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2016 Regular Session
SENATE BILL NO. 193
BY SENATOR LONG
HEALTH/ACC INSURANCE. Provides relative to the adequacy of networks utilized by
health insurance issuers for the provision of health care services. (8/1/16)
1 AN ACT
2 To amend and reenact R.S. 22:1019.1(D), 1019.2, and 1019.3(A) and to enact R.S.
3 22:1019.3(E), relative to the network adequacy act; to provide definitions; to provide
4 with respect to the adequacy of networks utilized by health insurance issuers for the
5 provision of health care services; to provide with respect to enforcement, penalties,
6 and regulations; and to provide for related matters.
7 Be it enacted by the Legislature of Louisiana:
8 Section 1. R.S. 22:1019.1(D), 1019.2, and 1019.3(A) are hereby amended and
9 reenacted and R.S. 22:1019(E) is hereby enacted to read as follows:
10 §1019.1. Short title; purpose; scope; definitions
11 * * *
12 D. As used in this Subpart:
13 (1) "Base health care facility" means a facility or institution providing health
14 care services, including but not limited to a hospital or other licensed inpatient
15 center, ambulatory surgical or treatment center, skilled nursing facility, inpatient
16 hospice facility, residential treatment center, diagnostic, laboratory, or imaging
17 center, or rehabilitation or other therapeutic health setting that has entered into a
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1 contract or agreement with a facility-based physician.
2 (2) "Commissioner" means the commissioner of insurance.
3 (3) "Contracted reimbursement rate" means the aggregate maximum amount
4 that a participating or contracted health care provider has agreed to accept from all
5 sources for payment of covered health care services under the health insurance
6 coverage applicable to the covered person.
7 (4) "Covered health care services" means health care services that are either
8 covered and payable under the terms of health insurance coverage or required by law
9 to be covered.
10 (5) "Covered person" means a policyholder, subscriber, enrollee, insured, or
11 other individual participating in a health benefit plan.
12 (6) "Emergency medical condition" means a medical condition manifesting
13 itself by symptoms of sufficient severity, including severe pain, such that a prudent
14 layperson, who possesses an average knowledge of health and medicine, could
15 reasonably expect that the absence of immediate medical attention would result in
16 serious impairment to bodily functions, serious dysfunction of a bodily organ or part,
17 or would place the person's health or, with respect to a pregnant woman, the health
18 of the woman or her unborn child, in serious jeopardy.
19 (7) "Emergency services" means health care items and services furnished or
20 required to evaluate and treat an emergency medical condition.
21 (8) "Essential community providers" means providers that serve
22 predominantly low-income, medically underserved individuals, including those
23 providers defined in Section 340B(a)(4) of the Public Health Service Act and
24 providers described in Section 1927(c)(1)(D)(i)(IV) of the Social Security Act as set
25 forth by Section 221 of Public Law 111-8.
26 (9) "Facility-based physician" means a physician licensed to practice
27 medicine who is required by the base health care facility to provide services in a base
28 health care facility, including an anesthesiologist, hospitalist, intensivist,
29 neonatologist, pathologist, radiologist, emergency room physician, or other on-call
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1 physician, who is required by the base health care facility to provide covered health
2 care services related to any medical condition.
3 (10) "Health benefit plan" means a policy, contract, certificate, or subscriber
4 agreement entered into, offered, or issued by a health insurance issuer to provide,
5 deliver, arrange for, pay for, or reimburse any of the costs of health care services.
6 (11) "Health care facility" means an institution providing health care services
7 or a health care setting, including but not limited to hospitals and other licensed
8 inpatient centers, ambulatory surgical or treatment centers, skilled nursing centers,
9 diagnostic, laboratory and imaging centers, and rehabilitation and other therapeutic
10 health settings.
11 (12) "Health care professional" means a physician or other health care
12 practitioner licensed, certified, or registered to perform specified health care services
13 consistent with state law.
14 (13) "Health care provider" or "provider" means a health care professional
15 or a health care facility.
16 (14) "Health care services" means services, items, supplies, or drugs for the
17 diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury,
18 or disease.
19 (15) "Health insurance coverage" means benefits consisting of medical care
20 provided or arranged for directly, through insurance or reimbursement, or otherwise,
21 and includes health care services paid for under any health benefit plan.
22 (16) "Health insurance issuer" means an entity subject to the insurance laws
23 and regulations of this state, or subject to the jurisdiction of the commissioner, that
24 contracts or offers to contract, or enters into an agreement to provide, deliver,
25 arrange for, pay for, or reimburse any of the costs of health care services, including
26 a sickness and accident insurance company, a health maintenance organization, a
27 preferred provider organization or any similar entity, or any other entity providing
28 a plan of health insurance or health benefits.
29 (17) "Network of providers" or "network" means an entity, including a health
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1 insurance issuer, that, through contracts or agreements with health care providers,
2 provides or arranges for access by groups of covered persons to health care services
3 by health care providers who are not otherwise or individually contracted directly
4 with a health insurance issuer.
