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Summary of differences between federal and state regulations
Employee health plans are generally covered under the federal jurisdiction of the Employee Retirement Income Security Act (ERISA).
Federal ERISA plans generally do not have to comply with state laws. ERISA rules preempt or block state laws that relate to ERISA plans. State insurance laws, however, do apply.
Louisiana laws include the following coverage provisions:
- Whenever the terms "physician,” "surgeon," "medical doctor," or any other terms which refer to licensed practitioners of the healing arts are used in a plan that provides coverage for hospital service, medical, or surgical benefits, such terms shall be construed to include a dentist. (22:213.1)
- Plans must provide coverage without regard to the insured's obligation of deductibles or copayments for the service charges. (22:213.2)
- The plan shall not prohibit the receipt of payment under another such policy for any health care service covered under such other policy. (22:213.4)
- If your plan provides dental coverage, which provides that the payment of benefits under the policy be based upon the usual and customary fee charged by licensed dentists, it must contain disclosure requirements. (22:213.5)
- The plan shall not discriminate on the basis of prenatal test results. (22:213.6)
- The plan shall not discriminate on the basis of genetic information, obtain genetic information without individual authorization, or disclose genetic information. (22:213.7)
- If the plan covers members of the insured's immediate family, it must cover illnesses and injuries of unmarried dependent children of the insured and unmarried grandchildren in the legal custody of the grandparent from the date of birth to the attainment of the limiting age, and include congenital defects and premature birth, but need not include routine well baby care. (22:215.1)
- If the plan covers members of the insured's immediate family, it must cover transportation by professional ambulance services, including air or surface transport, of all newborns, as well as the medically disabled mothers of ill newborns when accompanying the ill newborns to the nearest available hospital or neonatal special care unit for treatment of illnesses, injuries, congenital defects, and complications of premature birth. (22:215.1)
- Attainment of limiting age shall not work to terminate the coverage of a child if the child is incapable of self sustaining employment, and chiefly dependent upon the policyholder, employee or member for support and maintenance. (22:215.2)
- Plans must include optional benefits for the treatment of alcoholism and for the treatment of drug abuse, rendered or prescribed by a physician. (22:215.5)
- Plans must cover treatment and correction of cleft lip and cleft palate, including benefits for secondary conditions and treatment attributable to that primary medical condition. (22:215.8)
- Plans must cover expenses incurred for services performed by a qualified interpreter/transliterator, when such services are used in connection with medical treatment or diagnostic consultations performed by a physician, dentist, chiropractor, or podiatrist, provided such medical treatment or consultation is covered, and provided the services are required because of a hearing impairment or a failure to understand or otherwise communicate in spoken language. (22:215.10)
- Plans must include benefits payable for immunizations for dependent children from birth to age six. (22:215.14)
- Plans must include benefits payable for diagnosis and treatment of attention deficit/hyperactivity disorder. (22:215.15)
- If the plan provides medical and surgical benefits for accident and health services, it must cover a qualified individual for scientifically proven bone mass measurement for the diagnosis and treatment of osteoporosis. (22:215.16)
- If the plan covers cancer treatment, it shall not exclude coverage for any drug prescribed for the treatment of cancer on the ground that the drug is not approved by the United States Food and Drug Administration for a particular indication if that drug is recognized for treatment of the covered indication in a standard reference compendia or in substantially accepted peer-reviewed medical literature. (22:215.20)
- If the plan provides comprehensive major medical benefits, it must provide coverage for the equipment, supplies, and outpatient self-management training and education, including medical nutrition therapy, for the treatment of insulin-dependent diabetes, insulin-using diabetes, gestational diabetes, and non-insulin using diabetes if prescribed by a physician or, if applicable, the patient's primary care physician. (22:215.21)
