§1005. Continuity of care of health care services

A. For purposes of this Subsection:

(1) "Covered health care services" means services, items, supplies, or drugs for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or disease that are either covered and payable under the terms of health insurance coverage or required by law to be covered.

(2) "Enrollee" or "insured" means an individual who is enrolled in or insured by a health insurance issuer for health insurance coverage.

(3) "Health care provider" or "provider" means a physician licensed by the Louisiana State Board of Medical Examiners to practice medicine or other health care practitioner licensed, certified, or registered to perform specified health care services consistent with state law subject to direct supervision by such a licensed physician.

(4) "Health insurance issuer" means any entity that offers health insurance coverage through a policy or certificate of insurance subject to state law that regulates the business of insurance. For purposes of this Subpart, a "health insurance issuer" shall include a health maintenance organization, as defined and licensed pursuant to Subpart I of Part I of Chapter 2 of this Title, and nonfederal government plans subject to the provisions of Subpart B of Part II of Chapter 6 of this Title, including the Office of Group Benefits.

(5) "Health insurance issuer liability" means the contractual liability of a health insurance issuer for covered health care services pursuant to the plan or policy provisions between the enrollee or insured and the health insurance issuer.

(6) "Life-threatening illness" means a severe, serious, or acute condition for which death is probable.

B. In the event a contract or agreement between a health insurance issuer and health care provider is terminated, the health care provider shall notify the health insurance issuer of any enrollee or insured who has begun a course of treatment by the provider before the effective date of the termination. Based on this notice from the health care provider, the health insurance issuer shall notify the enrollee or insured of a termination of a health care provider from a health insurance issuer's network and the enrollee's or insured's right to continuity of care. The following provisions of this Subsection shall be applicable whether such termination is initiated by the health insurance issuer or the health care provider.

(1) In the event an enrollee or insured has been diagnosed as being in a high-risk pregnancy or is past the twenty-fourth week of pregnancy, the enrollee or insured shall be allowed to continue receiving covered health care services, subject to the consent of the treating health care provider, through delivery and postpartum care related to the pregnancy and delivery.

(2) In the event an enrollee or insured has been diagnosed with a life-threatening illness, the enrollee or insured shall be allowed to continue receiving covered health care services, subject to the consent of the treating health care provider, until the course of treatment is completed, not to exceed three months from the effective date of such termination.

(3) In the event a treating health care provider advises the health insurance issuer of an enrollee or insured who meets the criteria of Paragraph (1) or (2) of this Subsection, the health insurance issuer shall continue payment of the health insurance issuer liability to the health care provider that was in effect prior to the termination of the contract or agreement with such health care provider. In addition, the contractual requirements for the health care provider to follow the health insurance issuer's utilization management and quality management policies and procedures shall remain in effect for the applicable period specified in Paragraph (1) or (2) of this Subsection.

C. The provisions of this Section shall not apply when:

(1) The reason for such termination is due to suspension, revocation, or applicable restriction of the health care provider’s license to practice in this state by the Louisiana State Board of Medical Examiners, or for another documented reason related to quality of care.

(2) The enrollee or insured chooses to change health care provider.

(3) The enrollee or insured moves out of the geographic service area of the health care provider or health insurance issuer.

(4) The enrollee or insured requires only routine monitoring for a chronic condition but is not in an acute phase of the condition.

D. A health care provider shall be prohibited from discount billing and dual billing pursuant to R.S. 22:1871 et seq. For purposes of this Section, the treating health care provider shall be deemed to be a contracted health care provider pursuant to R.S. 22:1871 et seq.

Acts 2004, No. 504, §1, eff. June 25, 2004; Redesignated from R.S. 22:230.6 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009.

NOTE: Former R.S. 22:1005 redesignated as R.S. 22:703 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009.