5 (18) "Participating provider" or "contracted health care provider" means a
6 health care provider who, under a contract or agreement with the health insurance
7 issuer or with its contractor or subcontractor, has agreed to provide health care
8 services to covered persons with an expectation of receiving payment, other than in-
9 network coinsurance, copayments, or deductibles, directly or indirectly from the
10 health insurance issuer.
11 (19) "Person" means an individual, a corporation, a partnership, an
12 association, a joint venture, a joint stock company, a trust, an unincorporated
13 organization, any similar entity, or any combination thereof.
14 (20) "Primary care professional" means a participating health care
15 professional designated by a health insurance issuer to supervise, coordinate, or
16 provide initial care or continuing care to covered persons, and who may be required
17 by the health insurance issuer to initiate a referral for specialty care and maintain
18 supervision of health care services rendered to covered persons.
19 (1) "Commissioner" means the insurance commissioner of this state.
20 (2) "Covered benefit" or "benefit" means any of those health care
21 services to which a covered person is entitled under the terms of a health benefit
22 plan.
23 (3) "Covered person" means a policyholder, subscriber, enrollee, or
24 other individual participating in a health benefit plan.
25 (4) "Emergency medical condition" means a physical, mental, or
26 behavioral health condition that manifests itself by acute symptoms of sufficient
27 severity, including severe pain that would lead a prudent layperson, possessing
28 an average knowledge of medicine and health, to reasonably expect, in the
29 absence of immediate medical attention, to result in:
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1 (a) Placing the individual's physical, mental or behavioral health or, with
2 respect to a pregnant woman, the woman's or her unborn child's health in
3 serious jeopardy.
4 (b) Serious impairment to a bodily function.
5 (c) Serious impairment of any bodily organ or part.
6 (d) With respect to a pregnant woman who is having contractions.
7 (i) That there is inadequate time to effect a safe transfer to another
8 hospital before delivery.
9 (ii) That transfer to another hospital may pose a threat to the health or
10 safety of the woman or her unborn child.
11 (5) "Emergency services" means, with respect to an emergency
12 condition:
13 (a) A medical or mental health screening examination that is within the
14 capability of the emergency department of a hospital, including ancillary
15 services routinely available to the emergency department to evaluate the
16 emergency medical condition.
17 (b) Any further medical or mental health examination and treatment to
18 the extent they are within the capabilities of the staff and facilities available at
19 the hospital to stabilize the patient.
20 (6) "Essential community provider" or "ECP" means a provider that:
21 (a) Serves predominantly low-income, medically underserved
22 individuals, including a health care provider defined in Section 340B(a)(4) of the
23 Public Health Service Act (PHSA).
24 (b) Is described in Section 1927(c)(1)(D)(i)(IV) of the Social Security Act,
25 as set forth by Section 221 of Pub.L.111-8.
26 (7) "Facility" means an institution providing health care services or a
27 health care setting, including but not limited to hospitals and other licensed
28 inpatient centers, ambulatory surgical or treatment centers, skilled nursing
29 centers, residential treatment centers, urgent care centers, diagnostic,
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1 laboratory and imaging centers, and rehabilitation and other therapeutic health
2 settings.
3 (8) "Health benefit plan" means a policy, contract, certificate, or
4 agreement entered into, offered, or issued by a health insurance issuer to
5 provide, deliver, arrange for, pay for, or reimburse any of the costs of health
6 care services.
7 (9) "Health care professional" means a physician or other health care
8 practitioner licensed, accredited or certified to perform specified health care
9 services consistent with their scope of practice under state law.
10 (10) "Health care provider" or "provider" means a health care
11 professional, a pharmacy, or a facility.
12 (11) "Health care services" means services for the diagnosis, prevention,
13 treatment, cure, or relief of a physical, mental or behavioral health condition,
14 illness, injury, or disease, including mental health and substance use disorders.
15 (12) "Health insurance issuer" or "issuer" means an entity subject to the
16 insurance laws and regulations of this state, or subject to the jurisdiction of the
17 commissioner, that contracts or offers to contract, or enters into an agreement
18 to provide, deliver, arrange for, pay for, or reimburse any of the costs of health
19 care services, including a health insurance issuer, a health maintenance
20 organization, a hospital and health service corporation, or any other entity
21 providing a plan of health insurance, health benefits, or health care services.
22 (13) "Limited scope dental plan" means a plan that provides coverage
23 substantially all of which is for treatment of the mouth, including any organ or
24 structure within the mouth, which is provided under a separate policy,
25 certificate, or contract of insurance or is otherwise not an integral part of a
26 group benefit plan.
27 (14) "Limited scope vision plan" means a plan that provides coverage
28 substantially all of which is for treatment of the eye that is provided under a
29 separate policy, certificate, or contract of insurance or is otherwise not an
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1 integral part of a group benefit plan.
2 (15) "Network" means the group or groups of participating providers
3 providing services under a network plan.
