Plan designs (indemnity, HMO, PPO, POS, HDHP with an HSA), cost sharing, and the federal ACA rules are covered in the national Medical Plans guide. This guide covers Louisiana's rules for medical expense coverage. Group continuation is in the Louisiana group health guide, and individual policy provisions are in the Louisiana individual accident and health provisions guide.

HMOs

A Louisiana HMO is a corporation domiciled in Louisiana that provides or arranges basic health care services for enrollees in return for a prepaid charge (R.S. 22:242).

Mandated screenings (R.S. 22:1028)

• Mammography. Plans cover an annual mammogram for women 40 and older, plus a baseline mammogram at ages 35 to 39.
• Prostate screening. Plans cover a digital rectal exam and PSA test for men over 50, and for men over 40 when medically necessary.

Prompt payment (R.S. 22:1821)

• Health and accident claims are paid within 30 days of written notice and proof of claim.
• If the insurer has no just and reasonable grounds for the delay, it owes a penalty of double the benefits due during the delay, plus attorney fees.
• Disability income benefits are paid at least every 30 days.
• Accidental death benefits under a health and accident contract are settled within 60 days of proof of death, or they bear interest.

Grace and notices

• Every individual, group, family, blanket and association health and accident policy has a 30-day grace period (R.S. 22:977(A)).
• If an individual policyholder hasn't paid 15 days before the grace period ends, the insurer mails a lapse notice by first-class mail. The notice explains how to reinstate (22:977(B)).
• A policy the insurer may cancel or nonrenew at its option must say so on the first page (22:973(8)).

Underwriting limits

• Health insurers may not discriminate in issuing, paying, cancelling or nonrenewing coverage based on prenatal test results (R.S. 22:1964(23)) or genetic test results (22:1964(24)).
• An insurer may not unilaterally cancel a health policy after receiving a covered claim for a terminal, incapacitating or debilitating condition, as long as the insured remains eligible (22:1012).
• Tying is prohibited. An insurer may not require an individual or small employer to buy another product, such as auto insurance, to get a health plan. Selling group life with group health is allowed (22:1964(10)).

Federal rules

The national guide covers the federal ACA rules: essential health benefits, guaranteed issue, preventive care, and dependents to 26. It also has the 2026 HSA and HDHP figures.

Common exam traps

• Louisiana health claims are due in 30 days. The penalty for an unjustified delay is double the benefits plus attorney fees.
• The grace period is 30 days for both individual and group policies.
• The lapse notice goes out 15 days before the grace period ends.
• Mammograms are covered yearly from age 40. PSA screening is covered from age 50, or 40 when medically necessary.
• An insurer can't cancel after a claim for a terminal or debilitating condition.