- If your company provides pharmacy services including prescription drugs to employees or retirees as part of any health insurance or health maintenance program, you may not require employees or retirees to obtain prescription drugs from a mail order pharmacy as a condition of obtaining payment for such drugs; or impose a copayment fee or other condition not imposed upon employees or retirees who utilize the designated mail order pharmacy upon employees or retirees who do not utilize a designated mail order pharmacy. (22:226)
- Plans shall provide benefits for anesthesia when rendered in a hospital setting and for associated hospital charges when the mental or physical condition of the insured requires dental treatment to be rendered in a hospital setting. (22:228.7)
- Effective 8/15/09, plans must provide for a special enrollment period for employees or dependents if the employee/dependent loses eligibility for Medicare or the Louisiana CHIP or becomes eligible to participate in a premium assistance program under Medicaid or the Louisiana CHIP, and the employee requests coverage under the group plan within 60 days. (22:1062.1, Act 243)
- Effective January 1, 2013, for continuation of benefits, health insurance issuers must use only a single, standardized prior authorization form for obtaining any prior authorization for prescription drug benefits. The form must not exceed two pages in length, excluding any instructions or guiding documentation. The form is to be developed by health insurance issuers. Such prior authorization forms are to be submitted to the Department of Insurance. (22:1006.1, Act 318)
State
Contact
Louisiana Department of Insurance
Regulations
Louisiana Revised Statutes - Insurance
http://legis.la.gov/Legis/LawSearch.aspx Click on “Louisiana Laws,” “Table of Contents,” Revised Statutes,” “Title 22” (Insurance), and scroll to applicable section.
22:213.1 Prohibition of discrimination against dental care services
22:213.2 Health and accident policy provisions; service charges; penalties
22:213.4 Additional sources; required coverage
22:213.5 Dental reimbursement or payments
22:213.6 Prohibited discrimination; prenatal test results
22:213.7 Prohibited discrimination; genetic information; disclosure requirements; definitions
22:215.1 Group, family group, blanket, and association health and accident insurance; mandatory coverage
22:215.2 Mandatory coverage and continued coverage of physically or mentally handicapped children of insured
22:215.3 Coverage of vocational-technical students
22:215.4 Coverage of unmarried students
22:215.5 Group, blanket, and association health insurance, treatment for alcoholism and drug abuse
22:215.8 Group, family group, blanket, and association health and accident insurance; cleft lip and cleft palate coverage; mandatory coverage
22:215.9 Group, family group, blanket, and association health and accident insurance; notice required for certain premium increase, cancellation, or nonrenewal
22:215.10 Hearing-impaired interpreter expenses
22:215.14 Immunizations; coverage
22:215.15 Attention deficit/hyperactivity disorder; coverage; diagnosis
22:215.16 Osteoporosis; bone mass measurement; mandatory coverage
22:215.20 Coverage for use of drugs in treatment of cancer
22:215.21 Health insurance coverage for diabetes
22:227 Insurance pending adoption
22:228 Cancellation prohibited after claim for terminal, incapacitating, or debilitating condition
22:229.2 Discrimination against recovered or rehabilitated alcoholics; prohibited
22:250.3 Prohibiting discrimination against individual participants and beneficiaries based on health status
22:250.19 Protections required for victims of the crime of domestic violence
22:226 Employer-provided health plan; limitation to specific pharmacies prohibited; penalty
22:665 Hospital and medical expense policies; services of licensed psychologists
22:669 Severe mental illness and other mental disorders; policy provisions; minimum requirements; group, blanket, and association policies
22:662 Reimbursement for services, podiatrist
22:664 Visual services, choice of practitioners
22:668 Selection of type of treatment; reimbursement
22:223 Surgical services; place of service
22:228.7 Coverage for dental procedures; anesthesia and hospitalization
22:657 Payment of claims; health and accident policies; prospective review; penalties; self-insurers; telemedicine reimbursement by insurers
22:230.1 Coverage for rehabilitative physical therapy, occupational therapy, and speech and language pathology therapy; optional coverage
22:230.4 Health coverage; participants in clinical trials
Federal
Contact
Employee Benefits Security Administration (EBSA)
Regulations
29 CFR chapter XXV (Parts 2509 – 2590)