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Regular Session, 2012
HOUSE BILL NO. 1206 (Substitute for House Bill No. 921 by Representative Johnson)
BY REPRESENTATIVE JOHNSON
INSURANCE/HEALTH: Provides for the adequacy of health care services offered through
providers in a health plan benefit's network
AN ACT1
To enact R.S. 22:972(D) and 1019, relative to network adequacy in health insurance; to2
provide for the filing of the network of participating health care providers; to provide3
for definitions; to require all health insurance issuers to have an adequate network4
of providers; to provide for penalties for violation of network adequacy rules; and5
to provide for related matters.6
Be it enacted by the Legislature of Louisiana:7
Section 1. R.S. 22:972(D) and 1019 are hereby enacted to read as follows: 8
§972. Approval and disapproval of forms; filing of rates9
* * *10
D. An initial filing of policy forms by a health insurance issuer as described11
in Subsection A of this Section shall include the network of providers, if any, to be12
used in connection with the policy forms in accordance with the provisions of R.S.13
22:1019(C)(1) and (2). If benefits under a health insurance policy do not rely on a14
network of providers, the issuer shall state such fact in the forms filing.15
* * *16
§1019. Network adequacy and accessibility; definitions; requirements; penalties17
A. The purpose and intent of this Section is to establish standards for the18
creation and maintenance of networks by health insurance issuers.19
B. For the purposes of this Section:20 HLS 12RS-3105 ENGROSSED
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(1) "Commissioner" means the insurance commissioner of this state.1
(2) "Covered health care services" or "covered benefits" or "benefits" means2
services, items, supplies, or drugs for the diagnosis, prevention, treatment, cure, or3
relief of a health condition, illness, injury, or disease that are either covered and4
payable under the terms of health insurance coverage or required by law to be5
covered.6
(3) "Covered person" means a policyholder, subscriber, enrollee, or other7
individual participating in a health benefit plan.8
(4) "Critical access or acute care hospital" means any institution, facility,9
place, building, or agency, public or private, whether for profit or not, maintaining10
and operating facilities, twenty-four hours a day, seven days a week, having at least11
ten licensed beds or more, properly staffed and equipped for the diagnosis, treatment,12
and care of persons admitted for overnight stay or longer who are suffering from13
illness, injury, infirmity or deformity or other physical or mental condition for which14
medical, surgical, or obstetrical services would be available and appropriate.15
(5) "Health benefit plan" means a policy, contract, certificate, or agreement16
entered into, offered or issued by a health insurance issuer to provide, deliver,17
arrange for, pay for, or reimburse any of the costs of covered health care services.18
However, a "health benefit plan" shall not include limited benefit and supplemental19
health insurance.20
(6) "Health care physician" means a physician licensed, certified, or21
registered to perform specified health care services consistent with state law.22
(7) "Health care provider" or "provider" means a licensed health care23
physician or a hospital or the agent or assignee of such physician or hospital.24
(8) "Health insurance issuer" means an entity subject to the insurance laws25
and regulations of this state, or subject to the jurisdiction of the commissioner, that26
contracts or offers to contract, or enters into an agreement to provide, deliver,27
arrange for, pay for, or reimburse any of the costs of covered health care services,28
including a sickness and accident insurance company, a health maintenance29 HLS 12RS-3105 ENGROSSED
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organization, or any other entity providing a plan of health insurance, health benefits,1
or health services.2
(9) "Network of providers" or "network" means an entity other than a health3
insurance issuer that, through contracts with health care providers, provides or4
arranges for access by groups of covered persons to health care services by health5
care providers who are not otherwise or individually contracted directly with a health6
insurance issuer.7
(10) "Participating health care provider" means a health care provider who,8
under a contract with the health insurance issuer or with its contractor or9
subcontractor, has agreed to provide covered health care services to covered persons10
with an expectation of receiving payment, other than coinsurance, copayments, or11
deductibles, directly or indirectly, from the health insurance issuer.12
C.(1) A health insurance issuer that uses a network of providers will13
effectively provide or arrange for the provision of covered health care services14
through its network of participating health care providers.15
(2) For any health benefit plan that utilizes a network of providers, a health16
insurance issuer shall maintain a network that is adequate in numbers and types of17
health care providers to assure that all covered health care services will be accessible18
to covered persons without unreasonable delay. Adequacy shall be determined in19
accordance with this Section and may be established by reference to any reasonable20
criteria used by the health insurance issuer, including but not limited to:21
(a) The geographic accessibility of participating primary care providers22
within a thirty-mile radius and participating specialty care providers within a sixty-23
mile radius, except in geographic areas in which there is limited availability of24
providers of certain specialty types.25
(b) Waiting times for appointments with participating health care providers.26
(c) Hours of operation.27 HLS 12RS-3105 ENGROSSED
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(d) Adequate availability of technological and specialty services available1
to serve the needs of covered persons requiring technologically advanced or specialty2
care.3
(e) Access to emergency services twenty-four hours per day, seven days per4
week.5
(3) A health insurance issuer's network of providers shall not be considered6
inadequate on the basis of the lack in a health insurance issuer's network of providers7
of a particular type of health care provider, when the health insurance issuer8
demonstrates that it has made all reasonable efforts to contract with available9
providers of that type and the health insurance issuer submits to the commissioner10
an alternate access plan that provides health care services from the particular types11
of health care providers to the covered persons. The health insurance issuer shall be12
prohibited from marketing or advertising in any manner which falsely states or13
implies that it has an adequate network for the purposes of this Section. In addition,14
