Current through Register Vol. 50, No. 9, September 20, 2024
A. Prohibition on
the Use of Gag Clauses-Applies to HMO Coverage. Patients have a right to talk
freely with health care professionals about their health, medical conditions,
and any treatment options that are available, including those not covered by
their health plan.
R.S.
22:215.18(B) prohibits a
managed care plan from adopting any requirement that interferes with the
ability of a health care professional to communicate with a patient regarding
his or her health care. This statutory protection also includes communications
regarding treatment options and medical alternatives, or other coverage
arrangements. The managed care plan is only allowed to prohibit a health care
professional from soliciting alternative coverage arrangements for the purpose
of securing financial gain by the health care professional.
B. Prohibition on Incentives to Restrict,
Delay or Deny Medically Necessary Care-Applies to HMO and Major Medical
Insurance Coverage. Patients have a right to receive medically necessary and
appropriate services covered under a managed care plan.
R.S.
22:215.19 prohibits managed care plans from
offering any financial incentives to health care professionals to deny, reduce,
limit, or delay specific, medically necessary, and appropriate
services.
C. Holding Managed Care
Plans Liable for their Actions, Omissions, or Activities-Applies to HMO and
Major Medical Insurance Coverage. Managed care plans are responsible for their
actions, activities or omissions that result in harm to the patient.
R.S.
22:215.18(G) prohibits
managed care plans from transferring their liability related to activities,
actions or omissions of the plan to a health care professional treating the
insured. This right does not relieve health care professionals of their
responsibilities to appropriately practice within the scope of license,
certification, or registration.
D.
Guaranteed Direct Access to Obstetricians/ Gynecologists-Applies to HMO and
Major Medical Insurance Coverage. Women have a right to see an Obstetrician or
Gynecologist for routine care.
R.S.
22:215.17 requires health insurance coverage
to include direct access to these health care professionals without prior
authorization. In addition, health insurance coverage is required to include up
to two annual routine visits and follow up treatment within 60 days of either
visit if a related condition is diagnosed or treated during the visits. This
requirement also applies to pregnancy related care if covered by the policy or
plan.
E. Requirement for
Appropriate Access to Covered Medical Services-Applies to HMO Coverage
1. Formal managed care plans operated by
health maintenance organizations are required to maintain an adequate number of
health care professionals to serve plan participants. Covered services must be
provided within a reasonable period of time once ordered or prescribed.
R.S. 22:2004,
2005, 2013, 2016, and 2021 establish requirements for HMO plans to document
that their networks of primary care physicians and specialists are adequate.
HMOs are allowed to use point of service options to expand networks and assure
access to plan participants.
2.
Other health insurance coverage is only allowed to offer managed care as a
coverage option. These plans must offer traditional payment of medical claims
based on the terms of the policy for deductibles and co-insurance.
F. Confidentiality of Medical
Records-Applies to HMO Coverage
1. Any data or
information pertaining to the diagnosis, treatment, or health of any enrollee
or potential enrollee obtained from such persons or from any provider by any
formal managed care plan shall be held in confidence and shall not be disclosed
to any person except:
a. to the extent that it
may be necessary to carry out the purposes of operating a formal managed care
plan as permitted by law;
b. upon
the express consent of the enrollee or potential enrollee;
c. pursuant to statute or court order for the
production of evidence or the discovery thereof;
d. in the event of a claim or litigation
between such person and the formal managed care plan wherein such data or
information is pertinent.
2. A formal managed care plan shall be
entitled to claim any statutory privileges against such disclosure which the
provider who furnished such information to the formal managed care plan is
entitled.
G. Prohibit
Unreasonable Denial of Emergency Care-Applies to HMO and Major Medical
Insurance Coverage
1. Any managed care plan
that includes emergency medical services shall provide coverage and shall
subsequently pay health care professionals for emergency medical services
provided to a covered patient who presents himself/herself with an emergency
medical condition.
2. No health
insurance plan shall retrospectively deny or reduce payment to health care
professionals for emergency medical services of a covered patient even if it is
determined that the emergency medical condition initially presented is later
identified through screening not to be an actual emergency, except in the
following cases:
a. material
misrepresentation, fraud, omission, or clerical error;
b. any payment reductions due to applicable
co-payments, co-insurance, or deductibles that may be the responsibility of the
covered patient;
c. cases in which
the covered patient does not meet the emergency medical condition definition,
unless the covered patient has been referred to the emergency department by the
insured's primary care physician or other agent acting on behalf of the health
insurance plan.
