§160.4. Administration and implementation of the Louisiana Access to Better Care Medicaid Insurance Demonstration Project

A. In order to implement the provisions of this Subpart, the department shall promulgate rules and regulations, including but not limited to coverage, benefits, information, and financial stability requirements for an insurer or plan which may desire to be certified to provide health care services to the demonstration project by marketing or offering a policy or plan to a participant or other eligible individual.

(1)(a) An insurer shall provide at least one policy or plan that provides coverage for an amount that does not exceed the reimbursable premium amount indicated on the voucher.

(b) An insurer shall offer at least one policy that is considered high deductible catastrophic health insurance, which shall be specifically designed to provide a participant or other eligible individual with the maximum residual account amount available.

(c) An insurer or managed care plan may market or offer an unlimited number of health insurance policies or managed care plans to a participant or other eligible individual.

(2) The health insurance policy or managed care plan contract to provide health care services to a participant or other eligible individual shall not be subject to any state mandatory benefits defined in Title 22 of the Louisiana Revised Statutes of 1950, as amended.

(3) Each certified plan, with the exception of the high deductible health insurance policy, shall include at a minimum the following:

(a) All federal Medicaid mandated benefits.

(b) Inpatient care coverage for mental health and substance abuse as delineated in the rules and regulations promulgated by the department.

(c) Prescription drug coverage.

(d) Prenatal coverage.

(e) Preventive medicine education programs and incentives for healthier lifestyles.

(f) Chiropractic services as delineated in the rules and regulations promulgated by the department.

(4) Each health and accident insurer or managed care plan shall provide prospective participants or other eligible individuals with information regarding the following:

(a) Coverage provisions and exclusions.

(b) Prior authorization or other utilization review requirements.

(c) Financial arrangements that would limit services, restrict referral options, and establish incentives not to deliver certain services.

(d) Plan limitations and the impact of any limitations upon a participant or other eligible individual.

(e) Insured and enrollee satisfaction statistics compiled on an annual basis from insurers and managed care plans offering products similar to their certified health plans for at least two prior years.

(5) An insurer or plan shall not impose any waiting period for its coverage or benefits, or otherwise reduce or restrict its coverage or benefits, to a participant or other eligible individual for any claim that is a result of a high risk condition.

B. In order to implement the provisions of this Subpart, the following shall apply:

(1) The department shall establish minimum standards for a health and accident insurance, high deductible catastrophic health insurance, managed care plan, or benefits payment schedule plan pursuant to this Subpart. The minimum standards to become a certified health plan shall be consistent with and no more stringent than the requirements of an insurer or managed care plan that offers a health care benefit package to the Federal Employee Health Benefit Program. The department shall determine by rule what constitutes high deductible catastrophic health insurance.

(2) Each insurer or plan which meets the minimum standards shall become a certified health plan and may enter into a contract with the department to issue health insurance, high deductible catastrophic health insurance, a benefit schedule, or a managed care plan to a participant or other eligible individual in exchange for payment by the department pursuant to a voucher or from an account.

(3) The department shall certify that an insurer or plan has met this Section's requirements and may market or offer its certified plan to a participant or other eligible individual.

(4) Each such certified health plan shall meet the capital and surplus requirements established by law, specifically Title 22 of the Louisiana Revised Statutes of 1950, as amended, and any other financial requirements that may be established by the department in its rules and regulations. Any such additional financial stability requirements shall be developed by the department with the assistance of the commissioner of insurance.

(5) A participant or other eligible individual shall be given a voucher and make the choice of health and accident insurance, high deductible catastrophic health insurance, a managed care plan, or a benefit payment schedule plan. If a participant or other eligible individual has not made his choice of health insurance, high deductible catastrophic health insurance, a managed care plan, or a benefit payment schedule within thirty days of his receipt of a voucher or if a certified health plan's request for premium or enrollment fee payment for a participant or other individual has not been communicated to the department within thirty days of the participant's or other eligible individual's receipt of a voucher, the participant or other eligible individual shall be assigned to one of the certified health plans through a fair and equitable assignment process devised by the department.

(6)(a) The department shall, within thirty days of such a request by a certified health plan, pay on behalf of each participant or other eligible individual either:

(i) The amount of premium for the health and accident insurance plan chosen by and issued for a participant or other eligible individual.

(ii) The amount of premiums for high deductible catastrophic health insurance chosen by and issued for a participant or other eligible individual.

(iii) The amount of enrollment fee for a managed care plan chosen by a participant or other eligible individual.

(iv) The amount of premium for a benefit payment schedule chosen by and issued for a participant or other eligible individual.

(b) Such payment shall not exceed the reimbursable premium amount in accordance with such insurer's or plan's contract with the department. Notwithstanding any other law to the contrary, a participant or other eligible individual shall be covered by the project and considered an insured or enrollee of his chosen certified health plan at 12:01 a.m. on the date of the department's receipt of such certified health plan's premium or enrollment fee request whether or not payment by the department has been made on behalf of the participant or other individual.

(7)(a) A participant or other eligible individual may choose to pay an insurer's or plan's deductibles or copayments, or both, if any, from his account or from his own resources.

(b) Within thirty days after the first anniversary date of the establishment of an account and at any time thereafter, upon the request of a participant or other eligible individual, the department shall give a voucher to such participant or other eligible individual in an amount equal to the balance remaining in the account after payment of all deductibles, copayments, and other payments authorized and required to be paid for health care services provided before the anniversary date of the establishment of the account. This balance shall represent the amount of money in an account prior to the department's subsequent annual credit deposit amount. A voucher issued pursuant to this Subparagraph may be used only for health care services which are not covered by the benefits package of a participant's health insurance, managed care plan, or benefit payment schedule, and other health care service expenses delineated in rules and regulations promulgated by the department.

(c) If a participant or other eligible individual discovers or otherwise identifies a billed item or health care service that was not received by or rendered to such participant or individual, the insurer, upon good cause shown, shall reimburse that cost amount to the project and the department shall credit to the participant's or individual's account a portion of the reimbursement. An insurer or plan may collect the full amount of any valid overpayment from the health care provider.

(8) The department shall internally develop a mechanism and procedure for administration of the project. The department shall establish and may contract with a person, corporation, or other legal entity to furnish an electronic or telecommunication debit system which shall include a debit instrument or debit card that shall be given to each participant or other individual after his specific selection of health insurance, high deductible catastrophic health insurance, a managed care plan, or a benefit payment schedule. Such debit instrument or debit card shall be presented to a health care provider to evidence that a participant or other individual is covered by the project, and it shall provide for immediate electronic confirmation of the status and residual account amount of a participant or other eligible individual, if applicable.

(9) If a participant or other individual chooses to discontinue his coverage by the demonstration project or the project is interrupted, payment of claims shall be made to the provider of health care services. Such discontinuation in the project does not relieve an insurer, managed care plan, or benefit payment schedule from any contractual obligation incurred under this Subpart.

(10) A contract executed pursuant to this Subpart between the department and a certified health plan shall provide coverage for all health care services offered to a participant or other eligible individual as required by this Subpart and the rules and regulations promulgated pursuant to it, with the exception of long-term care services, and subject to the requirement of the payment of deductibles, if any.

(11) Upon approval of the necessary waiver required under this Subpart, the department shall administer the project. The department shall promulgate rules and regulations to implement the provisions of this Subpart pursuant to the Administrative Procedure Act.

C. The department may establish the demonstration project on a statewide, regional, or health care planning district basis, or based on a specific segment of the Medicaid population.

Acts 1995, No. 1242, §1, eff. June 29, 1995; Acts 1997, No. 46, §1, eff. June 11, 1997.