HLS 12RS-1170 ORIGINAL
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Regular Session, 2012
HOUSE BILL NO. 583
BY REPRESENTATIVE RITCHIE
INSURANCE/HEALTH: Provides relative to continuity of care by a health care provider
under health insurance coverage
AN ACT1
To amend and reenact R.S. 22:1005, relative to continuity of care by a health care provider2
under health insurance coverage; to provide for definitions; to provide with respect3
to such continuity of care when the contract between the health care provider and the4
health insurance issuer is terminated; to provide for applicability; and to provide for5
related matters.6
Be it enacted by the Legislature of Louisiana:7
Section 1. R.S. 22:1005 is hereby amended and reenacted to read as follows: 8
ยง1005. Continuity of care of health care services9
A. For purposes of this Subsection: Section:10
(1) "Covered health care services" means services, items, supplies, or drugs11
for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness,12
injury, or disease that are either covered and payable under the terms of health13
insurance coverage or required by law to be covered.14
(2) "Enrollee or insured" means an individual who is enrolled in or insured15
by a health insurance issuer for health insurance coverage.16
(3) "Health care provider" or "provider" means:17
(a) a A physician licensed by the Louisiana State Board of Medical18
Examiners to practice medicine or other health care practitioner licensed, certified,19 HLS 12RS-1170 ORIGINAL
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or registered, or otherwise authorized to perform specified health care services1
consistent with state law subject to direct supervision by such a licensed physician.2
(b) A facility or institution providing health care services, including but not3
limited to a hospital or other licensed inpatient center, ambulatory surgical or4
treatment center, skilled nursing facility, inpatient hospice facility, residential5
treatment center, diagnostic, laboratory, or imaging center, or rehabilitation or other6
therapeutic health setting.7
(4) "Health insurance issuer" means any entity that offers health insurance8
coverage through a policy or certificate of insurance subject to state law that9
regulates the business of insurance. For purposes of this Subpart, a "health insurance10
issuer" shall include a health maintenance organization, as defined and licensed11
pursuant to Subpart I of Part I of Chapter 2 of this Title, and nonfederal government12
plans subject to the provisions of Subpart B of Part II of Chapter 6 of this Title,13
including the Office of Group Benefits.14
(5) "Health insurance issuer liability" means the contractual liability of a15
health insurance issuer for covered health care services pursuant to the plan or policy16
provisions between the enrollee or insured and the health insurance issuer.17
(6) "Life-threatening illness" means a severe, serious, or acute condition for18
which death is probable.19
(7) "Participating provider" means a health care provider that has a contract20
with a health insurance issuer for the provision of health care services to enrollees21
or insureds of the health insurance issuer.22
B. Except as provided in Subsection F of this Section, a health insurance23
issuer shall, with respect to covered benefits, provide coverage to an enrollee or24
insured for the services of a provider, regardless of whether the provider is a25
participating provider at the time the services are provided, if the health insurance26
issuer represented that the provider was, or would be, a participating provider in27
marketing materials that were provided or available to the enrollee or insured at any28
of the following times:29 HLS 12RS-1170 ORIGINAL
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(1) If the plan under which the enrollee or insured has coverage has an open1
enrollment period, the most recent open enrollment period.2
(2) If the plan under which the enrollee or insured has coverage has no open3
enrollment period, the time of the enrollee's or insured's enrollment or most recent4
coverage renewal, whichever is later.5
C. Except as provided in Subsection F of this Section, a health insurance6
issuer shall provide the coverage required under Subsection B of this Section with7
respect to the services of a provider for the following period of time:8
(1) For an enrollee or insured of a plan with an open enrollment period, until9
the end of the plan year for which it was represented that the provider was, or would10
be, a participating provider.11
(2) For an enrollee or insured of a plan with no open enrollment period, until12
the end of the current plan year.13
D. In addition to all other provisions of this Section, if a health care provider14
was included in a network of a health insurance issuer pursuant to a contract between15
the health care provider and the health insurance issuer but such contract is16
terminated prior to the time periods defined in Subsections B and C of this Section,17
the following provisions shall apply:18
(1) The provisions of this Section shall be applicable whether such19
termination is initiated by the health insurance issuer or the health care provider.20
(2) The health insurance issuer shall continue payment of the health21
insurance issuer liability to the health care provider that was in effect prior to the22
termination of the contract or agreement with such health care provider. In addition,23
the contractual requirements for the health care provider to follow the health24
insurance issuer's utilization management and quality management policies and25
procedures shall remain in effect for the applicable period specified in this Section.26
(3) The payment of copayments, deductibles, or other cost-sharing27
components by the enrollee or insured during the period of completion of covered28
services with a terminated provider shall be the same copayments, deductibles, or29 HLS 12RS-1170 ORIGINAL
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other cost-sharing components that would be paid by the enrollee or insured when1
receiving care from a provider currently contracting with the health insurance issuer.2
(4) This Section shall not require an insurer to cover services or provide3
benefits that are not otherwise covered under the terms and conditions of the health4
insurance issuer contract.5
B. E. In addition to the provisions in Subsections C and D of this Section6
and if the enrollee or insured renews coverage with the same health insurance issuer,7
the following provisions shall be applicable in the event a contract or agreement8
between a health insurance issuer and health care provider is terminated,: the health9
care provider shall notify the health insurance issuer of any enrollee or insured who10
has begun a course of treatment by the provider before the effective date of the11
termination. Based on this notice from the health care provider, the health insurance12
issuer shall notify the enrollee or insured of a termination of a health care provider13
from a health insurance issuer's network and the enrollee's or insured's right to14
continuity of care. The following provisions of this Subsection shall be applicable15
whether such termination is initiated by the health insurance issuer or the health care16
provider.17
