Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 53 - Regulation 62-Managed Care Contracting Requirements › Section XIII-5303 - Definitions

Current through Register Vol. 50, No. 6, June 20, 2024
Accreditation/Certification
- a hospital that
				  is accredited by the Joint Commission on Accreditation of Health Care
				  Organizations (JCAHO) or Medicare certified for provision of acute care
				  hospital services.
Community
- the parish in which a qualifying
				  rural hospital is located.
Discriminate
- to apply a payment methodology
				  that relies upon terms and conditions that are more restrictive than those
				  terms and conditions applicable to non-rural hospitals or their practicing
				  physicians in a region which result unreasonable payment to a qualifying rural
				  hospital or physician practicing in such hospitals. A payment methodology that
				  results in reimbursement to a qualifying rural hospital or practicing physician
				  that is equal to or greater than the reimbursement to non-rural participating
				  hospitals or physicians in the region, shall be considered
				  non-discriminating.
Employee
- a person employed directly by a
				  managed care organization and does not include any contract, temporary, or
				  other type of employment arrangement.
Geographic Area
-a parish.
Health Benefit Plan
- any health insurance
				  policy, plan, or health maintenance organization subscriber agreement, issued
				  for delivery in this state under a valid certificate of authority by an entity
				  authorized by law to bear risk for the payment of health care services.
Health Care Provider
- a physician duly
				  licensed to practice medicine by the Louisiana State Board of Medical
				  Examiners, or other health care professional duly licensed in Louisiana, or an
				  acute care hospital licensed to provide medical care in this state. The term
				  shall also mean any legal entity or organization formed for the primary purpose
				  of providing medical or health care services and provides such services
				  directly or through its participants.
Incentive Arrangement
- any payment or
				  contractual obligation included in a general payment plan, capitation contract,
				  shared risk arrangement, or other agreement between a managed care organization
				  and a health care provider that is tied to utilization of covered
				  benefits.
Managed Care Organization
- a health
				  maintenance organization or other entity authorized by law to bear risk for the
				  payment of health care services that holds a valid certificate of authority to
				  issue for delivery in this state a health benefit plan.
Pass Through Payments
- any funds or payments
				  received by a managed care organization for the purpose of reimbursing the cost
				  of services provided by a health care provider, that are not covered by the
				  health care provider's contract, including but not limited to research grants,
				  and federal payments for indigent care.
Payment Differential
- a difference in the
				  amount paid to a health care provider resulting from negotiations to establish
				  a capitation, risk sharing, or other payment arrangement that is based on
				  financial incentives necessary to establish medical services within a
				  geographic area of the state.
Practicing
- a physician licensed to practice
				  medicine by the Louisiana State Board of Medical Examiners who has established
				  his/her practice in the geographic area where the rural hospital is located,
				  maintains active hospital staff privileges, and provides medical treatment in
				  said hospital on a weekly basis. The term shall also include any physician
				  whose participation is essential to provision of services covered under a rural
				  hospital's contract with a managed care organization or treatment of enrollees
				  admitted to the hospital, provided such services are appropriate and within the
				  scope of the hospital's accreditation/certification. The term does not include
				  physicians who are merely affiliated, or associated with a rural hospital or
				  any physician whose participation is essential to treatment of enrollees
				  admitted to the hospital based on the unreasonable refusal of a hospital to
				  utilize another physician available through the managed care organization who
				  is qualified to provide the needed medical services to the patient.
Region
- a group of parishes designated by a
				  managed care organization for establishing reimbursement amounts for payment of
				  practicing health care providers. A managed care organization may follow
				  congressional districts or such other reasonable grouping of contiguous
				  parishes in establishing regions. In establishing regions, a managed care
				  organization shall include all parishes of the state and limit the total number
				  of regions to seven. In no event shall any regional configuration be
				  established that acts to discriminate unfairly against qualifying rural
				  hospitals or their practicing physicians.
Rural Hospital
- a hospital qualifying to
				  participate in a Health Maintenance Organization under the requirements of Part
				  L of Chapter 5 of Title 40 of the Louisiana Revised Statutes of 1950, comprised
				  of
				  R.S.
				  40:1300.115.
AUTHORITY NOTE: Adopted
				  in accordance with R.S. 22,
				  R.S.
				  22:3,
				  R.S.
				  22:215.18,
				  22:2006,
				  22:2014,
				  22:2018,
				  22:2019,
				  22:2021
				  and
				  22:2022.