4 (16) "Network plan" means a health benefit plan that either requires a
5 covered person to use, or creates incentives, including financial incentives, for
6 a covered person to use health care providers managed, owned, under contract
7 with, or employed by the health insurance issuer.
8 (17) "Participating provider" means a provider who, under a contract
9 with the health insurance issuer or with its contractor or subcontractor, has
10 agreed to provide health care services to covered persons with an expectation
11 of receiving payment, other than coinsurance, copayments, or deductibles,
12 directly or indirectly from the health insurance issuer.
13 (18) "Person" means an individual, a corporation, a partnership, an
14 association, a joint venture, a joint stock company, a trust, an unincorporated
15 organization, any similar entity, or any combination of the foregoing.
16 (19) "Primary care" means health care services for a range of common
17 physical, mental, or behavioral health conditions provided by a physician or
18 non-physician primary care professional.
19 (20) "Primary care professional" means a participating health care
20 professional designated by the health insurance issuer to supervise, coordinate,
21 or provide initial care or continuing care to a covered person, and who may be
22 required by the health insurance issuer to initiate a referral for specialty care
23 and maintain supervision of health care services rendered to the covered
24 person.
25 (21)(a) "Specialist" means a physician or non-physician health care
26 professional who:
27 (i) Focuses on a specific area of physical, mental, or behavioral health or
28 a group of patients.
29 (ii) Has successfully completed required training and is recognized by the
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1 state in which he or she practices to provide specialty care.
2 (b) "Specialist" includes a subspecialist who has additional training and
3 recognition above and beyond his or her specialty training.
4 (22) "Specialty care" means advanced medically necessary care and
5 treatment of specific physical, mental, or behavioral health conditions or those
6 health conditions which may manifest in particular ages or subpopulations, that
7 are provided by a specialist, preferably in coordination with a primary care
8 professional or other health care professional.
9 (23) "Telemedicine" or "Telehealth" means health care services
10 provided through telecommunications technology by a health care professional
11 who is at a location other than the location of the covered person.
12 (24) "Tiered network" means a network that identifies and groups some
13 or all types of providers and facilities into specific groups to which different
14 provider reimbursement, covered person cost sharing, or provider access
15 requirements, or any combination thereof, apply for the same services.
16 (25) "To stabilize" means, with respect to an emergency medical
17 condition, to provide such medical treatment of the condition as may be
18 necessary to assure, within a reasonable medical probability, that no material
19 deterioration of the condition is likely to result from or occur during the
20 transfer of the individual to or from a facility, or, with respect to an emergency
21 birth with no complications resulting in a continued emergency, to deliver the
22 child and the placenta.
23 (26) "Transfer" means the movement, including the discharge, of an
24 individual outside a hospital's facilities at the direction of any person employed
25 by, or affiliated or associated, directly or indirectly, with the hospital, but does
26 not include the movement of an individual who:
27 (a) Has been declared dead.
28 (b) Leaves the facility without the permission of any such person.
29 §1019.2. Network adequacy
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1 A. A health insurance issuer providing a health benefit plan shall maintain
2 a network that is sufficient in numbers and types of health care providers to ensure
3 that all health care services to covered persons will be accessible without
4 unreasonable delay. In the case of emergency services and any ancillary emergency
5 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 the
7 requirements of this Subpart. In determining sufficiency criteria, such criteria shall
8 include but not be limited to ratios of health care providers to covered persons by
9 specialty, ratios of primary care providers to covered persons, geographic
10 accessibility, waiting times for appointments with participating providers, hours of
11 operation, and volume of technological and specialty services available to serve the
12 needs of covered persons requiring technologically advanced or specialty care.
13 B.(1) Each health insurance issuer shall maintain a network of providers that
14 includes but is not limited to providers that specialize in mental health and substance
15 abuse services, facility-based physicians, and providers that are essential community
16 providers.
17 (2) A health insurance issuer shall establish and maintain adequate
18 arrangements to ensure reasonable proximity of participating providers to the
19 primary residences of covered persons. In determining whether a health insurance
20 issuer has complied with this Paragraph, the commissioner shall give due
21 consideration to the relative availability of health care providers in the service area
22 under consideration and the geographic composition of the service area. The
23 commissioner may consider a health insurance issuer's adjacent service area
24 networks that may augment health care providers if a health care provider deficiency
25 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 all
28 contracted health care services to covered persons.
29 (4) A health insurance issuer shall maintain a directory of its network of
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1 providers on the Internet. The directory of network providers must be furnished in
2 printed form to any covered person upon request. The directory of network
3 providers shall identify all health care providers that are not accepting new referrals
4 of covered persons or are not offering services to covered persons.