(1) In the event an enrollee or insured has been diagnosed as being in a high-18
risk pregnancy or is past the twenty-fourth week of pregnancy, the enrollee or19
insured shall be allowed to continue receiving covered health care services, subject20
to the consent of the treating health care provider, through delivery and postpartum21
care related to the pregnancy and delivery.22
(2) In the event an enrollee or insured has been diagnosed with a life-23
threatening illness, the enrollee or insured shall be allowed to continue receiving24
covered health care services, subject to the consent of the treating health care25
provider, until the course of treatment is completed, not to exceed three months from26
the effective date of such termination.27
(3) In the event a treating health care provider advises the health insurance28
issuer of an enrollee or insured who meets the criteria of Paragraph (1) or (2) of this29 HLS 12RS-1170 ORIGINAL
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Subsection, the health insurance issuer shall continue payment of the health1
insurance issuer liability to the health care provider that was in effect prior to the2
termination of the contract or agreement with such health care provider. In addition,3
the contractual requirements for the health care provider to follow the health4
insurance issuer's utilization management and quality management policies and5
procedures shall remain in effect for the applicable period specified in Paragraph (1)6
or (2) of this Subsection.7
C. F. The provisions of this Section shall not apply when:8
(1) The reason for such termination is due to suspension, revocation, or9
applicable restriction of the health care provider's license to practice or operate in10
this state by the Louisiana State Board of Medical Examiners, or for another11
documented reason related to quality of care. other applicable state licensing entity.12
(2) The enrollee or insured chooses to change health care provider.13
(3) The enrollee or insured moves out of the geographic service area of the14
health care provider or health insurance issuer.15
(4) The enrollee or insured requires only routine monitoring for a chronic16
condition but is not in an acute phase of the condition.17
D. G. A health care provider shall be prohibited from discount billing and18
dual billing pursuant to R.S. 22:1871 et seq. For purposes of this Section, the19
treating health care provider shall be deemed to be a contracted health care provider20
pursuant to R.S. 22:1871 et seq.21
H. This Subpart shall not apply to dental insurance or to any managed care22
organization contracted with the state of Louisiana to provide Medicaid benefits to23
Medicaid eligible recipients.24 HLS 12RS-1170 ORIGINAL
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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)]
Ritchie HB No. 583
Abstract: Provides with respect to continuity of care of an enrollee or insured by a health
care provider, including a health care facility, in the event the contract between the
health care provider and the enrollee's or insured's health insurance issuer is
terminated.
Present law provides for continuity of care for certain insureds or enrollees (covered
persons) by a health care provider in the event of termination of the contract between a
health insurance issuer and the health care provider. Applies only to those covered persons
with high-risk or advanced pregnancies until delivery and postpartum care or covered
persons with life-threatening illnesses for not more than three months.
Proposed law extends such continuity of care, as follows:
(1)Provides that "health care provider" shall include a facility or institution providing
health care services. Also defines a "participating provider" as a health care provider
contracted with a health insurance issuer for the provision of health care services to
its covered persons.
(2)Provides for continuity of care under health insurance coverage, regardless of
whether the provider is a participating provider at the time the services are provided,
if the health insurance issuer represented that the provider was or would be a
participating provider in marketing materials provided or available to covered
persons at open enrollment or, for plans without an open enrollment period, at the
time of coverage renewal. Requires that such coverage extend until the end of the
year for which it was represented that provider was or would be a participating
provider or, for plans without an open enrollment period, until the end of the current
plan year.
(3)Provides that if a health care provider was contractually included in a network of a
health insurance issuer but such contract was terminated prior to the time periods
specified in (2) above, the following provisions shall apply whether such termination
is initiated by the health insurance issuer or the health care provider:
(a)Payment of its liability by the health insurance issuer to the health care
provider that was in effect prior to the contract termination would be
continued. In addition, the contractual requirements for the health care
provider to follow the health insurance issuer's utilization management and
quality management policies and procedures would remain in effect.
(b)The payment of copayments, deductibles, or other cost-sharing components
by the covered person during the period of completion of covered services
with a terminated provider would be the same as would be paid by the
covered person when receiving care from a current contracting provider.
(4)Shall not require a health insurance issuer to cover services or provide benefits not
otherwise contractually covered. Makes applicable whether such contract termination
was initiated by the health insurance issuer or the health care provider. HLS 12RS-1170 ORIGINAL
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(5)Present law provides that continuity of care shall not apply when the reason for
contract termination is the suspension, revocation, or applicable restriction of the
health care provider's license by the La. State Board of Medical Examiners, or
another documented reason related to quality of care.
Proposed law additionally provides that continuity of care shall not apply when the
reason for contract termination is suspension, revocation, or applicable restriction of
the health care provider's license by any applicable state licensing agency. Deletes
inapplicability for another documented reason related to quality of care.
(6)Present law provides that continuity of care shall not apply when: the covered person
chooses to change health care provider, moves out of the geographic service area of
the health care provider or health insurance issuer, or requires only routine
monitoring for a chronic condition but is not in an acute phase of the condition.
Proposed law deletes inapplicability when the covered person requires only routine
monitoring and is not in an acute phase of the condition; otherwise retains present
law.
(7)Proposed law retains present law prohibiting a health care provider from discount
billing and dual billing pursuant to present law.
(8)Proposed law provides that it shall not apply to dental insurance or to any managed
care organization contracted with the state to provide Medicaid benefits to Medicaid
eligible recipients.
(Amends R.S. 22:1005)