§1019.2. Network adequacy
A.A health insurance issuer providing a health benefit plan shall maintain a network
that is sufficient in numbers and types of healthcare providers to ensure that all healthcare
services to covered persons will be accessible without unreasonable delay. In the case of
emergency services and any ancillary emergency healthcare services, covered persons shall
have access twenty-four hours per day, seven days per week. Healthcare services shall also
be made accessible, in the same manner as provided in this Subsection, for a covered person
diagnosed with a disease or condition by a licensed healthcare provider, if the disease or
condition requires the covered person to receive life-sustaining treatments, including but not
limited to chemotherapy, radiotherapy, dialys
Free access — add to your briefcase to read the full text and ask questions with AI
§1019.2. Network adequacy
A. A health insurance issuer providing a health benefit plan shall maintain a network
that is sufficient in numbers and types of healthcare providers to ensure that all healthcare
services to covered persons will be accessible without unreasonable delay. In the case of
emergency services and any ancillary emergency healthcare services, covered persons shall
have access twenty-four hours per day, seven days per week. Healthcare services shall also
be made accessible, in the same manner as provided in this Subsection, for a covered person
diagnosed with a disease or condition by a licensed healthcare provider, if the disease or
condition requires the covered person to receive life-sustaining treatments, including but not
limited to chemotherapy, radiotherapy, dialysis, and heart surgery, and the covered person
is forced to temporarily relocate to another state when the governor declares a state of
emergency, pursuant to R.S. 29:724, for a named storm as defined in R.S. 22:1267.1(A)(2).
Sufficiency shall be determined in accordance with the requirements of this Subpart. In
determining sufficiency criteria, the criteria shall include but not be limited to ratios of
healthcare providers to covered persons by specialty, ratios of primary care providers to
covered persons, geographic accessibility, waiting times for appointments with participating
providers, hours of operation, and volume of technological and specialty services available
to serve the needs of covered persons requiring technologically advanced or specialty care.
B.(1) Each health insurance issuer shall maintain a network of providers that
includes but is not limited to providers that specialize in mental health and substance abuse
services, facility-based physicians, and providers that are essential community providers.
(2) A health insurance issuer shall establish and maintain adequate arrangements to
ensure reasonable proximity of participating providers to the primary residences of covered
persons. In determining whether a health insurance issuer has complied with this Paragraph,
the commissioner shall give due consideration to the relative availability of health care
providers in the service area under consideration and the geographic composition of the
service area. The commissioner may consider a health insurance issuer's adjacent service
area networks that may augment health care providers if a health care provider deficiency
exists within the service area.
(3) A health insurance issuer shall monitor, on an ongoing basis, the ability, clinical
capacity, and legal authority of its participating providers to furnish all contracted health care
services to covered persons.
(4) Repealed by Acts 2018, No. 290, §2, eff. Jan. 1, 2019.
(5) A health insurance issuer shall annually file with the commissioner an access
plan meeting the requirements of this Subpart for each of the health benefit plans that the
health insurance issuer offers in this state. Any existing, new, or initial filing of policy forms
by a health insurance issuer shall include the network of providers, if any, to be used in
connection with the policy forms. If benefits under a health insurance policy do not rely on
a network of providers, the health insurance issuer shall state this fact in the policy form
filing. The health insurance issuer may request the commissioner to consider sections of the
access plan to contain proprietary or trade secret information that shall not be made public
in accordance with the Public Records Law, R.S. 44:1 et seq., or to contain protected health
information that shall not be made public in accordance with R.S. 22:42.1. If the
commissioner concurs with the request, those sections of the access plan shall not be subject
to the Public Records Law or shall not be made public in accordance with R.S. 22:42.1 as
applicable. The health insurance issuer shall make the access plans, absent any such
proprietary or trade secret information and protected health information, available and readily
accessible on its business premises and shall provide the plans to any interested party upon
request, subject to the provisions of the Public Records Law and R.S. 22:42.1.
