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Regular Session, 2010
SENATE BILL NO. 359
BY SENATOR BROOME
INSURANCE DEPARTMENT. Provide for network adequacy in the health insurance
market. (8/15/10)
AN ACT1
To amend and reenact R.S. 22:972 (A) and (B) and to enact R.S. 22:1016, relative to2
network adequacy in health insurance; provide with respect to the filing of the3
network of participating health care providers; provide for definitions; provide with4
respect to the requirement of all health insurance issuers to have an adequate network5
of providers; provide for penalties for violation of network adequacy rules; and to6
provide for related matters.7
Be it enacted by the Legislature of Louisiana:8
Section 1. R.S. 22:972(A) and (B) are hereby amended and reenacted and R.S.9
22:1016 is hereby enacted to read as follows:10
§972. Approval and disapproval of forms; filing of rates11
A. No policy of health and accident insurance shall be delivered or issued12
for delivery in this state, nor shall any endorsement, rider, or application which13
becomes a part of any such policy be used in connection therewith until a copy of the14
form and of the premium rates and of the classifications of risks pertaining thereto15
and the network of participating health care providers have been filed with the16
commissioner of insurance; nor shall any such policy, endorsement, rider, or17 SB NO. 359
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application be so used until the expiration of thirty days after the form and network1
of participating health care providers has been filed unless the commissioner of2
insurance shall sooner give his written approval thereto. The commissioner of3
insurance shall notify in writing the insurer which has filed any such form or4
network of participating health care providers if it does not comply with the5
provisions of this Subpart, specifying the reasons for his opinion; and it shall6
thereafter be unlawful for such insurer to issue such form or use such network of7
participating providers in this state. An aggrieved party affected by the8
commissioner's decision, act, or order may demand a hearing in accordance with9
Chapter 12 of this Title, R.S. 22:2191 et seq.10
B. After twenty days' notice, the commissioner of insurance may withdraw11
his approval of any such form or network of participating providers on any of the12
grounds stated in this Section. It shall be unlawful for the insurer to issue such form13
or network of participating providers or use it in connection with any policy after14
the effective date of such withdrawal of approval. An aggrieved party affected by the15
commissioner's decision, act, or order may demand a hearing in accordance with16
Chapter 12 of this Title, R.S. 22:2191 et seq.17
* * *18
§1016. Network adequacy and accessibility; definitions; requirements;19
penalties20
A. The purpose and intent of this Section is to establish standards for the21
creation and maintenance of networks by health insurance issuers.22
B. For the purposes of this Section:23
(1) "Commissioner" means the insurance commissioner of this state.24
(2) "Covered health care services" or "covered benefits" or "benefits"25
means services, including ancillary services, items, supplies, or drugs for the26
diagnosis, prevention, treatment, cure, or relief of a health condition, illness,27
injury, or disease that are either covered and payable under the terms of health28
insurance coverage or required by law to be covered.29 SB NO. 359
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(3) "Covered person" means a policyholder, subscriber, enrollee or1
other individual participating in a health benefit plan.2
(4) "Health benefit plan" means a policy, contract, certificate or3
agreement entered into, offered or issued by a health insurance issuer to4
provide, deliver, arrange for, pay for or reimburse any of the costs of health5
care services.6
(5) "Health care physician" means a physician licensed, certified, or7
registered to perform specified health care services consistent with state law.8
(6) "Health care provider" or "provider" means a health care9
physician, licensed health care support staff or a hospital or the agent or10
assignee of such physician, support staff or hospital.11
(7) "Health insurance issuer" means an entity subject to the insurance12
laws and regulations of this state, or subject to the jurisdiction of the13
commissioner, that contracts or offers to contract, or enters into an agreement14
to provide, deliver, arrange for, pay for or reimburse any of the costs of health15
care services, including a sickness and accident insurance company, a health16
maintenance organization, preferred provider organization, a nonprofit hospital17
and health services corporation, or any other entity providing a plan of health18
insurance, health benefits or health services.19
(8) "Network of providers" or "network" means an entity other than20
a health insurance issuer that, through contracts with health care providers,21
provides or arranges for access by groups of enrollees or insureds to health care22
services by health care providers who are not otherwise or individually23
contracted directly with a health insurance issuer.24
(9) "Participating health care provider" means a health care provider25
who, under a contract with the health insurance issuer or with its contractor or26
subcontractor, has agreed to provide health care services to covered persons27
with an expectation of receiving payment, other than coinsurance, copayments28
or deductibles, directly or indirectly from the health insurance issuer.29 SB NO. 359
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C.(1) A health insurance issuer shall effectively provide or arrange for1
the provision of health care services through its network of participating health2
care providers.3
(2) Any network filed for approval by the commissioner shall contain:4
(a) A copy of the contract or the form of any contract made, or to be5
