. TITLE 37 INSURANCE PART XI CHAPTER 27: EMERGENCY - RULE 17 or DIRECTIVE 187

Transcription

1 . TTLE 37 NSURANCE PART X CHAPTER 27: EMERGENCY - RULE 17 or DRECTVE 187 SUSPENSON OF CERTAN STATUTES AND REGULATONS REGARDNG HEALTH NSURANCE.. ANDRELATEDPROVSONSREGARDNG ANY AND ALL NSURANC:EMATTERS AFFECTNG NSUREDS N LOUSANA CAUSED BY HURRCANE KATRNA TO: All Health nsurance ssuers and any other health nsurance enttes regulated by the Commssoner of nsurance and the Lousana Department of nsurance. ' Emergency Rule 17 s ssuedpursuant to the plenary authorty of the Commssonerof nsurance for the.'stateof Lousana,ncludng,butnotlmtedto, the followng: ~roclamaton No. 48 KBB 2005 ssued on August 26, 2005 by GovernanceKathleen Babneaux Blanco declarng.a State of Emergency;.Executve order No. _ KBB 2005 ssued September _, 2005 by Governor Kathleen Babneaux Blanco.transferrngauthorty over any and all nsurance matters to the Commssoner of nsurancej. Robert Wooley, LSA RS. 29:724; LSA RS. 29:766; LSA RS, 22:2; LSA RS. 22:3; LSAR.S. 22:1214 (7), (12) and (14);LSA RS. 49:950, et seq. On August 26, 2005, Governor Kathleen Babneaux Blanco declared the exstence of a State of emergency wthn the state OfLousanacaused by Hurrcane Katrna. Ths State of Emergency extends from Frday,August 26, 2005 tbrough Sunday, September 25, Thousands of Lousana ct~ns have suffered damages due to Hurrcane Katrna. n. some places, t 'could be months before electrcty s restored.. The homes of many ctzens were destroyed precludng habtaton and the delvery of mal. Ths dsrupton has affected the ablty of these ctzens to pay th~r nsurance premums, access ther nsurance polces, and communcate wth nsurance producers and ther respectve msurance companes for nsurance related matters. HUrrcaneKatrna has created a mass dsrupton to the normalcy prevouslyenjoyed by Lousanansand produced an mmedatethreatto the publc health, safety, and welfare of Lousanactzens. The Commssoner and the Lousana Department of nsurance wll be hndered n the proper performance of the dutes and responsbltes regardng ths State of Emergency wthout the authorty to suspend certan statutes n the Lousana nsurance Code and the rules and regulatons that mplement. the LOusanansurance Code ncludng, but not lmted to, cancellaton, nonrenewal, renstatement, ' premum payment and clam flngs wth regard to any and all types of nsurance subject to the Lousana nsurance Code. n lght of ths, hereby ssue Emergency'Rule 17to all health nsurancessuers and other enttes subject to regulaton by the Commssonerof nsurance and the LousanaDepartment of nsurance,

2 regardng any and all types of health nsurancesubject to regulaton under the Lousana nsurance Code. Emergency Rule 17 apples to every nsured,member, or enrollee (h~renafterreferred to collectvely as "nsured") whose address on record wth the health nsurance ssuer on August 26, 2005 was n any of, the followngseven(7)of the thrty-one(31)parsheselgbleforthe ndvdualassstanceprogram G'stered by the Federal EmergencyManagementAgency (FEMA) pursuant to FEMA's declaraton ssued on August 29,2005: Jefferson, Orleans, Plaquemnes,St. Bernard, S1.Tammany, -, ' Tangpahoa, and Washngton. The zp codes applcable to these seven (7) parshes nclude, but dsaster:> may lmted to, the lst dentfed as "Hurrcane Katrna Zp Code Lst" found on the offcal Lousana Department of nsurance nternet webste at Emergency Rule 17 applesto every employer group nsured by a health nsurance ssuer f the employer's physcal locaton on August 26,2005 was n any of the seven parshes named above. f the employer mantans more than one physcal locaton,ths Rule applesonly to that physcal locaton n one of the seven named parshes. ' n the ordnary course of busness, health nsurance ssuers are regulated by the Commssoner of nsurance and' the Lousana Department of nsurance regardng any and all types of health nsurance, ncludng, but not lmted to, health and accdent nsurance, lmted beneft nsurance, Medcare ~upplemental nsurance, HMOs, MCOs, PPOs, excess loss nsurance, stop loss nsurance, and any and all other health nsurance lcensed or regulated by the Lousana nsurance Code are subject to certan requrements wth regard to health nsurance matters affectng nsured ctzens n Lousana. Hurrcane Katrna has produced a dsrupton n the health, nsurance ndustry. Thus, many of Hurrcane Katrna's vctms are currently unable to tmely actor respond to ther health nsurance needs. Addtonally, some nsureds wth polces n force on August 26, 2005, who wsh to make tmely payment are also prevented from makng such payment because, of the aforementoned crcumstances. Ths could result n an nsured beng wthout coverage and/or potentally unnsured. Emergency Rule 17 provdes emergency relef of the nsureds of Lousana affected by Hurrcane Katrna so that they wll be nsured and ther coverage wll contnue under those polces that were n effect on or after August 26, All terms used n ths EmergencyRule 17 shall have the meanngs ascrbedto them n the Lousana nsurance Code. Nothng n ths Emergency Rule 17 shall be construed to requre or alter coverage for condtons or treatments that were not covered n the nsurancepolcy n effect on August 26,2005. Accordngly,-durngths State of Emergency,the followng rules shall apply: 1. Health nsurance ssuers shall wave all health care access restrctons for anynsured to whom ths Rule apples. Any such nsured s not requred to seek care from provders n the network applcableto hs or her health nsurance plan. To avod delays n accessng care, all health nsurancessuers shall wave requrementsfor pre-certfcaton, referrals, medcal'necesstyrevews, and notfcaton of hosptal admssons