C. A health insurance issuer shall file an access plan for written approval from the
commissioner for existing health benefit plans and prior to offering a new health benefit plan.
Additionally, a health insurance issuer shall inform the commissioner if the health insurance
issuer enters a new service or market area and shall submit an updated access plan
demonstrating that the health insurance issuer's network in the new service or market area
is adequate and consistent with this Subpart. Each access plan, including riders and
endorsements, shall be identified by a form number in the lower left hand corner of the first
page of the form. A health insurance issuer shall update an existing access plan whenever
it makes any material change to an existing health benefit plan. The access plan shall
describe or contain, at a minimum, each of the following:
(1) The health insurance issuer's network which includes but is not limited to the
availability of and access to centers of excellence for transplant and other medically intensive
services as well as the availability of critical care services, such as advanced trauma centers
and burn units.
(2) The health insurance issuer's procedure for making referrals within and outside
its network.
(3) The health insurance issuer's process for monitoring and ensuring, on an ongoing
basis, the sufficiency of the network to meet the health care needs of populations that enroll
in its health benefit plans and general provider availability in a given geographic area.
(4) The health insurance issuer's efforts to address the needs of covered persons with
limited English proficiency and illiteracy, with diverse cultural and ethnic backgrounds, or
with physical and mental disabilities.
(5) The health insurance issuer's methods for assessing the health care needs of
covered persons and their satisfaction with services.
(6) The health insurance issuer's method of informing covered persons of the health
benefit plan's services and features, including but not limited to the health benefit plan's
utilization review procedure, grievance procedure, external review procedure, process for
choosing and changing providers, and procedures for providing and approving emergency
services and specialty care. Additional information relating to these processes shall be
available upon request and accessible via the health insurance issuer's website.
(7) The health insurance issuer's system for ensuring coordination and continuity of
care for covered persons referred to specialty physicians, for covered persons using ancillary
health care services, including social services and other community resources, and for
ensuring appropriate discharge planning.
(8) The health insurance issuer's processes for enabling covered persons to change
primary care professionals, for medical care referrals, and for ensuring that participating
providers that require the use of health care facilities have hospital admission privileges.
(9) The health insurance issuer's proposed plan for providing continuity of care in
the event of contract termination between the health insurance issuer and any of its
participating providers, as required by R.S. 22:1005, or in the event of the health insurance
issuer's insolvency or other inability to continue operations. This description shall explain
how covered persons will be notified of contract termination, including but not limited to the
effective date of the contract termination, the health insurance issuer's insolvency, or other
cessation of operations, and how such covered persons will be transferred to other providers
in a timely manner.
(10) A geographic map of the area proposed to be served by the health benefit plan
by both parish and zip code.
(11) The policies and procedures to ensure access to covered health care services
under each of the following circumstances:
(a) When the covered health care service is not available from a participating
provider in any case when a covered person has made a good faith effort to utilize
participating providers for a covered service and it is determined that the health insurance
issuer does not have the appropriate participating providers due to insufficient number, type,
or distance, the health insurance issuer shall ensure, by terms contained in the health benefit
plan, that the covered person will be provided the covered health care service.
(b) When the covered person has a medical emergency within the network's service
area.
(c) When the covered person has a medical emergency outside the network's service
area.
(12) Any other information required by the commissioner to determine compliance
with the provisions of this Subpart.
D. A health insurance issuer shall file any proposed material changes to the access
plan with the commissioner prior to implementation of any such changes. The removal or
withdrawal of any hospital or multi-specialty clinic from a health insurance issuer's network
shall constitute a material change and shall be filed with the commissioner in accordance
with the provisions of this Subpart. Changes shall be considered approved by the
commissioner after sixty days unless specifically disapproved in writing by the commissioner
prior to expiration of the sixty days.
E. All filings containing any proposed material changes to an access plan as required
by this Subpart shall include but not be limited to each of the following:
(1) A listing of health care facilities and the number of hospital beds at each network
health care facility.
(2) The ratio of participating providers to current covered persons.
(3) Any other information requested by the commissioner.