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ACT No. 205
Regular Session, 2013
HOUSE BILL NO. 592
BY REPRESENTATIVE THIBAUT
Prefiled pursuant to Article III, Section 2(A)(4)(b)(i) of the Constitution of Louisiana.
AN ACT1
To amend and reenact R.S. 44:4.1(B)(11) and to enact Subpart A-1 of Part III of Chapter 42
of Title 22 of the Louisiana Revised Statutes of 1950, to be comprised of R.S.3
22:1019.1 through 1019.3, relative to ensuring the adequacy, accessibility, and4
quality of health care services offered to covered persons by a health insurance5
issuer in its health benefit plan networks; to provide for definitions; to provide with6
respect to standards for the creation and maintenance of health benefit plan networks7
by health insurance issuers; to provide with respect to the Public Records Law; to8
provide for regulation and enforcement by the commissioner of insurance, including9
imposition of fines and penalties; and to provide for related matters.10
Be it enacted by the Legislature of Louisiana:11
Section 1. Subpart A-1 of Part III of Chapter 4 of Title 22 of the Louisiana Revised12
Statutes of 1950, comprised of R.S. 22:1019.1 through 1019.3, is hereby enacted to read as13
follows: 14
SUBPART A-1. NETWORK ADEQUACY ACT15
§1019.1. Short title; purpose, scope, and definitions16
A. This Subpart shall be known and may be cited as the "Network Adequacy17
Act".18
B. The purpose and intent of this Subpart is to establish standards for the19
creation and maintenance of networks by health insurance issuers and to ensure the20
adequacy, accessibility, and quality of health care services offered to covered21
persons under a health benefit plan by establishing requirements for written22
agreements between health insurance issuers offering health benefit plans and23 ENROLLEDHB NO. 592
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participating providers regarding the standards, terms, and provisions under which1
such participating providers will provide services to covered persons.2
C. This Subpart shall apply to all health insurance issuers that offer health3
benefit plans but shall not include excepted benefits policies as defined in R.S.4
22:1061(3).5
D. As used in this Subpart:6
(1) "Base health care facility" means a facility or institution providing health7
care services, including but not limited to a hospital or other licensed inpatient8
center, ambulatory surgical or treatment center, skilled nursing facility, inpatient9
hospice facility, residential treatment center, diagnostic, laboratory, or imaging10
center, or rehabilitation or other therapeutic health setting that has entered into a11
contract or agreement with a facility-based physician.12
(2) "Commissioner" means the commissioner of insurance.13
(3) "Contracted reimbursement rate" means the aggregate maximum amount14
that a participating or contracted health care provider has agreed to accept from all15
sources for payment of covered health care services under the health insurance16
coverage applicable to the covered person.17
(4) "Covered health care services" means health care services that are either18
covered and payable under the terms of health insurance coverage or required by law19
to be covered.20
(5) "Covered person" means a policyholder, subscriber, enrollee, insured, or21
other individual participating in a health benefit plan.22
(6) "Emergency medical condition" means a medical condition manifesting23
itself by symptoms of sufficient severity, including severe pain, such that a prudent24
layperson, who possesses an average knowledge of health and medicine, could25
reasonably expect that the absence of immediate medical attention would result in26
serious impairment to bodily functions, serious dysfunction of a bodily organ or part,27
or would place the person's health or, with respect to a pregnant woman, the health28
of the woman or her unborn child, in serious jeopardy.29 ENROLLEDHB NO. 592
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(7) "Emergency services" means health care items and services furnished or1
required to evaluate and treat an emergency medical condition.2
(8) "Essential community providers" means providers that serve3
predominantly low-income, medically underserved individuals, including those4
providers defined in Section 340B(a)(4) of the Public Health Service Act and5
providers described in Section 1927(c)(1)(D)(i)(IV) of the Social Security Act as set6
forth by Section 221 of Public Law 111-8.7
(9) "Facility-based physician" means a physician licensed to practice8
medicine who is required by the base health care facility to provide services in a base9
health care facility, including an anesthesiologist, hospitalist, intensivist,10
neonatologist, pathologist, radiologist, emergency room physician, or other on-call11
physician, who is required by the base health care facility to provide covered health12
care services related to any medical condition.13
(10) "Health benefit plan" means a policy, contract, certificate, or subscriber14
agreement entered into, offered, or issued by a health insurance issuer to provide,15