5 (5)(a) Beginning January 1, 2014, except as otherwise provided in
6 Subparagraph (b) of this Paragraph, a health insurance issuer shall annually file with
7 the commissioner, an access plan meeting the requirements of this Subpart for each
8 of the health benefit plans that the health insurance issuer offers in this state. Any
9 existing, new, or initial filing of policy forms by a health insurance issuer shall
10 include the network of providers, if any, to be used in connection with the policy
11 forms. If benefits under a health insurance policy do not rely on a network of
12 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 the
14 access plan to contain proprietary or trade secret information that shall not be made
15 public in accordance with the Public Records Law, R.S. 44:1 et seq., or to contain
16 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 access
18 plan shall not be subject to the Public Records Law or shall not be made public in
19 accordance with R.S. 22:42.1 as applicable. The health insurance issuer shall make
20 the access plans, absent any such proprietary or trade secret information and
21 protected health information, available and readily accessible on its business
22 premises and shall provide such plans to any interested party upon request, subject
23 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 this
25 Paragraph, a health insurance issuer shall, beginning January 1, 2014, except as
26 otherwise provided in Subparagraph (c) of this Paragraph, submit proof of
27 accreditation from the National Committee for Quality Assurance (NCQA) or
28 American Accreditation Healthcare Commission, Inc./URAC to the commissioner,
29 including an affidavit and sufficient proof demonstrating its accreditation for
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1 compliance with the network adequacy requirements of this Subpart. The affidavit
2 shall include sufficient information to notify the commissioner of the health
3 insurance issuer's accreditation and shall include a certification that the health
4 insurance issuer's network of providers includes health care providers that specialize
5 in mental health and substance abuse services and providers that are essential
6 community providers. The affidavit shall also certify that the health insurance issuer
7 complies with the provider directory requirement contained in Paragraph (4) of this
8 Subsection. The commissioner may, at any time, recognize accreditation by any
9 other nationally recognized organization or entity that accredits health insurance
10 issuers; however, such entity's accreditation process shall be equal to or have
11 comparative standards for review and accreditation of network adequacy.
12 (c) A health insurance issuer that has submitted an application for
13 accreditation to NCQA or URAC prior to December 31, 2013, but has not yet
14 received such accreditation by January 1, 2014, shall be deemed accredited for the
15 purposes of this Subpart upon submission of an affidavit to the commissioner by
16 January 1, 2014, demonstrating that the issuer is in the process of accreditation.
17 Upon receipt of accreditation, the issuer shall submit proof of such accreditation to
18 the commissioner pursuant to Subparagraph (b) of this Paragraph. However, in the
19 event that the issuer withdraws its application for accreditation or does not receive
20 accreditation prior to July 1, 2015, such issuer shall file an access plan with the
21 commissioner pursuant to Subparagraph (a) of this Paragraph within sixty days of
22 such withdrawal or denial.
23 (d) If a health insurance issuer that has submitted proof of accreditation to
24 the commissioner subsequently loses such accreditation, the issuer shall promptly
25 notify the commissioner and file an access plan with him pursuant to Subparagraph
26 (a) of this Paragraph within sixty days of the loss of such accreditation.
27 (e) A health insurance issuer submitting proof of accreditation or an affidavit
28 demonstrating that the issuer is in the process of accreditation shall maintain an
29 access plan at its principal place of business. Such access plan shall be in accordance
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1 with the requirements of the accrediting entity.
2 C. A health insurance issuer not submitting proof of accreditation shall file
3 an access plan for written approval from the commissioner for existing health benefit
4 plans and prior to offering a new health benefit plan. Additionally, such a health
5 insurance issuer shall inform the commissioner when the issuer enters a new service
6 or market area and shall submit an updated access plan demonstrating that the
7 issuer's network in the new service or market area is adequate and consistent with
8 this Subpart. Each such access plan, including riders and endorsements, shall be
9 identified by a form number in the lower left hand corner of the first page of the
10 form. Such a health insurance issuer shall update an existing access plan whenever
11 it makes any material change to an existing health benefit plan. Such an access plan
12 shall describe or contain, at a minimum, each of the following:
13 (1) The health insurance issuer's network which includes but is not limited
14 to the availability of and access to centers of excellence for transplant and other
15 medically intensive services as well as the availability of critical care services, such
16 as advanced trauma centers and burn units.
17 (2) The health insurance issuer's procedure for making referrals within and
18 outside its network.
19 (3) The health insurance issuer's process for monitoring and ensuring, on an
20 ongoing basis, the sufficiency of the network to meet the health care needs of
21 populations that enroll in its health benefit plans and general provider availability in
22 a given geographic area.
23 (4) The health insurance issuer's efforts to address the needs of covered
24 persons with limited English proficiency and illiteracy, with diverse cultural and
25 ethnic backgrounds, or with physical and mental disabilities.
26 (5) The health insurance issuer's methods for assessing the health care needs
27 of covered persons and their satisfaction with services.
28 (6) The health insurance issuer's method of informing covered persons of the
29 health benefit plan's services and features, including but not limited to the health
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1 benefit plan's utilization review procedure, grievance procedure, external review
2 procedure, process for choosing and changing providers, and procedures for
3 providing and approving emergency services and specialty care. Additional
4 information relating to these processes shall be available upon request and accessible
5 via the health insurance issuer's website.