H. Appeal/Grievance Procedures for Denials of
Coverage-Applies to HMO and Major Medical Insurance Coverage
1. Formal managed care plans operated by
health maintenance organizations are required to have an administrative appeal
or grievance process for patients.
R.S.
22:2022 requires these plans to submit their
appeal/grievance procedures to the Department of Insurance to verify the
process or procedures used are reasonable and meet the intent of the
statute.
2. In addition, where any
insured patient is denied benefits under a health insurance coverage plan, a
request can be made to the Department of Insurance for investigation of the
denial. Where the denial is valid, the insured is so notified. Where the denial
is erroneous, the health insurance coverage plan is required to institute
corrective action and may be subject to fines and penalties if a statutory
violation has occurred.
I. Guaranteed Continuation of Group
Insurance-Applies to HMO and Major Medical Insurance Coverage
1.R.S.
22:215.13 guarantees Louisiana residents who
lose their eligibility for coverage under a group health insurance policy or
plan, the right to maintain such coverage in force for up to 12 months. This
guaranteed continuation of group health insurance does not include accident
only coverage, specific disease coverage, limited benefit coverage for dental,
vision care or any benefits provided in addition to the basic hospital,
surgical, or major medical benefits of the policy. This means that additional
or optional insurance coverage purchased is not guaranteed to be provided
during this 12-month continuation period. This continuation of group coverage
right is guaranteed for up to one year so long as the following conditions are
met:
a. the individual is not eligible for any
other group health coverage plan or government sponsored health plan, such as
Medicare and Medicaid;
b. the
individual timely pays the full monthly premium to keep coverage in
force;
c. the individual was not
terminated from coverage for fraud or failure to pay any required contribution
for the group insurance, and continues to meet the group policy's terms and
conditions other than membership in that original group;
d. all dependents covered under the group
policy or plan continue to be covered;
e. the group policy has not been terminated
or the employer has withdrawn participation in a multiple employer group
policy; and
f. the individual
continues to reside within the service area of the plan in the event that such
group coverage is provided by a Health Maintenance Organization.
2. This right is not automatic and
requires the employee or member who is losing coverage to make a written
election of continuation on a form furnished by the group policyholder and pay
for the first month's coverage prior to the date that coverage is being
terminated. Written notification of termination must be provided to the
individual in advance to allow election of this right.
3. Special continuation rights are provided
to a surviving spouse of an individual who was covered by a group health
insurance policy or plan at the time of death and is age 55 or older. Under
Louisiana law the surviving spouse is guaranteed the right to continue such
group coverage in effect until eligible for any other group coverage. The
surviving spouse is also allowed to provide coverage to all dependents that
were covered under the deceased spouse's policy or plan at the time of death so
long as they remain eligible under the policy.
J. Guaranteed Renewal of Health Insurance
Coverage-Applies to HMO and Major Medical Insurance Coverage
1. Under Louisiana law, once health insurance
coverage has been purchased, the insurer cannot cancel the coverage unless one
of the following conditions exists:
a. failure
to pay premiums or contributions in accordance with the terms of the
policy;
b. failure to comply with a
material plan provision relating to employer contribution or group
participation rules;
c. performance
of an act or practice that constitutes fraud or the intentional
misrepresentation of a material fact under the terms of coverage;
d. the policyholder no longer resides, lives,
or works in the service area in the event the coverage is provided under a
formal managed care plan operated by a Health Maintenance
Organization;
e. the policyholder's
coverage is purchased through a bona-fide association plan and the policyholder
is no longer eligible to participate in such association;
f. the insurance company is no longer
offering the type of coverage purchased and offers to replace the policy with
any other type of similar coverage being marketed within 90 days of renewal;
or
g. the insurance company is
leaving the market and will no longer be selling any group and/or individual
health insurance products in Louisiana for a period of at least five years. In
such instances the insurer must give each policyholder 180 days advance notice
in writing before the policy is terminated. All termination notices must be
filed and approved by the Department of Insurance prior to issuance.
