RS 22:1244

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RS 22:1244

§1244. Participation and requirements

A. Participating health insurance issuers shall offer minimal benefit hospital and medical insurance policies that allow enrollees or insureds access to at least one Prime Network. The Prime Network shall be specifically established for the minimal benefit hospital and medical policies to be offered pursuant to this Subpart. Health insurance issuers may contract directly with health care providers or through a network of providers.

B. Participating health insurance issuers shall offer minimal benefit hospital and medical insurance policies under which the enrollees or insureds shall be entitled to contracted reimbursement rates by contracted health care providers for covered health care services, whether paid for by the health insurance issuer, the enrollee, or the insured.

C. Every insured or enrollee shall at the time of enrollment and annually thereafter be provided with a directory listing of contracted health care providers, denoting whether such contracted health care providers participate in a Prime Network.

D. The health insurance issuer shall issue an identification card that sets forth the name of the health insurance issuer prominently displayed on the face of the identification card and contains the following statement:

"BEFORE YOU SEEK SERVICES FROM A PROVIDER, CONTACT THE HEALTH INSURANCE ISSUER AT THE TOLL-FREE NUMBER LISTED BELOW FOR BENEFITS OR NETWORK CONFIRMATION."

E. Notwithstanding any law to the contrary, minimal benefit hospital and medical policies offered under the program shall be exempt from the provisions of R.S. 22:972, 973, 975-983, 985-990, 992, 993, 999-1008, 1010-1014, 1021-1042, 1044-1048, 1091-1096, 1111, and 1156, R.S. 22:972 et seq., R.S. 22:984, and 1061 through 1079, and all other provisions of this Title, unless otherwise specifically provided herein.

F. Participating health insurance issuers may offer additional insurance products that include but are not limited to:

(1)Group health insurance that utilizes employer or employee funded savings, reimbursement, or personal care accounts in conjunction with the applicable deductible provisions.

(2)Employer funded personal care accounts shall not be taxable to the employee and shall be deductible to the employer, in accordance with applicable federal and state taxation laws.

(3)Minimal benefit hospital and medical insurance plans to employees of the state of Louisiana, and political subdivisions thereof; to the extent authorized by the Office of Group Benefits.

(4)Such additional insurance products as appropriate.

G. Employers that participate in the program shall:

(1)Pay at least fifty percent of the eligible employee premium cost. This provision shall not apply to the Office of Group Benefits.

(2)Enroll at least fifty percent of eligible employees in the program. This provision shall not apply to the Office of Group Benefits.

H. The commissioner may promulgate rules and regulations as may be necessary or proper to carry out the provisions of this Subpart. The commissioner shall issue reasonable regulations to establish specific standards and guidelines for Prime Network policies and certificates. No requirement of this Title relating to minimum required policy benefits, other than the minimum standards contained in this Subpart, shall apply to Prime Network policies. Such standards and guidelines shall address the following:

(1)Advertising and marketing.

(2)Applications and enrollment forms.

(3)Definition of terms.

(4)Form filing requirements and prohibitions.

(5)Policyholder requirements pertaining to individuals, trusts, associations, and employer groups.

(6)Uninsured impact report.

(7)Underwriting requirements relative to adverse selection.

I. For purposes of offering minimal benefits hospital and medical policies under this Subpart, a preferred provider organization shall be exempt from any mandated benefit requirements or mandated provider participation requirements pursuant to R.S. 40:2201 et seq. unless otherwise required by this Subpart.

Acts 2003, No. 528, §1, eff. June 24, 2003; Acts 2004, No. 493, §1, eff. June 25, 2004; Redesignated from R.S. 22:3103 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009.

NOTE: Former R.S. 22:1244 redesignated as R.S. 22:1925 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009.