§1222. Assignment of obligations limited

A. When a health insurance issuer contracts or subcontracts with another entity for the provision of services, the health insurance issuer shall be ultimately responsible for compliance with the laws and regulations governing risk-based capital (R.S. 22:631 et seq.), prompt payment of claims (R.S. 22:1831 et seq,), and medical necessity review (R.S. 22:1121 et seq.).

B. This Subpart shall not apply to health insurance coverage for services under the terms of a carve-out agreement. Nor does this Subpart apply to health insurance coverage or services provided pursuant to the terms of a contract with the federal government or any agency thereof, including but not limited to the Medicare Advantage program.

C. Nothing herein shall prohibit or restrict a health insurance issuer from establishing payment arrangements, including but not limited to capitated payment arrangements, with health care providers or other entities in which financial risk is contractually delegated and assumed.

D. Nothing herein shall prohibit or restrict a health insurance issuer from entering into an agreement with a health care provider or other entity to which financial risk is delegated in which such provider or entity is contractually responsible to the health insurance issuer for compliance with requirements specified in R.S. 22:1831 et seq. and R.S. 22:1121 et seq., including financial penalties.

E. Nothing herein shall prohibit or restrict a health insurance issuer or a health care provider or other entity to which financial risk is delegated from entering into contractual agreements with a health care provider rendering health care services in which the provider rendering services agrees to seek reimbursement only from the provider or entity that has assumed the delegated financial risk from the health insurance issuer.

F. The Department of Insurance is authorized to adopt rules and regulations needed to implement the provisions of this Subpart.

Acts 2004, No. 417, §1; Redesignated from R.S. 22:422 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009.