§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 health care providers to ensure that all health care services to covered persons will be accessible without unreasonable delay. In the case of emergency services and any ancillary emergency health care services, covered persons shall have access twenty-four hours per day, seven days per week. Sufficiency shall be determined in accordance with the requirements of this Subpart. In determining sufficiency criteria, such criteria shall include but not be limited to ratios of health care 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(4) Repealed by Acts 2018, No. 290, §2, eff.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) Beginning January 1, 2014, except as otherwise provided in Subparagraph (b) of this Paragraph, 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 such fact in the policy form filing. The health insurance issuer may request the commissioner to deem 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 such plans to any interested party upon request, subject to the provisions of the Public Records Law and R.S. 22:42.1.

(b) In lieu of meeting the filing requirements of Subparagraph (a) of this Paragraph, a health insurance issuer shall, beginning January 1, 2014, except as otherwise provided in Subparagraph (c) of this Paragraph, submit proof of accreditation from the National Committee for Quality Assurance (NCQA) or American Accreditation Healthcare Commission, Inc./URAC to the commissioner, including an affidavit and sufficient proof demonstrating its accreditation for compliance with the network adequacy requirements of this Subpart. The affidavit shall include sufficient information to notify the commissioner of the health insurance issuer's accreditation and shall include a certification that the health insurance issuer's network of providers includes health care providers that specialize in mental health and substance abuse services and providers that are essential community providers. The affidavit shall also certify that the health insurance issuer complies with the provider directory requirement contained in Paragraph (4) of this Subsection. The commissioner may, at any time, recognize accreditation by any other nationally recognized organization or entity that accredits health insurance issuers; however, such entity's accreditation process shall be equal to or have comparative standards for review and accreditation of network adequacy.

(c) A health insurance issuer that has submitted an application for accreditation to NCQA or URAC prior to December 31, 2013, but has not yet received such accreditation by January 1, 2014, shall be deemed accredited for the purposes of this Subpart upon submission of an affidavit to the commissioner by January 1, 2014, demonstrating that the issuer is in the process of accreditation. Upon receipt of accreditation, the issuer shall submit proof of such accreditation to the commissioner pursuant to Subparagraph (b) of this Paragraph. However, in the event that the issuer withdraws its application for accreditation or does not receive accreditation prior to July 1, 2015, such issuer shall file an access plan with the commissioner pursuant to Subparagraph (a) of this Paragraph within sixty days of such withdrawal or denial.

(d) If a health insurance issuer that has submitted proof of accreditation to the commissioner subsequently loses such accreditation, the issuer shall promptly notify the commissioner and file an access plan with him pursuant to Subparagraph (a) of this Paragraph within sixty days of the loss of such accreditation.

(e) A health insurance issuer submitting proof of accreditation or an affidavit demonstrating that the issuer is in the process of accreditation shall maintain an access plan at its principal place of business. Such access plan shall be in accordance with the requirements of the accrediting entity.

C. A health insurance issuer not submitting proof of accreditation 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, such a health insurance issuer shall inform the commissioner when the issuer enters a new service or market area and shall submit an updated access plan demonstrating that the issuer's network in the new service or market area is adequate and consistent with this Subpart. Each such 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. Such a health insurance issuer shall update an existing access plan whenever it makes any material change to an existing health benefit plan. Such an 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 not submitting proof of accreditation 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 deemed approved by the commissioner after sixty days unless specifically disapproved in writing by the commissioner prior to expiration of such 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.

Acts 2013, No. 205, §1, eff. June 10, 2013; Acts 2018, No. 290, §2, eff. Jan. 1, 2019.