Louisiana § RS 22:1245 - Plan of operation

§ RS 22:1245. Plan of operation

A.  A health insurance issuer shall submit a plan of operation to the  commissioner for review and approval whereby the health insurance issuer establishes policies and procedures:

(1)  For the determination of program eligibility of employers, as set forth in R.S. 22:1243.

(2)  Relative to the program network criteria, as set forth in R.S. 22:1244, and which shall contain at least the following:

(a)  Evidence that all covered Prime Network services are available and accessible through Prime Network providers, including demonstration that:

(i)  Covered Prime Network services can be provided by Prime Network providers with reasonable promptness with respect to geographic location, hours of operation, and availability of after hour care.  The hours of operation and availability of after hour care shall reflect usual practice in the local area. Geographic availability shall reflect usual practice in the community.

(ii)  The number of Prime Network providers in the service area is sufficient, with respect to current and expected policyholders.

(iii)  There are participation agreements with Prime Network providers that contain provisions prohibiting Prime Network providers from billing, collecting, or otherwise seeking reimbursement or recourse against any insured or enrollee, except for applicable amounts representing copayments, coinsurance, deductibles, or noncovered services.

(b)  A statement or map providing a clear description of the service area.

(c)  A formal description of the formal organization or structure of the health insurance issuer.

(d)  The written criteria for selection, retention, and removal of Prime Network providers.

(e)  A list and description of Prime Network providers, by specialty, if any.

B.(1)  A health insurance issuer shall file any proposed changes to the plan of operation with the commissioner prior to implementing the changes.  Changes shall be considered approved by the commissioner after thirty days unless specifically disapproved.  The health insurance issuer shall notify the commissioner of any changes of Prime Network providers.

(2)  Any updated list of Prime Network providers shall be filed with the commissioner at least quarterly.

(3)  A health insurance issuer shall make full and fair disclosure, in writing, of the provisions, restrictions, and limitations of the policy or certificate to each applicant. The disclosure shall include at least the following:

(a)  An outline of coverage and itemized benefits.

(b)  A description of the rights of the insured or enrollee.

C.  The Office of Group Benefits and participating health insurance issuers, respectively, shall be responsible for the administration of the minimal benefit hospital and medical plans or policies, as well as any other insurance products offered pursuant to this program, and shall bear all risk of loss therefor.

Acts 2003, No. 528, §1, eff. June 24, 2003; Acts 2004, No. 493, §1, eff. June 25, 2004; Redesignated from R.S. 22:3104 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009.

NOTE:  Former R.S. 22:1245 redesignated as R.S. 22:1926 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009.