deliver, arrange for, pay for, or reimburse any of the costs of health care services.16
(11) "Health care facility" means an institution providing health care services17
or a health care setting, including but not limited to hospitals and other licensed18
inpatient centers, ambulatory surgical or treatment centers, skilled nursing centers,19
diagnostic, laboratory and imaging centers, and rehabilitation and other therapeutic20
health settings.21
(12) "Health care professional" means a physician or other health care22
practitioner licensed, certified, or registered to perform specified health care services23
consistent with state law.24
(13) "Health care provider" or "provider" means a health care professional25
or a health care facility.26
(14) "Health care services" means services, items, supplies, or drugs for the27
diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury,28
or disease.29 ENROLLEDHB NO. 592
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(15) "Health insurance coverage" means benefits consisting of medical care1
provided or arranged for directly, through insurance or reimbursement, or otherwise,2
and includes health care services paid for under any health benefit plan.3
(16) "Health insurance issuer" means an entity subject to the insurance laws4
and regulations of this state, or subject to the jurisdiction of the commissioner, that5
contracts or offers to contract, or enters into an agreement to provide, deliver,6
arrange for, pay for, or reimburse any of the costs of health care services, including7
a sickness and accident insurance company, a health maintenance organization, a8
preferred provider organization or any similar entity, or any other entity providing9
a plan of health insurance or health benefits.10
(17) "Network of providers" or "network" means an entity, including a health11
insurance issuer, that, through contracts or agreements with health care providers,12
provides or arranges for access by groups of covered persons to health care services13
by health care providers who are not otherwise or individually contracted directly14
with a health insurance issuer.15
(18) "Participating provider" or "contracted health care provider" means a16
health care provider who, under a contract or agreement with the health insurance17
issuer or with its contractor or subcontractor, has agreed to provide health care18
services to covered persons with an expectation of receiving payment, other than19
in-network coinsurance, copayments, or deductibles, directly or indirectly from the20
health insurance issuer.21
(19) "Person" means an individual, a corporation, a partnership, an22
association, a joint venture, a joint stock company, a trust, an unincorporated23
organization, any similar entity, or any combination thereof.24
(20) "Primary care professional" means a participating health care25
professional designated by a health insurance issuer to supervise, coordinate, or26
provide initial care or continuing care to covered persons, and who may be required27
by the health insurance issuer to initiate a referral for specialty care and maintain28
supervision of health care services rendered to covered persons.29 ENROLLEDHB NO. 592
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§1019.2. Network adequacy1
A. A health insurance issuer providing a health benefit plan shall maintain2
a network that is sufficient in numbers and types of health care providers to ensure3
that all health care services to covered persons will be accessible without4
unreasonable delay. In the case of emergency services and any ancillary emergency5
health care services, covered persons shall have access twenty-four hours per day,6
seven days per week. Sufficiency shall be determined in accordance with the7
requirements of this Subpart. In determining sufficiency criteria, such criteria shall8
include but not be limited to ratios of health care providers to covered persons by9
specialty, ratios of primary care providers to covered persons, geographic10
accessibility, waiting times for appointments with participating providers, hours of11
operation, and volume of technological and specialty services available to serve the12
needs of covered persons requiring technologically advanced or specialty care.13
B.(1) Each health insurance issuer shall maintain a network of providers that14
includes but is not limited to providers that specialize in mental health and substance15
abuse services, facility-based physicians, and providers that are essential community16
providers.17
(2) A health insurance issuer shall establish and maintain adequate18
arrangements to ensure reasonable proximity of participating providers to the19
primary residences of covered persons. In determining whether a health insurance20
issuer has complied with this Paragraph, the commissioner shall give due21
consideration to the relative availability of health care providers in the service area22
under consideration and the geographic composition of the service area. The23
commissioner may consider a health insurance issuer's adjacent service area24
networks that may augment health care providers if a health care provider deficiency25