K. Limits on
Preexisting Medical Condition Exclusions from Coverage-A pplies to HMO and
Major Medical Insurance Coverage. Under Louisiana law, a health insurance plan
is allowed to exclude medical conditions from coverage for a limited period of
time. All policies now being sold are prohibited from excluding coverage for
preexisting medical conditions for more than 12 months. Regardless of the type
of coverage (group or individual), health plans are not allowed to apply an
exclusion of coverage based on a preexisting medical condition for more than 12
months.
1. Group Coverage. The medical
conditions that can be excluded from coverage are limited to those that were
diagnosed or treated during the six month period prior to the day coverage
begins under the policy. Any condition that was not being treated during the
prior six months cannot be excluded from coverage.
2. Individual Coverage. The medical
conditions that can be excluded from coverage are limited to those that were
diagnosed, treated or reasonably should have been treated during the 12 month
period prior to the day coverage begins under the policy. Any condition that
was not diagnosed, treated, or reasonably should have been treated during the
prior 12 months cannot be excluded from coverage.
L. Guaranteed Portability Protections-Applies
to HMO and Major Medical Insurance Coverage
1.
Individuals who are moving their health coverage from one employment situation
to another or from one group plan to another are guaranteed the following
rights provided they have enrolled in the new plan within 63 days of
termination from the prior plan:
a. if the new
plan imposes a 12-month preexisting exclusionary period, the individual must be
given one month's credit for each month of continuous coverage under the prior
plan. If the individual had 12 or more months of continuous coverage under the
prior plan, the preexisting exclusionary period has been satisfied. If the
individual had six months of continuous coverage under the prior plan, the
preexisting exclusionary period is reduced by six months;
b. if the new employer imposes an
exclusionary or waiting period for employees before coverage can begin, such
periods do not count as a break in coverage for applying portability
rights;
c. during any exclusionary
or waiting period, no premiums can be charged to the individual;
d. during any exclusionary or waiting period
the individual may maintain their prior coverage if eligible under state
continuation of coverage rights, federal COBRA rights, or through purchase of
an individual policy;
e.
individuals, who had at least 18 months of prior coverage under a group plan,
have exhausted or are not eligible for state continuation rights or COBRA
rights, are guaranteed access to individual health insurance coverage through
the Louisiana Health Insurance Association.
2. Any Louisiana resident who has individual
health insurance coverage is guaranteed credit for prior individual coverage
when replacing coverage if the insurance plan is applying the prior insurance
policy's lifetime benefit usage against the replacement policy. Residents can
waive credit for prior coverage to avoid any reduction in the lifetime benefit
limit of the replacement coverage. However, state law no longer allows the sale
of any policy of insurance that excludes coverage in excess of 18
months.
M. Prohibiting
Discrimination against Individuals Based on Health Status-Applies to HMO and
Major Medical Insurance Coverage
1. State and
federal law prohibit any group health coverage plan from discriminating against
individuals based on their health status. This means that an individual's
medical status cannot be used to determine eligibility to join a group health
plan with certain exceptions. Plans are specifically prohibited from adopting
any rules for eligibility or continued eligibility based on any of the
following health status related factors:
a.
health status;
b. medical
condition, including both physical and mental illness;
c. claims experience;
d. receipt of health care;
e. medical history;
f. genetic information;
g. evidence of insurability, including
conditions arising out of acts of domestic violence; and
h. disability.
2. A plan's rules for eligibility to enroll
under a plan also include rules defining any applicable waiting periods for
such enrollment. This means that the plan may only apply exclusionary or
waiting period uniformly based on date of hire for all eligible employees. No
exclusionary or waiting periods are allowed after coverage begins and premiums
are being collected from the insured.
N. Prohibition on Use of Prenatal and Genetic
Tests by Health Insurance Plans-Applies to HMO and Major Medical Insurance
Coverage. State law prohibits health insurance plans from requiring any
individual to take genetic tests or prenatal tests prior to being offered
coverage. Plans are also prohibited from requesting release of any genetic or
prenatal test results or using such information in the determination of
benefits or rates for an insured.
AUTHORITY NOTE:
Promulgated in accordance with
R.S.
22:3 and
R.S.
22:2014.