3 ( n detemnng the beneft plan levelto pay any clam, the health nsurance ssuer shall use the hghest n~networkbeneff1evelas defned n the affected nsured's health nsuranceplan that was n effect on August.26, The beneft plan establshes the approprate deductbles, copayments,consurance,and other cost-sharng oblgatonsthat would be used for payment of the clam. The purpose and ntent of usng the hghest n~networkbeneft plan level s to mnmze the nsured's out-of-pocketexpense durng ths EmergencyRule. Ths level of beneft wll be used to pay both contracted and non-contractedprovder clams a) Any clams ncurred for servcesrenderedby a contracted health care provder shall be pad accordng to the contract n effectwth that provder on August 26, All oblgatons of ~uchcontract shall reman n place except to the extent that they are altered by ths Rule. The nsured s lable for deductbles,copayments, consurance,and other cost-sharng oblgatons that applywhen servces are obtaned from a contracted provder. b) Any clams ncurred for servcesrenderedby a non-contracted health care provder shall be pad usng the non-contractedprovderpayment allowance used by the health nsurance ssuer on August 26, The nsured s lable for deductbles, copayments, consurance, and other cost~sharngoblgatonsthat apply to the hghest n-network beneft level as defned n the affectednsured's health nsuranceplan n effect on August 26, c) No health care provder shall balance bll the nsured for any amount exceedng the amount pad by the health nsurance ssuer for the clam, provded the amount was correctly calculated under ths Emergency Rule.... All.cancellaton,tennnaton, and contnuatonprovsons, ncludng,but not lmtedto, LSA RS. 22:22:250.7; ; 215.9; , 6~6.F & 2027, are hereby sus~nded. j: All clams notfcaton procedures, ncludng, but not lmted to, LSAR,s. 22:213.A (3)- (5) and Regulaton 33, are hereby suspended.. The followng rules shall apply to "Tmely Payment":. Medcal Care or Servces-LSA R.S. 22: and Regulaton 74 (Secton ) The Commssoner hereby suspends the forty-fve day tme lmt for payment of clams for non-electronc clams submsson and assocated penalty provsons untl further notce. See LSA RS..22: and LSA R.S..22: C. The Commssonerhereby suspendsthe twenty-fve day tme lmt for payment of.clams for electronc clams submssonand assocatedpenalty provsons untl further notce. See LSA R.S. 22: and LSA R.S. 22: C. The Commssonerhereby suspendsthe thrty day tme lmt for payment of clams and assocatedpenalty provsons for ssuers who have elected to utlze a thrty day payment.

4 standard for complance untl further notce. See LSA RS., 22: and LSA RS. 22: C and C.. Pharmacy Care or Servces- LSA RS. 22:250:53 -:-57 The Commssonerhereby suspendsthe forty-fveday tme lmt for payment of clams for non-electronc clams submssonuntl further notce. See LSA RS. 22:250.53and the penaltyprovsons oflsa RS. 22: C. The Commssonerhereby suspendsthe ffteen day tme lmt for payment of clamsfor electronlcclams submssonuntl furthernotce. See LSA R.S. 22: and the penalty provsons oflsa RS. 22: C. The Commssonerhereby suspends pharmacyrestrctons on reflls such that any. prescrptonsthatwerelost or leftbehndshallbe ref11ed. TheCommssoner. hereby authorzesthe payment of at least a 30 day supply of prescrpton medcatons beng taken on August 26, 2005 regardlessof the date of last refll. The Commssonerhereby suspendsany and all pre-certfcatonor step therapy proceduresrequred by the health nsurancessuer to fll a prescrpton. The authorzatonshall be for one 30 day supply. The Commssoner hereby suspends any restrctons for replacement prescrptons flled by mal order pharmaces. The mal order prescrpton can be maled to an alternate.addressf requested by the nsured. All health nsurance ssuers shall wave any and all restrctons relatve to out of network access to pharmacy servces or pr~scrptons. MedcalNecessty- LSA RS. 22: and Regulaton 17 (Secton ) The Commssoner hereby suspends the tme frames that an ssuer has to make and/or respond to medcal necessty revew.determnatons untl further notce. Physcan Credentalng - LSA RS. 22:11.1 The Commssonerhereby suspends LSA R.S. 22:11.1such that there are no credentalngrequrements wth regard to physcans. 8. Paymentof Medcare SupplementPremums-LSA R.S. 22:224.K The Commssoner hereby suspends the requrements that the payment of Medcare Supplement premums can only be made pursuant to LSA R.S. 22:224(K). \ n furtherance of the suspenson, any polces that contan restrctve language relatve to modes of premum payment shall allow for the acceptance of other payment methods