exists within the service area.26
(3) A health insurance issuer shall monitor, on an ongoing basis, the ability,27
clinical capacity, and legal authority of its participating providers to furnish all28
contracted health care services to covered persons.29 ENROLLEDHB NO. 592
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(4) A health insurance issuer shall maintain a directory of its network of1
providers on the Internet. The directory of network providers must be furnished in2
printed form to any covered person upon request. The directory of network3
providers shall identify all health care providers that are not accepting new referrals4
of covered persons or are not offering services to covered persons.5
(5)(a) Beginning January 1, 2014, except as otherwise provided in6
Subparagraph (b) of this Paragraph, a health insurance issuer shall annually file with7
the commissioner, an access plan meeting the requirements of this Subpart for each8
of the health benefit plans that the health insurance issuer offers in this state. Any9
existing, new, or initial filing of policy forms by a health insurance issuer shall10
include the network of providers, if any, to be used in connection with the policy11
forms. If benefits under a health insurance policy do not rely on a network of12
providers, the health insurance issuer shall state such fact in the policy form filing.13
The health insurance issuer may request the commissioner to deem sections of the14
access plan to contain proprietary or trade secret information that shall not be made15
public in accordance with the Public Records Law, R.S. 44:1 et seq., or to contain16
protected health information that shall not be made public in accordance with R.S.17
22:42.1. If the commissioner concurs with the request, those sections of the access18
plan shall not be subject to the Public Records Law or shall not be made public in19
accordance with R.S. 22:42.1 as applicable. The health insurance issuer shall make20
the access plans, absent any such proprietary or trade secret information and21
protected health information, available and readily accessible on its business22
premises and shall provide such plans to any interested party upon request, subject23
to the provisions of the Public Records Law and R.S. 22:42.1.24
(b) In lieu of meeting the filing requirements of Subparagraph (a) of this25
Paragraph, a health insurance issuer shall, beginning January 1, 2014, except as26
otherwise provided in Subparagraph (c) of this Paragraph, submit proof of27
accreditation from the National Committee for Quality Assurance (NCQA) or28
American Accreditation Healthcare Commission, Inc./URAC to the commissioner,29
including an affidavit and sufficient proof demonstrating its accreditation for30 ENROLLEDHB NO. 592
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compliance with the network adequacy requirements of this Subpart. The affidavit1
shall include sufficient information to notify the commissioner of the health2
insurance issuer's accreditation and shall include a certification that the health3
insurance issuer's network of providers includes health care providers that specialize4
in mental health and substance abuse services and providers that are essential5
community providers. The affidavit shall also certify that the health insurance issuer6
complies with the provider directory requirement contained in Paragraph (4) of this7
Subsection. The commissioner may, at any time, recognize accreditation by any8
other nationally recognized organization or entity that accredits health insurance9
issuers; however, such entity's accreditation process shall be equal to or have10
comparative standards for review and accreditation of network adequacy.11
(c) A health insurance issuer that has submitted an application for12
accreditation to NCQA or URAC prior to December 31, 2013, but has not yet13
received such accreditation by January 1, 2014, shall be deemed accredited for the14
purposes of this Subpart upon submission of an affidavit to the commissioner by15
January 1, 2014, demonstrating that the issuer is in the process of accreditation.16
Upon receipt of accreditation, the issuer shall submit proof of such accreditation to17
the commissioner pursuant to Subparagraph (b) of this Paragraph. However, in the18
event that the issuer withdraws its application for accreditation or does not receive19
accreditation prior to July 1, 2015, such issuer shall file an access plan with the20
commissioner pursuant to Subparagraph (a) of this Paragraph within sixty days of21
such withdrawal or denial.22
(d) If a health insurance issuer that has submitted proof of accreditation to23
the commissioner subsequently loses such accreditation, the issuer shall promptly24
notify the commissioner and file an access plan with him pursuant to Subparagraph25
(a) of this Paragraph within sixty days of the loss of such accreditation.26
(e) A health insurance issuer submitting proof of accreditation or an affidavit27
demonstrating that the issuer is in the process of accreditation shall maintain an28