the health insurance issuer shall promptly notify all covered persons that the15
applicable health care services cannot be obtained through the network and provide16
instructions on alternatives to obtaining such services.17
(4) No later than January 1, 2013, a health insurance issuer shall file for18
approval with the commissioner the network of participating providers, if any, that19
supports each of the health insurance issuer's health benefit plans. Any network filed20
for approval by the commissioner shall contain:21
(a) A copy of the sample contract or the standard participating provider22
agreement used by the health insurance issuer to contract with each provider type for23
the provision of covered services.24
(b) A statement describing the health insurance issuer's method of providing25
for covered health care services and describing the professional services to be26
rendered by numbers and types of participating physicians and hospitals. This27
statement shall include the health care delivery capabilities of each health benefit28
plan including the numbers and types of participating physicians and hospitals.29 HLS 12RS-3105 ENGROSSED
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(c) A statement reasonably describing the geographic service area or areas1
to be served by the health insurance issuer; this statement shall also include a listing2
of principal and other offices maintained in this state by the health insurance issuer.3
(5)(a) A health insurance issuer shall file a notice describing any material4
modification of any network filed for approval in accordance with this Section. The5
notice shall be filed with the commissioner as soon as possible but not later than6
thirty days following the material modification or receipt of any updated information7
by the health insurance issuer.8
(b) Material modification shall include but not be limited to the following:9
(i) Loss of a critical access or acute care hospital from the network.10
(ii) Any case where the health insurance issuer has an insufficient number11
or type of participating providers, according to the provisions of this Subsection, to12
provide a covered health care service.13
(iii) Any other circumstances deemed to be an adverse material modification14
to a covered person obtaining a covered health care service.15
(iv) Any other changes to a network of providers that, cumulatively,16
jeopardize adequacy of the network as described in this Subsection.17
(6) Whenever the commissioner believes, based on a filing required by R.S.18
22:972(D) or the filing required by this Subsection, that a health insurance issuer's19
network of providers is inadequate to provide covered health care services to covered20
persons, the commissioner may require the health insurance issuer to provide all or21
part of the information about its network described in Paragraph (3) of this22
Subsection. A health insurance issuer shall provide such requested information no23
later than thirty days of receipt of such request from the commissioner.24
D.(1) Whenever a health insurance issuer is in violation of the provisions of25
this Section, the commissioner shall notify the health insurance issuer in writing of26
such violation, directing the health insurance issuer to submit a corrective action plan27
or other response within thirty days.28 HLS 12RS-3105 ENGROSSED
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(2) If a health insurance issuer fails to submit a corrective action plan or1
other satisfactory response within thirty days, the commissioner may either:2
(a) Issue and cause to be served an order requiring the health insurance issuer3
to cease and desist the use of such health benefit plan or network of participating4
providers.5
(b) Issue and cause to be served an order to cease and desist any action that6
is in violation of this Section.7
(3)(a) The commissioner may not impose a cease and desist order if the8
commissioner evaluates and determines that the health insurance issuer has9
demonstrated that the health insurance issuer has remedied the reason for the notice10
from the commissioner or that there will be no detriment to the covered person11
obtaining covered health care services and upon a written agreement from the health12
insurance issuer ensuring that the covered person obtains covered health care13
services at an in-network benefit level.14
(b) If the commissioner determines that a health insurance issuer's network15
of providers is inadequate in a certain geographic area, any cease and desist order16
related to such inadequacy shall be limited to only that geographic area and shall not17
prohibit use of the health insurance issuer's network in other geographic areas of the18
state.19
(4) Following completion of the actions described in Paragraphs (1) through20
(3) of this Subsection, the commissioner may suspend or revoke any certificate of21
authority issued to a health insurance issuer pursuant to this Section if he finds that:22
(a) A health insurance issuer's network impairs the ability of the health23
insurance issuer to adequately provide or arrange for covered health care services for24
its covered persons.25
(b) The health insurance issuer is operating significantly in contravention of26
the documents submitted or in a manner contrary to that described in any information27
submitted pursuant to this Section, unless the health insurance issuer filed with the28
commissioner those modifications as required by this Section.29 HLS 12RS-3105 ENGROSSED
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E. The provisions of this Section shall not apply to the office of group1
benefits, any self-funded governmental or parish plan, or any other plan preempted2
under the provisions of the Employee Retirement Income Security Act of 1974.3
F. The provisions of this Section shall not apply to plans, policies, or4
products offered on any state or federal exchange created in accordance with the5
Patient Protection and Affordable Care Act or in regulations promulgated pursuant6
to such Act.7
G. The commissioner may promulgate rules and regulations in accordance8
with the Administrative Procedure Act that he determines are necessary for9
implementation of this Section.10
Section 2. This Act shall become effective upon signature by the governor or, if not11
signed by the governor, upon expiration of the time for bills to become law without signature12
by the governor, as provided by Article III, Section 18 of the Constitution of Louisiana. If13
vetoed by the governor and subsequently approved by the legislature, this Act shall become14
effective on the day following such approval.15
DIGEST
The digest printed below was prepared by House Legislative Services. It constitutes no part
of the legislative instrument. The keyword, one-liner, abstract, and digest do not constitute
part of the law or proof or indicia of legislative intent. [R.S. 1:13(B) and 24:177(E)]
Johnson HB No. 1206
Abstract: Provides for network adequacy in the health insurance market.
