Current through Register Vol. 50, No. 9, September 20, 2024
A.R.S.
40:1300.115 requires managed care
organizations to accept qualifying rural hospitals, and their practicing
physicians who meet specific statutory criteria, as providers of health care
subject to the terms and conditions that are no more restrictive than
applicable to other hospitals. This requirement applies in every parish where a
managed care organization holding a valid certificate of authority issued by
the Louisiana Department of Insurance, has policies, subscriber agreements, or
contracts for delivery of benefits in effect.
R.S.
22:2016.E. requires all hospitals and health
care providers utilized by health maintenance organizations to be licensed
under applicable state law.
R.S.
22:2021 prohibits health maintenance
organizations from adopting or utilizing administrative treatment guidelines
that fall below the appropriate standard of care. Additionally,
R.S.
22:2019 prohibits the utilization of a
certificate of authority by any person other than the organization or entity
issued said certificate.
1. All contracts for
delivery of covered medical services shall be between the managed care
organization and a health care provider, except contracts with other insurers
for provision of health coverage. A managed care organization is only
authorized to contract for delivery of health care services with one or more
health care providers. Contracts with brokers, agents, or any entity other than
a health care provider for the provision of covered medical services are
prohibited. A managed care organization may allow health care providers to
utilize other health care providers under contract with the managed care
organization.
2. A managed care
organization shall limit the medical services included under a health care
provider contract to those for which the health care provider is qualified and
reasonably capable of providing.
3.
A managed care organization shall not adopt or utilize payment standards for
health care providers that:
a. require or
induce by incentive or payment, the delivery of inappropriate medical care or
treatment services;
b. allow the
provision of inappropriate or unnecessary medical procedures or treatment
services;
c. allow health care
providers to perform, for payment, medical or treatment services for which they
are not qualified;
d. include an
incentive or specific payment made directly or indirectly, in any form, to a
health care provider as an inducement to deny, reduce, limit, or delay
specific, medically necessary, and appropriate services provided with respect
to a specific insured or groups of insureds with similar medical
conditions.
4. In any
review of the terms and conditions of a health care provider's contract
conducted by the Department of Insurance, the contract shall not be subject to
disclosure to any other health care provider without the expressed written
consent of the parties to such contract, except as otherwise allowed by
law.
AUTHORITY NOTE: Adopted
in accordance with R.S. 22,
R.S.
22:3,
R.S.
22:215.18,
22:2006,
22:2014,
22:2018,
22:2019,
22:2021
and
22:2022.