access plan at its principal place of business. Such access plan shall be in accordance29
with the requirements of the accrediting entity.30 ENROLLEDHB NO. 592
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C. A health insurance issuer not submitting proof of accreditation shall file1
an access plan for written approval from the commissioner for existing health benefit2
plans and prior to offering a new health benefit plan. Additionally, such a health3
insurance issuer shall inform the commissioner when the issuer enters a new service4
or market area and shall submit an updated access plan demonstrating that the5
issuer's network in the new service or market area is adequate and consistent with6
this Subpart. Each such access plan, including riders and endorsements, shall be7
identified by a form number in the lower left hand corner of the first page of the8
form. Such a health insurance issuer shall update an existing access plan whenever9
it makes any material change to an existing health benefit plan. Such an access plan10
shall describe or contain, at a minimum, each of the following:11
(1) The health insurance issuer's network which includes but is not limited12
to the availability of and access to centers of excellence for transplant and other13
medically intensive services as well as the availability of critical care services, such14
as advanced trauma centers and burn units.15
(2) The health insurance issuer's procedure for making referrals within and16
outside its network.17
(3) The health insurance issuer's process for monitoring and ensuring, on an18
ongoing basis, the sufficiency of the network to meet the health care needs of19
populations that enroll in its health benefit plans and general provider availability in20
a given geographic area.21
(4) The health insurance issuer's efforts to address the needs of covered22
persons with limited English proficiency and illiteracy, with diverse cultural and23
ethnic backgrounds, or with physical and mental disabilities.24
(5) The health insurance issuer's methods for assessing the health care needs25
of covered persons and their satisfaction with services.26
(6) The health insurance issuer's method of informing covered persons of the27
health benefit plan's services and features, including but not limited to the health28
benefit plan's utilization review procedure, grievance procedure, external review29
procedure, process for choosing and changing providers, and procedures for30 ENROLLEDHB NO. 592
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providing and approving emergency services and specialty care. Additional1
information relating to these processes shall be available upon request and accessible2
via the health insurance issuer's website.3
(7) The health insurance issuer's system for ensuring coordination and4
continuity of care for covered persons referred to specialty physicians, for covered5
persons using ancillary health care services, including social services and other6
community resources, and for ensuring appropriate discharge planning.7
(8) The health insurance issuer's processes for enabling covered persons to8
change primary care professionals, for medical care referrals, and for ensuring that9
participating providers that require the use of health care facilities have hospital10
admission privileges.11
(9) The health insurance issuer's proposed plan for providing continuity of12
care in the event of contract termination between the health insurance issuer and any13
of its participating providers, as required by R.S. 22:1005, or in the event of the14
health insurance issuer's insolvency or other inability to continue operations. This15
description shall explain how covered persons will be notified of contract16
termination, including but not limited to the effective date of the contract17
termination, the health insurance issuer's insolvency, or other cessation of operations,18
and how such covered persons will be transferred to other providers in a timely19
manner.20
(10) A geographic map of the area proposed to be served by the health21
benefit plan by both parish and zip code.22
(11) The policies and procedures to ensure access to covered health care23
services under each of the following circumstances:24
(a) When the covered health care service is not available from a participating25
provider in any case when a covered person has made a good faith effort to utilize26
participating providers for a covered service and it is determined that the health27
insurance issuer does not have the appropriate participating providers due to28
insufficient number, type, or distance, the health insurance issuer shall ensure, by29 ENROLLEDHB NO. 592
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terms contained in the health benefit plan, that the covered person will be provided1
the covered health care service.2
(b) When the covered person has a medical emergency within the network's3
service area.4
(c) When the covered person has a medical emergency outside the network's5
service area.6
(12) Any other information required by the commissioner to determine7