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 also requires all health and accident insurers to file its
network of participating health care providers at the initial filing of its policy forms. Further
provides that if the policy does not rely on a network of providers, such fact shall be stated
in the forms when filed.
Proposed law provides for the definitions of commissioner, covered health care services,
covered benefits, benefits, covered person, critical access or acute care hospital, 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 issuers that use a network of providers to
effectively provide or arrange for the provision of health care services through its network
of participating health care services. HLS 12RS-3105 ENGROSSED
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are additions.
Proposed law provides that a policy that utilizes a network of providers shall maintain a
network that is adequate in numbers and types of health care providers to assure that all
covered health care services will be accessible to covered persons. Further provides that
adequacy shall be determined and referenced by any reasonable criteria used by health
insurance issuer, including, but not limited to:
(1)Geographic accessibility of participating health care providers within a 30-mile
radius and participating specialty care providers within a 60-mile radius where
possible.
(2)Waiting time for appointments.
(3)Hours of operations.
(4)Adequate availability of technological and speciality services.
(5)Access to emergency services 24 hours per day, seven days a week.
Proposed law provides that a health insurance issuer's network of providers shall not be
considered inadequate if they demonstrate they have made all reasonable efforts to contract
with available providers of that type of service.
Proposed law prohibits a health insurance issuer from marketing or advertising that in any
way falsely states or implies that it has an adequate network in accordance with proposed
law.
Proposed law provides that a copy of the contract or the standard participating provider
agreement used by the health insurance issuer be filed with the commissioner for approval.
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 numbers
and types of participating physicians and hospitals.
Proposed law requires a statement to be issued describing the geographic service area or
areas to be served by the health insurance issuer. Requires the filing of notice of any material
modification to the network and requires the commissioner to give approval to the
modification. Requires the health insurance issuer to provide notice to the commissioner no
later than 30 days following a material modification. Defines material modification as the
loss of a critical access or acute care hospital from the network, any case where the health
insurance issuer has an insufficient number or type of participating providers to provide a
covered health care service or any other circumstances deemed to be an adverse material
modification to an insured or enrollee obtaining a covered health care service.
Proposed law requires the commissioner to notify the health insurance issuer in writing of
a violation and to direct the health insurance issuer to submit a corrective action plan or
other response within 30 days. If a satisfactory response is not issued within 30 days, the
commissioner may issue a cease and desist order regarding the use of the form or network
of participating providers or issue an order to cease and desist any action that is in violation.
Proposed law provides that the commissioner may not impose a cease and desist order if the
health insurance issuer demonstrates that the health insurance issuer has remedied the reason
for the notice from the commissioner or there will be no detriment to the insured or enrollee
obtaining covered health care services and upon a written agreement from the health
insurance issuer ensuring that the insured or enrollee obtains covered health care services
at no greater cost than if the covered health care services were obtained from participating
health care providers.
Proposed law allows the commissioner to suspend or revoke the certificate of authority of
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to adequately provide or arrange for covered health care services to its enrollees or insured
or if the health insurance issuer is operating significantly in contravention of the documents
submitted to the commissioner.
Proposed law exempts the office of group benefits, any self-funded governmental or parish
plan or any other plan preempted under the provisions of the Employee Retirement Income
Security Act.
Proposed law is not applicable to plans, policies, or products offered on any state or federal
exchange created in accordance with the Patient Protection and Affordable Care Act or
regulations promulgated pursuant to the Act.
Proposed law permits the commissioner to promulgate rules and regulations in accordance
with the Administrative Procedure Act.
Effective upon signature of governor or lapse of time for gubernatorial action.
(Adds R.S. 22:972(D) and 1019)