Used In Louisiana Revised Statutes 22:1244
- Commissioner: means the commissioner of insurance. See Louisiana Revised Statutes 22:1242
- Contract: A legal written agreement that becomes binding when signed.
- Covered 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 that are either covered and payable under the terms of the health insurance coverage. 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
- provider: means a health care professional or a health care facility or the agent or assignee of such professional or facility. See Louisiana Revised Statutes 22:1242
A. Participating health insurance issuers shall offer minimal benefit hospital and medical insurance policies that allow enrollees or insureds access to at least one Prime Network. The Prime Network shall be specifically established for the minimal benefit hospital and medical policies to be offered pursuant to this Subpart. Health insurance issuers may contract directly with health care providers or through a network of providers.
B. Participating health insurance issuers shall offer minimal benefit hospital and medical insurance policies under which the enrollees or insureds shall be entitled to contracted reimbursement rates by contracted health care providers for covered health care services, whether paid for by the health insurance issuer, the enrollee, or the insured.
C. Every insured or enrollee shall at the time of enrollment and annually thereafter be provided with a directory listing of contracted health care providers, denoting whether such contracted health care providers participate in a Prime Network.
D. The health insurance issuer shall issue an identification card that sets forth the name of the health insurance issuer prominently displayed on the face of the identification card and contains the following statement:
“BEFORE YOU SEEK SERVICES FROM A PROVIDER, CONTACT THE HEALTH INSURANCE ISSUER AT THE TOLL-FREE NUMBER LISTED BELOW FOR BENEFITS OR NETWORK CONFIRMATION.”
E. Notwithstanding any law to the contrary, minimal benefit hospital and medical policies offered under the program shall be exempt from the provisions of La. Rev. Stat. 22:972, 973, 975-983, 985-990, 992, 993, 999-1008, 1010-1014, 1021-1042, 1044-1048, 1091-1096, 1111, and 1156, La. Rev. Stat. 22:972 et seq., La. Rev. Stat. 22:984, and 1061 through 1079, and all other provisions of this Title, unless otherwise specifically provided herein.
F. Participating health insurance issuers may offer additional insurance products that include but are not limited to:
(1) Group health insurance that utilizes employer or employee funded savings, reimbursement, or personal care accounts in conjunction with the applicable deductible provisions.
(2) Employer funded personal care accounts shall not be taxable to the employee and shall be deductible to the employer, in accordance with applicable federal and state taxation laws.
(3) Minimal benefit hospital and medical insurance plans to employees of the state of Louisiana, and political subdivisions thereof; to the extent authorized by the Office of Group Benefits.
(4) Such additional insurance products as appropriate.
G. Employers that participate in the program shall:
(1) Pay at least fifty percent of the eligible employee premium cost. This provision shall not apply to the Office of Group Benefits.
(2) Enroll at least fifty percent of eligible employees in the program. This provision shall not apply to the Office of Group Benefits.
H. The commissioner may promulgate rules and regulations as may be necessary or proper to carry out the provisions of this Subpart. The commissioner shall issue reasonable regulations to establish specific standards and guidelines for Prime Network policies and certificates. No requirement of this Title relating to minimum required policy benefits, other than the minimum standards contained in this Subpart, shall apply to Prime Network policies. Such standards and guidelines shall address the following:
(1) Advertising and marketing.
(2) Applications and enrollment forms.
(3) Definition of terms.
(4) Form filing requirements and prohibitions.
(5) Policyholder requirements pertaining to individuals, trusts, associations, and employer groups.
(6) Uninsured impact report.
(7) Underwriting requirements relative to adverse selection.
I. For purposes of offering minimal benefits hospital and medical policies under this Subpart, a preferred provider organization shall be exempt from any mandated benefit requirements or mandated provider participation requirements pursuant to La. Rev. Stat. 40:2201 et seq. unless otherwise required by this Subpart.
Acts 2003, No. 528, §1, eff. June 24, 2003; Acts 2004, No. 493, §1, eff. June 25, 2004; Redesignated from La. Rev. Stat. 22:3103 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009.
NOTE: Former La. Rev. Stat. 22:1244 redesignated as La. Rev. Stat. 22:1925 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009.