6 (7) The health insurance issuer's system for ensuring coordination and
7 continuity of care for covered persons referred to specialty physicians, for covered
8 persons using ancillary health care services, including social services and other
9 community resources, and for ensuring appropriate discharge planning.
10 (8) The health insurance issuer's processes for enabling covered persons to
11 change primary care professionals, for medical care referrals, and for ensuring that
12 participating providers that require the use of health care facilities have hospital
13 admission privileges.
14 (9) The health insurance issuer's proposed plan for providing continuity of
15 care in the event of contract termination between the health insurance issuer and any
16 of its participating providers, as required by R.S. 22:1005, or in the event of the
17 health insurance issuer's insolvency or other inability to continue operations. This
18 description shall explain how covered persons will be notified of contract
19 termination, including but not limited to the effective date of the contract
20 termination, the health insurance issuer's insolvency, or other cessation of operations,
21 and how such covered persons will be transferred to other providers in a timely
22 manner.
23 (10) A geographic map of the area proposed to be served by the health
24 benefit plan by both parish and zip code.
25 (11) The policies and procedures to ensure access to covered health care
26 services under each of the following circumstances:
27 (a) When the covered health care service is not available from a participating
28 provider in any case when a covered person has made a good faith effort to utilize
29 participating providers for a covered service and it is determined that the health
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1 insurance issuer does not have the appropriate participating providers due to
2 insufficient number, type, or distance, the health insurance issuer shall ensure, by
3 terms contained in the health benefit plan, that the covered person will be provided
4 the covered health care service.
5 (b) When the covered person has a medical emergency within the network's
6 service area.
7 (c) When the covered person has a medical emergency outside the network's
8 service area.
9 (12) Any other information required by the commissioner to determine
10 compliance with the provisions of this Subpart.
11 D. A health insurance issuer not submitting proof of accreditation shall file
12 any proposed material changes to the access plan with the commissioner prior to
13 implementation of any such changes. The removal or withdrawal of any hospital or
14 multi-specialty clinic from a health insurance issuer's network shall constitute a
15 material change and shall be filed with the commissioner in accordance with the
16 provisions of this Subpart. Changes shall be deemed approved by the commissioner
17 after sixty days unless specifically disapproved in writing by the commissioner prior
18 to expiration of such sixty days.
19 E. All filings containing any proposed material changes to an access plan as
20 required by this Subpart shall include but not be limited to each of the following:
21 (1) A listing of health care facilities and the number of hospital beds at each
22 network health care facility.
23 (2) The ratio of participating providers to current covered persons.
24 (3) Any other information requested by the commissioner.
25 A.(1) A health insurance issuer providing a network plan shall maintain
26 a network that is sufficient in numbers and appropriate types of providers,
27 including those that serve predominantly low-income, medically underserved
28 individuals, to assure that all covered services to covered persons, including
29 children and adults, will be accessible without unreasonable travel or delay.
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1 (2) Covered persons shall have access to emergency services twenty-four
2 hours per day, seven days per week.
3 B. The commissioner shall determine sufficiency in accordance with the
4 requirements of this Section, and may establish sufficiency by reference to any
5 reasonable criteria, which may include but shall not be limited to:
6 (1) Provider-covered person ratios by specialty.
7 (2) Primary care professional covered person ratios.
8 (3) Geographic accessibility of providers.
9 (4) Geographic variation and population dispersion.
10 (5) Waiting times for an appointment with participating providers.
11 (6) Hours of operation.
12 (7) The ability of the network to meet the needs of covered persons,
13 which may include low-income persons, children and adults with serious,
14 chronic or complex health conditions or physical or mental disabilities or
15 persons with limited English proficiency.
16 (8) Other health care service delivery system options, such as
17 telemedicine or telehealth, mobile clinics, centers of excellence, and other ways
18 of delivering care.
19 (9) The volume of technological and specialty care services available to
20 serve the needs of covered persons requiring technologically advanced or
21 specialty care services.
22 (10) The extent to which participating physicians are authorized to admit
23 patients to participating hospitals.
24 (11) The extent to which participating providers are accepting new
25 patients.
26 (12) The regionalization of specialty care, which may require some
27 children and adults to cross state lines for care.
28 (13) The extent to which hospital-based providers are participating
29 providers.
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1 C.(1) A health insurance issuer shall have a process to assure that a
2 covered person obtains a covered benefit at an in-network level of benefits,
3 including an in-network level of cost sharing, from a nonparticipating provider,
4 or shall make other arrangements acceptable to the commissioner when:
5 (a) The health insurance issuer has a sufficient network, but does not
6 have a type of participating provider available to provide the covered benefit
7 to the covered person or does not have a participating provider available to
8 provide the covered benefit to the covered person without unreasonable travel
9 or delay.
10 (b) The health insurance issuer has an insufficient number or type of
11 participating providers available to provide the covered benefit to the covered
12 person without unreasonable travel or delay.