compliance with the provisions of this Subpart.8
D. A health insurance issuer not submitting proof of accreditation shall file9
any proposed material changes to the access plan with the commissioner prior to10
implementation of any such changes. The removal or withdrawal of any hospital or11
multi-specialty clinic from a health insurance issuer's network shall constitute a12
material change and shall be filed with the commissioner in accordance with the13
provisions of this Subpart. Changes shall be deemed approved by the commissioner14
after sixty days unless specifically disapproved in writing by the commissioner prior15
to expiration of such sixty days.16
E. All filings containing any proposed material changes to an access plan as17
required by this Subpart shall include but not be limited to each of the following:18
(1) A listing of health care facilities and the number of hospital beds at each19
network health care facility.20
(2) The ratio of participating providers to current covered persons.21
(3) Any other information requested by the commissioner.22
§1019.3. Enforcement provisions, penalties, and regulations23
A. If the commissioner determines that a health insurance issuer has not24
contracted with enough participating providers to ensure that covered persons have25
accessible health care services in a geographic area, that a health insurance issuer's26
access plan does not ensure reasonable access to covered health care services, or that27
a health insurance issuer has entered into a contract that does not comply with this28
Subpart, the commissioner may do either or both of the following:29 ENROLLEDHB NO. 592
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(1) Institute a corrective action plan that shall be followed by the health1
insurance issuer within thirty days of notice of noncompliance from the2
commissioner.3
(2) Use his other enforcement powers to obtain the health insurance issuer's4
compliance with this Subpart, including but not limited to disapproval or withdrawal5
of his approval.6
B. The commissioner shall not act to arbitrate, mediate, or settle disputes7
regarding a decision not to include a health care provider in a health benefit plan or8
in a provider network if the health insurance issuer has an adequate network as9
determined by the commissioner pursuant to the requirements contained in this10
Subpart.11
C. The commissioner may promulgate such rules and regulations as may be12
necessary or proper to carry out the provisions of this Subpart. Such rules and13
regulations shall be promulgated and adopted in accordance with the Administrative14
Procedure Act, R.S. 49:950 et seq.15
D.(1) The commissioner may issue, and cause to be served upon the health16
insurance issuer violating this Subpart, an order requiring such health insurance17
issuer to cease and desist from such act or omission for the whole state or any18
geographic area.19
(2) The commissioner may refuse to renew, suspend, or revoke the certificate20
of authority of any health insurance issuer violating any of the provisions of this21
Subpart, or in lieu of suspension or revocation of a license duly issued, the22
commissioner may levy a fine not to exceed one thousand dollars for each violation23
per health insurance issuer, up to one hundred thousand dollars aggregate for all24
violations in a calendar year per health insurance issuer, when such violations, in his25
opinion, after a proper hearing, warrant the refusal, suspension, or revocation of such26
certificate, or the imposition of a fine. The commissioner of insurance is authorized27
to withhold fines imposed under this Subpart. Such hearing shall be held in the28
manner provided in Chapter 12 of this Title, R.S. 22:2191 et seq. Additionally, the29 ENROLLEDHB NO. 592
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commissioner may take any other administrative action, including imposing those1
fines and penalties enumerated in R.S. 22:18.2
Section 2. R.S. 44:4.1(B)(11) is hereby amended and reenacted to read as follows:3
§4.1. Exceptions4
* * *5
B. The legislature further recognizes that there exist exceptions, exemptions,6
and limitations to the laws pertaining to public records throughout the revised7
statutes and codes of this state. Therefore, the following exceptions, exemptions, and8
limitations are hereby continued in effect by incorporation into this Chapter by9
citation:10
* * *11
(11) R.S. 22:2, 14, 42.1, 88, 244, 461, 572, 572.1, 574, 618, 706, 732, 752,12
771, 1019.2(B)(5)(a), 1203, 1460, 1466, 1546, 1644, 1656, 1723, 1927, 1929, 1983,13
1984, 2036, 230314
* * *15
Section 3. This Act shall become effective upon signature by the governor or, if not16
signed by the governor, upon expiration of the time for bills to become law without signature17
by the governor, as provided by Article III, Section 18 of the Constitution of Louisiana. If18
vetoed by the governor and subsequently approved by the legislature, this Act shall become19
effective on the day following such approval.20
SPEAKER OF THE HOUSE OF REPRESENTATI VES
PRESIDENT OF THE SENATE
GOVERNOR OF THE STATE OF LOUISIANA
APPROVED: