§ 22:1007 — Requirements of provider contracts; communications

§1007. Requirements of provider contracts; communications
A. As used in this Section, the following definitions shall apply:
(1) "Enrollee", "prospective enrollee", or "patient" means an individual, his spouse,
and any dependent, if any, who is enrolled in a health maintenance organization or is a
member or is applying to become a member of a health care benefit policy, plan, or package,
either furnished to him through his employment as part of his compensation or entitlement
furnished by a publicly funded program or purchased through his own financial resources.
(2) "Health care services" means any services rendered by providers which include,
but are not limited to medical and surgical care; social work, psychological, optometric,
optic, chiropractic, podiatric, nursing, and pharmaceutical services; health education,
rehabilitative, and home health services; physical therapy; inpatient and outpatient hospital
services; dietary and nutritional services; laboratory and ambulance services; and any other
services for the purpose of preventing, alleviating, curing, or healing human illness, injury,
or physical disability. Health care services also means dental care, limited to oral and
maxillofacial surgery as performed by board-certified oral and maxillofacial surgeons and
also include an annual PAP test for cervical cancer and minimum mammography
examination as defined in R.S. 22:1028.
(3) "Managed care organization" means a licensed insurance company, hospital or
medical benefit plan or program, health maintenance organization, integrated health care
delivery system, an employer or employee organization, or a managed care contractor which
operates a managed care plan. A managed care organization may include but is not limited
to a preferred provider organization, health maintenance organization, exclusive provider
organization, independent practice association, clinic without walls, management services
organization, managed care services organization, physician hospital organization, and
hospital physician organization.
(4) "Managed care plan" means a plan operated by a managed care entity which
provides for the financing and delivery of health care and treatment services to individuals
enrolled in such plan through its own employed health care providers or contracting with
selected specific providers that conform to explicit selection, standards, or both. A managed
care plan also customarily has a formal organizational structure for continual quality
assurance, a certified utilization review program, dispute resolution, and financial incentives
for individual enrollees to use the plan's participating providers and procedures.
(5) "Participating provider", "provider", or "health care provider" means a state-licensed, certified, or state-registered provider of health care services, treatment, or supplies,
including but not limited to those entities defined in R.S. 40:1231.1(A), that have entered
into a contract or agreement with a managed care entity to provide such services, treatment,
or supplies to an individual enrollee or a patient.
(6) "Rural hospital" means either:
(a) A hospital with sixty or fewer beds located in either:
(i) A parish with a population of less than fifty thousand according to the most recent
federal decennial census.
(ii) A municipality with a population of less than twenty thousand according to most
recent federal decennial census.
(b) A hospital classified as a sole community hospital pursuant to 42 CFR 412.92.
(7) "Subscriber" means the person who is responsible for payment to a managed care
organization or managed care entity or whose employment or other status, except for family
dependence, is the basis for eligibility for enrollment in the managed care organization or
managed care entity.
B. In a contract with a health care provider, a managed care organization shall not
include provisions that interfere with the ability of a health care provider to communicate
with a patient regarding his or her health care, including but not limited to communications
regarding treatment options and medical alternatives, or other coverage arrangements.
Notwithstanding the provisions of this Section, a managed care organization may include a
contract provision that provides that a health care provider shall not solicit for alternative
coverage arrangements for the primary purpose of securing financial gain.
C. No managed care organization shall refuse to contract, renew, cancel, restrict, or
otherwise terminate a contract with a health care provider solely on the basis of a medical
communication. No managed care organization shall refuse to refer patients to or allow
others to refer patients to the health care provider, refuse to compensate the health care
provider for covered services, or take other retaliatory action against the health care provider.
As used in this Subsection "medical communication" shall mean information regarding the
mental or physical health care needs or the treatment of a patient.
D. No communication regarding treatment options shall be represented or construed
to expand or revise the scope of benefits or covered services under a managed care plan or
insurance contract.
E. No managed care organization or managed care entity shall by contract, written
policy, or written procedure prohibit or restrict any provider from filing a complaint, making
a report, or commenting to an appropriate governmental body regarding the policies or
practices of such managed care organization or managed care entity which may negatively
impact upon the quality of, or access to, patient care.
F. No managed care organization or managed care entity shall by contract, written
policy, or written procedure prohibit or restrict any health care provider from advocating to
the managed care organization or managed care entity on behalf of the enrollee or subscriber
for approval or coverage of a particular course of treatment or for the provision of health care
services.
G. No contract or agreement between a managed care organization or managed care
entity and a health care provider shall contain any clause purporting to transfer to the health
care provider by indemnification or otherwise any liability relating to activities, actions, or
omissions of the managed care organization or managed care entity.
H. Notwithstanding any other provision of law to the contrary, no managed care
organization shall limit the right of a rural hospital to receive payment for covered health
care services as long as a claim for payment of such services is submitted within one year
after the date on which the rural hospital provided the services.
I. Notwithstanding any provision of law to the contrary, any contract or agreement
between a managed care organization and a health care provider shall include provisions that
establish the reimbursement of a health care provider in an instance in which the managed
care organization requests or requires substitution of a medication for an enrollee and the
provider has executed the requested or required substitution. The provisions of this Section
shall not apply to generic substitution or step therapy programs utilized by the managed care
organization or its delegated entity that promote generic drugs as a first-line therapy.
J.(1) A managed care organization that offers coverage for healthcare services
through one or more managed care plans shall not require a provider, as a condition of
participation or continuation in the provider network of one or more health benefit plans of
the managed care organization, to serve in the provider network of all or additional health
benefit plans of the managed care organization. A managed care organization is prohibited
from terminating a provider agreement based on the provider's refusal to serve in its network
for such additional plans.
(2) Nothing in this Subsection shall prohibit a managed care organization from
enabling its affiliated members from other states to obtain healthcare service benefits while
traveling or living in the managed care organization's service area including extending the
provisions of the provider contract to provide for such services.
K. Any contract provision, written policy, or written procedure in violation of this
Section shall be deemed to be unenforceable and null and void.
NOTE: Former R.S. 22:1007 redesignated as R.S. 22:705 by Acts 2008, No.
415, §1, eff. Jan. 1, 2009.

Legislative History

Acts 1997, No. 1232, §1; Acts 2001, No. 1198, §1, eff. June 29, 2001; Redesignated from R.S. 22:215.18 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009; Acts 2014, No. 396, §1, eff. Jan. 1, 2015; Acts 2016, No. 265, §1.