13 (2) The health insurance issuer shall specify and inform covered persons
14 of the process a covered person may use to request access to obtain a covered
15 benefit from a nonparticipating provider as provided in Paragraph (C)(1)
16 when:
17 (a) The covered person is diagnosed with a condition or disease that
18 requires specialized health care services or medical services.
19 (b) The health insurance issuer:
20 (i) Does not have a participating provider of the required specialty with
21 the professional training and expertise to treat or provide health care services
22 for the condition or disease.
23 (ii) Cannot provide reasonable access to a participating provider with the
24 required specialty with the professional training and expertise to treat or
25 provide health care services for the condition or disease without unreasonable
26 travel or delay.
27 (3) The health insurance issuer shall treat the health care services the
28 covered person receives from a nonparticipating provider pursuant to
29 Paragraph (C)(2) as if the services were provided by a participating provider,
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1 including counting the covered person's cost sharing for such services toward
2 the maximum out-of-pocket limit applicable to services obtained from
3 participating providers under the health benefit plan.
4 (4) The process described in Paragraphs (1) and (2) of this Subsection
5 shall ensure that requests to obtain a covered benefit from a nonparticipating
6 provider are addressed in a timely fashion appropriate to the covered person's
7 condition.
8 (5) The health insurance issuer shall have a system in place that
9 documents all requests to obtain a covered benefit from a nonparticipating
10 provider under this Subsection and shall provide this information to the
11 commissioner upon request.
12 (6) The process established in this Subsection is not intended to be used
13 by health insurance issuers as a substitute for establishing and maintaining a
14 sufficient provider network in accordance with the provisions of this Subpart
15 nor is it intended to be used by covered persons to circumvent the use of covered
16 benefits available through a health insurance issuer's network delivery system
17 options.
18 (7) Nothing in this Section prevents a covered person from exercising the
19 rights and remedies available under applicable state or federal law relating to
20 internal and external claims grievance and appeals processes.
21 D.(1) A health insurance issuer shall establish and maintain adequate
22 arrangements to ensure covered persons have reasonable access to participating
23 providers located near their home or business addresses. In determining
24 whether the health insurance issuer has complied with this requirement the
25 commissioner shall give due consideration to the relative availability of health
26 care providers with the requisite expertise and training in the service area
27 under consideration.
28 (2) A health insurance issuer shall monitor, on an ongoing basis, the
29 ability, clinical capacity, and legal authority of its participating providers to
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1 furnish all contracted covered benefits to covered persons.
2 E.(1) Beginning July 1, 2017, a health insurance issuer shall file with the
3 commissioner for review prior to or at the time it files a newly offered network,
4 in a manner and form prescribed by the commissioner, an access plan meeting
5 the requirements of this Subpart.
6 (2)(a) The health insurance issuer may request the commissioner to deem
7 sections of the access plan as proprietary information that shall not be made
8 public.
9 (b) For the purposes of this Subsection, information is proprietary if
10 revealing the information would cause the health insurance issuer's competitors
11 to obtain valuable business information.
12 (3) The health insurance issuer shall prepare an access plan prior to
13 offering a new network plan, and shall notify the commissioner of any material
14 change to any existing network plan within forty-five business days after the
15 change occurs. A material change is a change in inclusion of a major health
16 system or a significant number of providers that causes the network to be
17 significantly different from that which the covered person initially purchased.
18 The health insurance issuer shall include in the notice to the commissioner a
19 reasonable time frame within which it will submit an update to an existing
20 access plan to the commissioner for review.
21 F. The access plan shall describe or contain at a minimum the following:
22 (1) The health insurance issuer's network, including how the use of
23 telemedicine or telehealth or other technology may be used to meet network
24 access standards, if applicable.
25 (2) The health insurance issuer's procedures for making and authorizing
26 referrals within and outside its network, if applicable.
27 (3) The health insurance issuer's process for monitoring and assuring on
28 an ongoing basis the sufficiency of the network to meet the health care needs of
29 populations that enroll in network plans.
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1 (4) The factors used by the health insurance issuer to build its provider
2 network, including a description of the network and the criteria used to select
3 tier providers.
4 (5) The health insurance issuer's efforts to address the needs of covered
5 persons, including but not limited to children and adults, including those with
6 limited English proficiency or illiteracy, diverse cultural or ethnic backgrounds,
7 physical or mental disabilities, and serious, chronic, or complex medical
8 conditions. This includes the insurance issuer's efforts, when appropriate, to
9 include various types of ECPs in its network.
10 (6) The health insurance issuer's methods for assessing the health care
11 needs of covered persons and their satisfaction with services.
12 (7) The health insurance issuer's method of informing covered persons
13 of the plan's covered services and features, including but not limited to:
14 (a) The plan's grievance and appeals procedures.
15 (b) Its process for choosing and changing providers.
16 (c) Its process for updating its provider directories for each of its
17 network plans.
