Health maintenance organizations must give potential enrollees a written explanation of covered and excluded services and access methods, and they must meet licensing or certification requirements where required by law.
§260. Statutory construction; relationship to other laws A. Except as otherwise provided in this Subpart and in R.S. 22:1037, provisions of the insurance law and provisions of Subpart C of this Part, R.S. 22:111 et seq., shall not be applicable to any health maintenance organization granted a certificate of authority under this Subpart. This provision shall not apply to an insurer or an entity licensed under the provisions of Subpart C of this Part except with respect to its health maintenance organization activities authorized and regulated pursuant to this Subpart. B. Solicitation of enrollees by a health maintenance organization granted a certificate of authority, or its representatives, shall not be construed to violate any provision of law relating to solicitation or advertising by health professionals, but such health professionals shall be individually subject to the laws, rules, and regulations governing their individual profession. C. Every health maintenance organization shall make available in writing to its potential enrollees a reasonable explanation of the services to be provided or arranged for. This explanation shall also identify those services excluded from coverage and shall set forth the methods of access to all forms of treatment or class of providers included in the plan. D. Any health maintenance organization authorized under this Subpart shall not practice medicine and shall not be deemed to practice medicine, provided however, that the administrative treatment guidelines of the health maintenance organization shall not impinge upon nor encumber the independent medical judgment of the treating physician or health care provider. Nothing in this Subsection shall be construed to prevent a health maintenance organization from conducting a utilization review and quality assurance program. E. Each health maintenance organization shall meet the following requirements: (1) All facilities located in this state including but not limited to hospitals, medical facilities, and nursing care and intermediate care facilities to be utilized by the health maintenance organization shall be licensed, if such licensure is required by law. (2) All personnel employed by or under contract to the health maintenance organization shall be licensed or certified by their respective board or agency, if such licensure or certification is required by law. (3) All equipment required to be licensed or registered by law shall be so licensed or registered and the operating personnel for such equipment shall be licensed or certified as required by law. Acts 1986, No. 1065, §1; Acts 2003, No. 190, §1; Redesignated from R.S. 22:2016 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009; Acts 2009, No. 503, §1. NOTE: Former R.S. 22:260 redesignated as R.S. 22:150 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009.