made, between the health insurance issuer and any provider of health care6
services. The payment rendered or to be rendered to such provider shall be7
deemed confidential and shall not be divulged by the commissioner, or his staff,8
except that payment may be disclosed and become public record in any9
legislative, administrative, or judicial proceeding or inquiry.10
(b) A statement describing the health insurance issuer's method of11
providing for health care services and describing the professional services to be12
rendered. This statement shall include the health care delivery capabilities of13
each health benefit plan including the number of primary health care14
physicians, the number of nonprimary health care physicians identified by15
specialty, the numbers and types of licensed health care support staff, and the16
number of contracted hospitals. For purposes of this Section, primary health17
care physicians shall include general and family practitioners, internists,18
pediatricians, obstetricians, and gynecologists.19
(c) A statement reasonably describing the geographic service area or20
areas to be served by the health insurance issuer. This statement shall also21
include a listing of principal and other offices maintained in this state by the22
health insurance issuer.23
(3) A health insurance issuer shall file a notice describing any material24
modification of any network filed for approval in accordance with this Section.25
The notice shall be filed with the commissioner prior to the modification. If the26
commissioner does not disapprove the proposed modification within thirty days27
of filing, or request a thirty day extension in writing, the modification shall be28
deemed approved.29 SB NO. 359
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(4) The commissioner may suspend or revoke any certificate of authority1
issued to a health insurance issuer under this Section if he finds that:2
(a) A health insurance issuer's network impairs the ability of the health3
insurance issuer to adequately provide or arrange for covered health care4
services for its enrollees or insureds.5
(b) The health insurance issuer is operating significantly in6
contravention of the documents submitted or in a manner contrary to that7
described in any information submitted under this Section, unless the health8
insurance issuer filed with the commissioner those modifications as required by9
this Section.10
D. The commissioner of insurance shall promulgate rules and11
regulations that he determines are necessary for implementation of this Section.12
Such implementation shall be subject to the legislative oversight of the House13
of Representatives and Senate committees on insurance in accordance with R.S.14
49:968.15
The original instrument and the following digest, which constitutes no part
of the legislative instrument, were prepared by Cheryl Horne.
DIGEST
Present law requires all policies of health and accident insurance to be filed with and
approved by the commissioner of insurance prior to delivery or issuance in the state.
Proposed law retains present law and additionally requires that all health and accident
insurers also file for approval with the commissioner of insurance its network of
participating health care providers.
Present law prohibits the use of any form that has been disapproved by the commissioner
and providers for a right to a hearing to appeal any decision, act or order by the
commissioner.
Proposed law retains present law and extends these prohibitions and rights to any network
of participating health providers that is denied for use by the commissioner.
Proposed law provides for the definitions of commissioner, covered health care services,
covered benefits, benefits, covered person, health benefit plan, health care physician, health
care provider, provider, health insurance issuer, network of providers, network, and
participating health care provider.
Proposed law requires all health insurance issuer's to effectively provide or arrange for the
provision of health care services through its network of participating health care services. SB NO. 359
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Coding: Words which are struck through are deletions from existing law;
words in boldface type and underscored are additions.
Proposed law requires the filing with the commissioner, a copy of the contract between the
health insurance issuer and any provider of health care services. Provides that the payment
rendered would be deemed confidential and not divulged to the commissioner or his staff
except if disclosed during any legislative, administrative or judicial proceeding or inquiry.
Proposed law provides that the filing describe the method of providing health care services
and shall include the health care delivery capabilities of each health benefit plan including
a listing of all providers by specialty, number of support staff, and number of contracted
hospitals.
Proposed law requires a statement providing the geographic service area or areas to be
served by the health insurance issuer, including a list of principal and other offices
maintained in the state.
Proposed law requires the filing of a notice of any material modification to the network for
approval by the commissioner prior to the modification.
Proposed law allows the commissioner to suspend or revoke the certificate of authority of
the health insurance issuer if the network impairs the ability of the health insurance issuer
to adequately provide or arrange for covered health care services to its enrollees or insureds
or if the health insurance issuer is operating significantly in contravention of the documents
submitted to the commissioner.
Proposed law permits the commissioner to promulgate rules and regulations he deems
necessary for implementation of proposed law. Provides that such implementation shall be
subject to legislative oversight.
Effective August 15, 2010.
(Amends R.S. 22:972(A) and (B); adds R.S. 22:1016)