18 (d) A statement of health care services offered, including those services
19 offered through the preventive care benefit, if applicable.
20 (e) Its procedures for covering and approving emergency, urgent, and
21 specialty care, if applicable.
22 (8) The health insurance issuer's system for ensuring the coordination
23 and continuity of care:
24 (a) For covered persons referred to specialty physicians.
25 (b) For covered persons using ancillary services, including social services
26 and other community resources, and for ensuring appropriate discharge
27 planning.
28 (9) The health insurance issuer's process for enabling covered persons
29 to change primary care professionals, if applicable.
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1 (10) The health insurance issuer's proposed plan for providing continuity
2 of care in the event of contract termination between the health insurance issuer
3 and any of its participating providers, or in the event of the health insurance
4 issuer's insolvency or other inability to continue operations. The description
5 shall explain how covered persons will be notified of the contract termination,
6 or the health insurance issuer's insolvency or other cessation of operations, and
7 the plan to transition covered persons to other providers in a timely manner.
8 (11) The health insurance issuer's process for monitoring access to
9 physician specialist services in emergency room care, anesthesiology, radiology,
10 pathology and laboratory services at their participating hospitals.
11 (12) Any other information required by the commissioner to determine
12 compliance with the provisions of this Subpart.
13 F. A health insurance issuer shall not be required to file an access plan
14 with the commissioner pursuant to this Subpart if the health insurance issuer:
15 (1) Is accredited by the National Committee for Quality Assurance
16 (NCQA) or American Accreditation Healthcare Commission, Inc./URAC.
17 (2) Leases or in some other manner utilizes networks accredited by the
18 National Committee for Quality Assurance (NCQA) or American Accreditation
19 Healthcare Commission, Inc./URAC.
20 (3) Insures or provides for health care services for seven hundred fifty
21 or fewer covered persons in a market in this state.
22 §1019.3. Enforcement provisions; penalties; regulations; other requirements
23 A. If the commissioner determines that a health insurance issuer that is
24 required to file an access plan has not contracted with enough participating
25 providers to ensure that covered persons have accessible health care services in a
26 geographic area, that a health insurance issuer's access plan does not ensure
27 reasonable access to covered health care services, or that a health insurance issuer
28 has entered into a contract that does not comply with this Subpart, the commissioner
29 may do either or both of the following:
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1 * * *
2 E. Every health insurance issuer shall maintain an electronically
3 available and current and accurate provider directory for each of its network
4 plans, and shall make such directory available to covered persons in printed
5 format upon request.
The original instrument and the following digest, which constitutes no part
of the legislative instrument, were prepared by Cheryl Cooper.
DIGEST
SB 193 Original 2016 Regular Session Long
Present law requires a health insurance issuer providing a health benefit plan, excluding
excepted benefits policies, to maintain a network that is sufficient in numbers and types of
health care providers to ensure that all health care services to covered persons will be
accessible without unreasonable delay. Provides for numerous definitions, including defining
a health insurance issuer as an entity subject to the insurance laws and regulations of this
state, or subject to the jurisdiction of the commissioner, that contracts or offers to contract,
or enters into an agreement to provide, deliver, arrange for, pay for, or reimburse any of the
costs of health care services, including a sickness and accident insurance company, a health
maintenance organization, a preferred provider organization or any similar entity, or any
other entity providing a plan of health insurance or health benefits.
Proposed law retains present law requirements.
Present law places various requirements upon issuers, including the following:
(1)Maintenance of a network of providers that includes providers that specialize in
mental health and substance abuse services, facility-based physicians, and providers
that are essential community providers.
(2)Reasonable proximity of its providers to the primary residences of covered persons.
(3)Monitoring of the ability, clinical capacity, and legal authority of its providers to
furnish all contracted health care services.
(4)Maintenance of a directory of its network of providers on the Internet.
Proposed law retains present law requirements.
Present law provides that in order to meet the network adequacy requirements an issuer
shall, beginning Jan. 1, 2014, either: (a) submit proof of accreditation from the National
Committee for Quality Assurance (NCQA) or from the American Accreditation Healthcare
Commission Inc./URAC, including an affidavit of compliance to the commissioner of
insurance; or (b) submit all filings required to the commissioner of insurance in order for
him to conduct a review for the purposes of ascertaining network adequacy. Further provides
that an issuer who is in the process of applying for accreditation from NCQA or URAC shall
be deemed accredited upon submission of an affidavit to that effect to the commissioner.
Specifies that if such accreditation is withdrawn or not subsequently received by such an
issuer by July 1, 2015, that issuer shall submit all filings to the commissioner. Also requires
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such submission if an issuer subsequently loses its NCQA or URAC accreditation. Further
requires an issuer submitting proof of accreditation or in the process of applying for
accreditation to maintain an access plan at its principal place of business. Specifies that such
plan shall be in accordance with the requirements of the accrediting entity.
