Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 91 - Regulation 68-Patient Rights under Health Insurance Coverage in Louisiana › Section XIII-9107 - Patient Rights under Policies or Plans of Health Insurance Coverage

Current through Register Vol. 50, No. 6, June 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.