5 durng ths perod to ncludebut not be lmtedto credt card, debt card, FEMA, federal assstance,stateassstance,etc a. No polcy shall be cancelled or non-renewedsolely because of a clam resultng from Hurrcane Katrna. A cancellaton or nonrenewalmay not occur pror to the expraton of the state of Emergencyor any subsequentlydeclared State of Emergency related to Hurrcane Katrna except at the.wrtten request or wrtten concurrence of the polcyholder... t. b. Any notce of cancellaton, notce of nonrenewal or nonrenstatement of an nsurance polcy n force and effect at 12:01 a.m..onaugust 26, 2005, shall be null-and vod and shall have no force and effect. Furthermore, any such notce shall be ressued de novo to the polcyholder n accordance wth exstng statutory requrements, but not untl the present State of Emergency or any subsequent State of Emergency has been lfted by Governor Blanco. c. The renewal of any and all group health nsurancepolces shall Qedeferred whle ths Rules n effect.. d. f a grace perod for payment of premumwas n effect on August 26, 2005, the grace perod shall be extended untl the expraton of the State of Emergency or any subsequent State of Emergency declaredwth respect to HurrcaneJ{atrna. Any grace perod that. may come nto effect durng ths State of Emergencyor such subsequently.declared State of Emergency shall be extended untl the expratonof the State of Emergency or the subsequentlydeclaredstate of Emergency. Ths grace perod shall not be deemedto be a waver of premums. e. The premum for all group health polces n effect at 12:01 a.m. on August 2.6,2005,.shall not be ncreased whle ths Rule s n effect. Notces of premum ncreases may be sent to group.polcyholdersfor the duraton of ths Rule; however,.any premum ncrease may not be mplementeduntl the expraton of ths Ru1e. 10. Ths Rule shall not releve a pol~cyholderor nsured who has a clam caused by Hurrcane Katrna from complyng wth polcy oblgatonsto provde nformaton and cooperate n the clam adjudcatonprocess. 11. No nterest, penalty or other charge shall accrue or be assessed as the result of the suspensonsrequred n ths Rule. f. J 12. A health nsurancessuer payng a clam for an nsured owng.a premum may offset the premum due from any clam payment made under the polcy Nothng n ths Rule shall be Gonstrued to exempt or excuse lablty for.premums otherwse due for actual nsurance coverage provded

6 ' Anytmelmtsmposedby thelousanansuranc.ecoderelatedto admttng. recevables as assets shall be extendedto conform,.tothe extensons of tme requred by ths Rule. All tme lmts mposed by LSA R.S. 22: shall be extended to conform to the extensonsof tme requre~by ths Rule. Notwthstandngany other provson contaned heren, the Commssonermay exempt any ssuer from complancewth EmergencyRule 17upon wrtten request of the ssuer f the Commssonerdetermnesthat complancewth EmergencyRule 17may be reasonably expected to result n sad ssuer beng subjectto hardshp, mparment or nsolvency. 17. The provsons of EmergencyRule 17 shall be lberally construedto effectuatethe ntent and purposes expressed heren and to afford maxmum consumerprotecton for the nsureds of Lousana. ; 18. EmergencyRule 17 shall be deemedto be a prohbtorylaw. Accordngly, any health nsurancessuer or.other entty regulated by the Commssonerof nsurance and the LousanaDepartment of nsurancewho volates any provson of Emergency Rule 17 shall be subjectto prosecuton under any applcableprovsons of the Lousana nsurance Code, ncludng the provsons of the L8A RS. 22:1211, et seq., and specfcallyncludng, but not lmted to, LSA R.S. 22:1214(7),(12) and (14). Addtonally,the penalty provsonsset forth n LSA RS. 22:1217shall be applcable. These provsons nclude cvl penaltes of $1, for each separate act, or $25, for each separate act f the volatorknew or reasonably ~houldhave known he was n volaton of EmergencyRule 17,as well as a cease and desst order and the mposton of other cvl penaltes and suspensonor revocaton of the lcense. Addtonally,LSA R.S. 22:1220,whch, among other thngs, mposes the oblgatonof good fath and far dealng shall be deemed to be a prohbtorylaw. Thslawsetsforthcvlpenaltesand exemplary.damageswhch shall be enforceablefor any volaton of Emergency Rule 17. Fnally, any volator shall be subject to any and all other applcable cvl and crmnal. sanctons for volatons or EmergencyRlle 17. [, f. J 19. Emergencyrule 17 shall become effectve at 12:01 a.m. on August 26,2005 and shall contnue n full force and effect for the duraton of the present State of Emergency proclamed by Governor Kathleen BabneauxBlanco, or anysubsequent State of Emergencyproclamaton made thereafter. ( \