Proposed law retains accreditation by NCQA or URAC in lieu of filing an access plan, and
requires such plans to be submitted for review by the department by July 1, 2017. Exempts
health insurance issuers with 750 or fewer covered persons from filing an access plan.
Permits health insurance issuers that lease, rent, or in some other way utilize networks that
are accredited by NCQA or URAC an exemption from filing the access plan.
Present law requires an issuer not submitting proof of accreditation to annually file an access
plan with the commissioner, portions of which may be deemed proprietary or trade secret
information, pursuant to the Public Records Law, or protected health information, pursuant
to Title 22. Absent such information, requires issuers to make such plans available under
certain conditions. Provides that such a plan shall be subject to written approval by the
commissioner, and updated upon material change, for existing plans and prior to offering a
new health benefit plan.
Present law requires an issuer to inform the commissioner when the issuer enters a new
service or market area and to submit an updated access plan. Specifies numerous
components of the access plan.
Proposed law deletes present law access plan requirements and replaces them with the
following access plan requirements:
(1)The health insurance issuer's network, including how the use of telemedicine or
telehealth or other technology may be used to meet network access standards, if
applicable.
(2)The health insurance issuer's procedures for making and authorizing referrals within
and outside its network, if applicable.
(3)The health insurance issuer's process for monitoring and assuring on an ongoing
basis the sufficiency of the network to meet the health care needs of populations that
enroll in network plans.
(4)The factors used by the health insurance issuer to build its provider network,
including a description of the network and the criteria used to select tier providers.
(5)The health insurance issuer's efforts to address the needs of covered persons,
including but not limited to children and adults, including those with limited English
proficiency or illiteracy, diverse cultural or ethnic backgrounds, physical or mental
disabilities, and serious, chronic, or complex medical conditions. This includes the
insurance issuer's efforts, when appropriate, to include various types of ECPs in its
network.
(6)The health insurance issuer's methods for assessing the health care needs of covered
persons and their satisfaction with services.
(7)The health insurance issuer's method of informing covered persons of the plan's
covered services and features, including but not limited to:
(a)The plan's grievance and appeals procedures.
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(b)Its process for choosing and changing providers.
(c)Its process for updating its provider directories for each of its network plans.
(d)A statement of health care services offered, including those services offered
through the preventive care benefit, if applicable.
(e)Its procedures for covering and approving emergency, urgent, and specialty
care, if applicable.
(8)The health insurance issuer's system for ensuring the coordination and continuity of
care:
(a)For covered persons referred to specialty physicians.
(b)For covered persons using ancillary services, including social services and
other community resources, and for ensuring appropriate discharge planning.
(9)The health insurance issuer's process for enabling covered persons to change primary
care professionals, if applicable.
(10)The health insurance issuer's proposed plan for providing continuity of care in the
event of contract termination between the health insurance issuer and any of its
participating providers, or in the event of the health insurance issuer's insolvency or
other inability to continue operations including, how covered persons will be notified
of the contract termination, or the insolvency or other cessation of operations, and
the plan to transition covered persons to other providers in a timely manner.
(11)The health insurance issuer's process for monitoring access to physician specialist
services in emergency room care, anesthesiology, radiology, pathology, and
laboratory services at their participating hospitals.
(12)Any other information required by the commissioner to determine compliance with
the provisions of proposed law.
Present law further requires an issuer not submitting proof of accreditation to file any
proposed material changes to the access plan with the commissioner prior to implementation
of the changes, including the removal or withdrawal of any hospital or multi-specialty clinic
from an issuer's network.
Proposed law retains present law.
Present law provides that filings containing any proposed material changes to an access plan
shall include certain specific information.
Proposed law deletes the present law requirement of specificity for amended filings.
Present law provides that if the commissioner determines that an issuer has not contracted
with enough participating providers to ensure that covered persons have accessible health
care services in a geographic area, that an issuer's access plan does not ensure reasonable
access to covered health care services, or that an issuer has entered into a contract that does
not comply with present law, he may institute a corrective action plan that shall be followed
by the issuer within 30 days of notice or the commissioner may use any of his other
enforcement powers to obtain the issuer's compliance.
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Present law prohibits the commissioner from acting to arbitrate, mediate, or settle disputes
regarding a decision not to include a provider in a plan or a provider network if the issuer
has an adequate network as determined by the commissioner.
Proposed law retains present law.
Present law authorizes the commissioner to promulgate rules and regulations, to issue orders
requiring issuers to cease and desist from an act or omission which violates law, or to refuse
to renew, suspend, or revoke the certificate of authority of an issuer violating present law.
In lieu of suspension or revocation of a license, authorizes the commissioner to levy a fine
not to exceed $1,000 for each violation per health insurance issuer, up to $100,000 for all
violations in a calendar year per issuer, after a proper hearing. Also authorizes the
commissioner to take other administrative actions, including imposing fines and penalties.
Proposed law retains present law.
Effective August 1, 2016.
(Amends R.S. 22:1019.1(D), 1019.2, and 1019.3(A); adds R.S. 22:1019.3(E))
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