Current through Register Vol. 50, No. 9, September 20, 2024
A. The
LA Health Plan provides for the following minimum, or their actuarial
equivalent, primary health care provider services.
1. The LA Health Plan will provide for health
care provider services, with such care including the general treatment of
illness and diagnostic studies used to diagnose the cause of an
illness.
2. All care received by a
LA Health insured shall be related to the cause or symptom of the insured's
illness or injury. Payment will not be made for care and treatment which is not
deemed medically necessary.
3.
Participating provider office visits are subject to a $10 per visit co-payment.
Covered services in the participating provider's office include:
a. laboratory and x-ray services;
b. immunizations for children under age
19;
c. prenatal care visits. Only
one co-payment for all visits shall be charged if the participating provider
bills in one lump sum;
d. an annual
physical exam.
4. Fees
for X-ray and laboratory tests made on an outpatient basis for diagnosis or
treatment of an illness are covered when ordered by a participating provider.
This benefit has a $1,000 calendar year maximum and is subject to the insured
paying either $5 co-payment or a maximum of 10 percent of the charge up to a
maximum of $1,100 per calendar year. The authorized carrier shall specify which
option is to be taken in applying to participate in the LA Health
Plan.
5. Surgical and related
expenses are covered under the LA Health Plan up to a maximum of $5,000 per
insured per calendar year. A $50 per surgical procedure co-payment is
required.
6. Maternity care is a
covered service subject to the following co-payment requirements:
a. normal vaginal delivery-$50
co-payment;
b. Cesarean
delivery-$100 co-payment;
c. if
hospitalization follows delivery, the $50 per day inpatient co-payment shall
apply.
B.
Outpatient mental health care services provided by a provider licensed to
diagnose and treat mental and nervous disorders are covered when provided by a
participating provider up to a maximum of $1,000 per calendar year with a $10
per visit co-payment.
C. Benefits
for the following services are paid subject to the benefits listed in the
regulation:
1. use of a participating
hospital operating and treatment rooms and equipment;
2. diagnostic X-rays, laboratory procedures
and medical diagnostic procedures used to determine the cause of an illness
when performed within 14 days prior to participating hospital
admission.
D. Benefits
shall be provided for mammograms. A $5 per screening co-payment is required
when performed by a participating provider and performed with the following
frequency:
1. once as a base line mammogram
for any female between 35 and 40 years of age;
2. once every two years for any female
between 40 and 50 years of age;
3.
once every year for any female age 50 or above; and
4. when recommended by a participating
provider for a female at risk. Female at risk means a female:
a. who has a personal history of breast
cancer;
b. who has a personal
history of biopsy proven benign breast disease;
c. whose grandmother, mother, sister, or
daughter has had breast cancer; or
d. who has not given birth prior to age
30.
E.
Benefits are provided for one pap smear examination per year when performed
upon recommendation of a participating provider. A $5 per examination
co-payment is required.
F. Benefits
are provided for annual prostate antigen tests for covered males who are 45
years of age or older; or covered males who are 40 years of age or older, if
ordered by a participating provider. A $5 per test co-payment is
required.
G. Benefits are provided
for colon cancer screening when ordered by a participating provider. A $5 per
screening co-payment is required.
AUTHORITY NOTE:
Promulgated in accordance with
R.S.
22:244-247 of the Insurance
Code.
