La. Admin. Code tit. 37 § XIII-3133

Current through Register Vol. 50, No. 11, November 20, 2024

Section XIII-3133 - Provider Services

A. The LA Health Plan provides for the following minimum, or their actuarial equivalent, primary health care provider services.

1. The LA Health Plan will provide for health care provider services, with such care including the general treatment of illness and diagnostic studies used to diagnose the cause of an illness.

2. All care received by a LA Health insured shall be related to the cause or symptom of the insured's illness or injury. Payment will not be made for care and treatment which is not deemed medically necessary.

3. Participating provider office visits are subject to a $10 per visit co-payment. Covered services in the participating provider's office include:

a. laboratory and x-ray services;

b. immunizations for children under age 19;

c. prenatal care visits. Only one co-payment for all visits shall be charged if the participating provider bills in one lump sum;

d. an annual physical exam.

4. Fees for X-ray and laboratory tests made on an outpatient basis for diagnosis or treatment of an illness are covered when ordered by a participating provider. This benefit has a $1,000 calendar year maximum and is subject to the insured paying either $5 co-payment or a maximum of 10 percent of the charge up to a maximum of $1,100 per calendar year. The authorized carrier shall specify which option is to be taken in applying to participate in the LA Health Plan.

5. Surgical and related expenses are covered under the LA Health Plan up to a maximum of $5,000 per insured per calendar year. A $50 per surgical procedure co-payment is required.

6. Maternity care is a covered service subject to the following co-payment requirements:

a. normal vaginal delivery-$50 co-payment;

b. Cesarean delivery-$100 co-payment;

c. if hospitalization follows delivery, the $50 per day inpatient co-payment shall apply.

B. Outpatient mental health care services provided by a provider licensed to diagnose and treat mental and nervous disorders are covered when provided by a participating provider up to a maximum of $1,000 per calendar year with a $10 per visit co-payment.

C. Benefits for the following services are paid subject to the benefits listed in the regulation:

1. use of a participating hospital operating and treatment rooms and equipment;

2. diagnostic X-rays, laboratory procedures and medical diagnostic procedures used to determine the cause of an illness when performed within 14 days prior to participating hospital admission.

D. Benefits shall be provided for mammograms. A $5 per screening co-payment is required when performed by a participating provider and performed with the following frequency:

1. once as a base line mammogram for any female between 35 and 40 years of age;

2. once every two years for any female between 40 and 50 years of age;

3. once every year for any female age 50 or above; and

4. when recommended by a participating provider for a female at risk. Female at risk means a female:

a. who has a personal history of breast cancer;

b. who has a personal history of biopsy proven benign breast disease;

c. whose grandmother, mother, sister, or daughter has had breast cancer; or

d. who has not given birth prior to age 30.

E. Benefits are provided for one pap smear examination per year when performed upon recommendation of a participating provider. A $5 per examination co-payment is required.

F. Benefits are provided for annual prostate antigen tests for covered males who are 45 years of age or older; or covered males who are 40 years of age or older, if ordered by a participating provider. A $5 per test co-payment is required.

G. Benefits are provided for colon cancer screening when ordered by a participating provider. A $5 per screening co-payment is required.

La. Admin. Code tit. 37, § XIII-3133

Promulgated by the Department of Insurance, Office of the Commissioner, LR 20:1012 (September 1994).

AUTHORITY NOTE: Promulgated in accordance with R.S. 22:244-247 of the Insurance Code.