Health maintenance organizations must give advance written notice for certain prepaid charge increases and cancellations, provide a 30-day grace period, and allow direct access to in-network OB/GYN care for routine gynecological services.
§272. Notice required for certain prepaid charge rate increases, cancellation or nonrenewal of service agreements; other requirements A.(1) Every health maintenance organization regulated by this Subpart shall notify each master contract group in writing at least forty-five days before any increase of twenty percent or more in prepaid charges or at least sixty days before any cancellation or nonrenewal of an agreement for basic health care services. (2) The notice required by Paragraph (1) of this Subsection may be waived for a basic health care service agreement which covers one hundred or more persons, provided a provision for such waiver is made part of the basic health care services agreement agreed upon by the insurer and the holder of the master contract. B. Nothing in this Section shall be construed to grant to the health maintenance organization any additional authorization in relation to cancellation, nonrenewal, or other termination of an agreement for basic health care services and all provisions of this Subpart which regulate such events shall apply. No basic health care services agreement shall be cancelled, nonrenewed, or otherwise terminated because the health maintenance organization failed to meet the notice provisions of this Section. C.(1) The notice provisions of Subsections A and B of this Section shall not apply to cancellations due to nonpayment on a timely basis of the prepaid charges. (2) Every health maintenance organization issuing a contract for health care services shall include in such contract a provision providing the subscriber or enrollee a grace period of thirty days from the date the prepaid charge was due. If the prepaid charge is paid during the grace period, then coverage shall remain in effect pursuant to the provisions of the contract. (3) Whenever a health maintenance organization does not receive a prepaid charge payment fifteen days prior to the end of the grace period, the health maintenance organization shall mail, by first class mail, a notice to the subscriber or enrollee. The notice shall state that if the prepaid charge has not been paid by the end of the grace period, the contract will lapse as provided by the provisions of the contract. The notice shall also state that the contract will be reinstated with no penalties whatsoever to the subscriber or enrollee if the full payment is received within the period allowed for reinstatement. D.(1)(a) Every health maintenance organization authorized under this Subpart may include in its plan obstetricians or gynecologists as primary care physicians. In addition, the health maintenance organization shall not limit direct access to an in-network obstetrician or gynecologist for routine gynecological care. This selection shall be permitted without penalty or denial of the benefits provided under the health maintenance organization. (b) Routine gynecological care as used in this Section shall mean a minimum of two routine annual visits, provided that the second visit shall be permitted based upon medical need only, and follow-up treatment within sixty days following either visit if related to a condition diagnosed or treated during the visits, and any care related to a pregnancy. Nothing in this Section shall prevent a policy, program, or plan from requiring that an obstetrician-gynecologist treating a covered patient coordinate that care with the patient's primary care physician, if applicable, or in conjunction with other oversight procedures. (2) Any provision in a health maintenance organization plan which is delivered, renewed, issued for delivery, or otherwise contracted for in this state which is contrary to this Section shall, to the extent of such conflict, be void. E. Repealed by Acts 2016, No. 145, §2, eff. May 19, 2016. F. Every health maintenance organization authorized under this Subpart shall also be subject to the requirements of Subpart B of Part II of Chapter 6 of this Title, R.S. 22:1831 et seq. Acts 1990, No. 538, §1; Acts 1995, No. 637, §1; Acts 1997, No. 1313, §1; Acts 1997, No. 1341, §1; Acts 1999, No. 1017, §1, eff. July 9, 1999; Acts 2006, No. 396, §1, eff. Jan. 1, 2007; Redesignated from R.S. 22:2027 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009; Acts 2009, No. 503, §1; Acts 2010, No. 919, §1, eff. Jan. 1, 2011; Acts 2016, No. 145, §2, eff. May 19, 2016.